§ 3.59 p.m.
§ Mr. Richard Wood (Bridlington)
It is a matter of some regret to me that the first speech which I make in this House on the subject of the National Health Service should be made at a time when it is plain to everyone that a crisis faces the Service, some say the greatest crisis since 1948. The focal point of this crisis, as the House will be only too well aware, is the anxiety and dissatisfaction that exists among general practitioners. I will come to that focal point later.
I will, first, speak generally about the National Health Service. This is a short debate and I understand that a number of hon. Members wish to speak. I hope that nothing I say will make more difficult the task of the right hon. Gentleman the Minister of Health, which is, as I see it, to develop and improve the services not 1198 only to those who are unwell, but to those who are not unwell; both the curative and preventive services.
Looking back, I think that we all agree that the idea of a comprehensive service was not only a most imaginative one, but was also extremely bold, because the resources with which to implement it—the human resources, resources of building equipment, and so on—never were and never will be unlimited. The competing claims on those resources were and always will be strong and the demand for benefits, not only at the start but right through, has remained keen and buoyant.
Therefore, the danger has existed, since the very inception of the Health Service, that at times or at some time the demand for medical care would overwhelm or intolerably strain the means of providing it. As we are aware, this pressure on resources has been evident at various points and times since the inception of the Service. At present, it is the general practitioners who are likely to occupy the attention of the nation and Parliament, so much of what I say—and much of what all hon. Members will say today—will be concerned with the general practitioner.
We are also conscious of the strain which is at present imposed on the nursing services, physiotherapists—I had occasion this morning, in one of the newer hospitals, to discuss these difficulties—and a host of ancillary workers whose contribution to the National Health Service is indispensable. And in the local authority sphere of health and welfare there is a similar pressure of demand.
In the promises which appeared in the Socialist election manifesto and in the election addresses of a number of prominent Labour candidates who now occupy extremely lofty positions in Her Majesty's Government we noticed a great deal of vague speculation—which was, no doubt, attractive to some—about the acceleration of programmes, more staff, improved conditions and expansion in the various branches of the Health Service. We had from the right hon. Gentleman the Secretary of State for Economic Affairs these words:The health of the nation demands, and will get, an intensive programme of new hospital building, an increased supply of doctors, nurses and other qualified staff.1199 When I recently suggested to the Minister of Health that many of his right hon. and hon. Friends who had criticised the modesty of the Conservative plans for hospital building—which seems to be a clear implication of the election address of his right hon. Friend the Secretary of State for Economic Affairs—he, with his great astuteness, referred me to the earlier view of the Chancellor of the Exchequer; that the Conservative programme could not be exceeded by any party with any degree of responsibility. No doubt it is that remark which both he and the Prime Minister would most like to recall.
Instead of the Secretary of State for Economic Affairs' intensive programme of hospital building we have a review of the building programme which, the Minister of Health told us last week, would be "a lengthy business." All we know of the immediate future, or of the future at all, is that the Government intend to provide £5 million more than the original estimate of expenditure for 1965–66. I find this most welcome, but I am bound to say that its significance in real terms is beginning to be a little doubtful in view of the cost increases which are now taking place.
What the Minister of Health has done, if I may so describe it, is to switch off the light which my right hon. Friend the Member for Wolverhampton, South-West (Mr. Powell) cast on this subject; and after the end of the next financial year we will find ourselves plunged into a darkness which will make it impossible for us to deduce either the intentions of the Government, or the rapidity of their desire to honour the pledges of the Secretary of State for Economic Affairs and others to get on with the intensive programme of hospital building. Perhaps this is the whole point of the exercise. I hope that the Minister, when he replies, will give us some idea of the likely duration of the review, of what this "lengthy business" means.
I also ask the right hon. Gentleman to confirm his intention, when the review is completed, then to announce its result and his conclusions to the House of Commons so that hon. Members will be able to satisfy themselves that the anxieties of their constituents are being fully attended to and that the momentum of hospital building in the early 'sixties is being fully maintained.
1200 The problem which, naturally, will claim most of our attention today is the mounting strain on the medical services, the dissatisfaction of general practitioners with the recent pay award and the deep anxiety of a great many of them about their future. This problem faces us as a great crisis because of the place of general practitioners in our medical system. This seems to be of such importance that any serious breakdown in this part of the system carries an immediate threat to the whole structure of the Health Service.
It is the general practitioner alone who really knows the individual, his family, his past and his whole background. The general practitioner must play a leading part in the health team, in its task of curing the patient. While he may not have the specialised knowledge of the consultants who are dealing with his patients, it is he who has the specialised knowledge of the individuals with whom the consultants must deal.
The Review Body set up in 1962 to advise the Prime Minister has now issued its fifth Report. The Government have accepted its recommendations and the general practitioners have made no secret of their dissatisfaction. That is the situation, as I see it, which we face this afternoon.
Some time ago the Minister of Health declined in the House of Commons to give a description of the pool system, not because he lacked the ability to do so but because he feared, probably rightly, that most hon. Members—including myself would lack the ability to comprehend it. If I were tempted to describe the pool system I should be deterred from doing so for precisely the opposite reasons.
§ Mr. Wood
We look forward to that and hope that our comprehension will have improved.
I was about to make the boast that although I do not intend to have a shot at it, I will lay my hand on my heart and claim to have mastered its essential principles. I have frequently learned from experience that when complicated intellectual conceptions, after years of struggle, are finally squeezed within the scope of my mental equipment, those conceptions have the awkward habit of 1201 suddenly and disconcertingly losing all practical significance.
It has happened to me very often. Sad as I should be to feel that my weary hours of studying, and mastering, the pool system should be completely wasted, I must admit to very serious doubts whether a system of remuneration, either in its present form or with the modifications proposed by the Review Body, which seems to be so widely disliked and distrusted by general practitioners, can long continue to occupy the place in the Health Service which it has held since that Service started.
I realize—and, of course, the doctors do—that this was the system that they chose in 1948, but many of us—including, I think, the right hon. Gentleman himself—have become very conscious of its weaknesses. In fact, I recall that in the debate on 27th July last the right hon. Gentleman said—and perhaps he intends to remind us of it today:… 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."—[OFFICIAL REPORT, 27th July, 1964; Vol. 699, c. 1012.]My understanding of this is that, whilst it is the Review Body which recommends the amount of remuneration, the method of remuneration is properly a matter for discussion directly between the Ministry of Health and the profession, either within or outside the Working Party on General Practice—the France Committee.
Therefore, I shall ask the right hon. Gentleman to tell us today, either that he has already begun talks with the profession on these lines or that he is prepared to do so immediately, with a view to reaching agreement on an alternative method of remuneration which the doctors will find satisfactory. Perhaps he will, at the same time, tell us whether he has yet reached agreement with the profession on a change in the method of reimbursing practice expenses.
Will the right hon. Gentleman tell us whether or not he and his predecessors have given undertakings to the profession—as I believe they did give them—that such changes will not be introduced without the profession agreeing to them?
In that debate of 27th July of last year, the hon. Member for Birmingham, Small 1202 Heath (Mr. Denis Howell), who is now a Joint Under-Secretary of State for Education and Science—expressed himself on remuneration in forthright it not particularly scientific terms. He said:People have … said that money is not the root of all their discontent, but we know that at the bottom it jolly well is …"—[OFFICIAL REPORT, 27th July, 1964; Vol. 699, c. 1060.]I would not dare to be so dogmatic. I have no doubt that remuneration is of great importance, but I also have no doubt that other things in this connection are most important, too. Long hours, constant availability, responsibility—literally—for life and death are bound to impose their own strain on any human being, and I suppose that most people—and I expect that most of us this afternoon will have a go at it—could name a long list of additions to these natural burdens.
There is the widespread feeling that the doctor's professional skill is not being used to the best advantage; that there is no link between skill or experience and reward; that there is no proper career structure. Many doctors feel that the doctor has too little time for his patients, who very often need reassurance and advice, which can take a very long time to give, more than any actual treatment in the narrow sense. They feel that the doctor has too little opportunity to maintain contact with his patients in hospital, especially those who are in for short stay. The doctor very often finds difficulty in arranging home helps or home nursing for his patients.
There is also the difficulty—and this is of extreme importance—of remaining a good doctor. I think that it was the Porritt Committee which emphasised the increased importance of postgraduate training, but how many hard-pressed general practitioners can, in these days, keep up with the continual accumulation of new knowledge? Then there are the doctor's personal anxieties—the burden on his wife, the problem of educating his children, and the future for his wife and children if he overworks and dies.
I do not think that any hon. Member doubts the sincerity and sympathy of the right hon. Gentleman, although many of the election statements of his right hon. Friends make some of us suspect that they do not share his knowledge or his 1203 insight into these very important problems. He himself told us last year that his party planned to establish at least four new medical schools. His right hon. Friend the Prime Minister, in his election address, told the voters of Huyton that they could expect urgent steps to overcome the serious staffing difficulty. Everyone appreciates that staffing difficulties cannot immediately be overcome, but we are justified in expecting, from the Prime Minister's words in his election address, that the steps will be taken at once, particularly as we were told that all Labour's plans were poised four months ago to "swing into instant operation".
We would, therefore, like the Minister to tell us this afternoon what plans he has for reducing shortages of staff, when they would be put into operation, and when they will begin to have effect. We should also like him to tell us whether or not he has already persuaded his right hon. Friend the Chancellor of the Exchequer to provide the money, not only for the new medical schools but for the expansion of places at existing schools, and for the encouragement of such improvements as a widened system of group practice. Further, will he refrain, particularly at the present time, from putting new burdens on to general practitioners and, instead, do all that he possibly can to reduce the load they carry at present?
My third point is one that I have already made, and it is by far the most important. I hope that he will be able to answer in perfectly satisfactory terms the request that the Government should accept the responsibility that now lies upon them to lead the way out of this grave crisis that at present faces the National Health Service and that, therefore, he will immediately begin discussions with the profession with a view to devising a new framework within which general practitioners will be willing to work and to provide the best service for their patients.
§ 4.18 p.m.
§ The Minister of Health (Mr. Kenneth Robinson)
Perhaps I may begin by congratulating the right hon. Member for Bridlington (Mr. Wood) on his first speech in his "shadow" capacity. I am sure that the whole House will agree that in so far as his speech related to 1204 the immediate crisis it was constructive; and that nothing he said has made my task any more difficult than it already is. I am grateful to him for that.
The right hon. Gentleman mentioned a number of other things besides the doctors' dispute, and perhaps I should here warn you, Mr. Speaker, and the House, that it is my intention later to seek leave of the House to reply very briefly to the debate. I should like to deal with those other topics then, but I want to devote my opening remarks to the doctors' dispute. First, however, I should like to speak briefly about another and no less essential profession—that of nursing.
There are amongst nurses recruitment and staffing problems, but the latest available total for all grades of nursing and midwifery staff in Great Britain is the highest we have ever had. It is true that the number of student nurses has regrettably fallen slightly below last year's figure, but it remains the second highest figure ever recorded. I hope that recruitment of nurses will be helped by the pay settlement for student nurses which has just been reached, with increases ranging from between 6 per cent. and 12 per cent. in rough figures, which will become effective on 1st March. Negotiations on increases for other nursing staffs are continuing amicably and I hope that a settlement will be reached in a couple of months.
§ Mr. Eric Lubbock (Orpington)
Does the Minister intend to say anything about pupil nurses while he is dealing with recruitment?
§ Mr. Robinson
The figures I gave of student nurses included pupil nurses. I have not separate figures for pupil nurse recruitment, but they, too, benefit from this pay increase. I hope all this has some relevance to the remarks of the right hon. Gentleman about the staffing of hospitals. I hope, too, that the House will note a marked contrast here with the bitter pay negotiations for nurses about three years ago.
There is, I think, not a great deal between the two sides of the House on the question of the crisis in the general medical services, but there is one point which, I think to his credit, the right hon. Gentleman did not make, but which 1205 has been made in the Press and, which, according to the Press, may be made by hon. Members opposite during the debate and which I should like to get out of the way before I get to the main part of my speech. That is the Government's decision to abolish prescription charges. I think that it is wholly irrelevant to the main issue in this debate. I am not aware that the decision was opposed by the party opposite and it has not so far tabled a Prayer to annul the Regulations. Should it do so, I should be glad to deploy the full case.
I only want to say today very briefly that the Labour Party has been pledged for more than 10 years to get rid of these charges—for very good reasons, in our view Throughout that period until last July we were supported in our view wholeheartedly by the doctors themselves, and then on a single occasion, at a meeting highly charged with emotion over a number of different issues, the doctors suddenly and without any previous warning reversed their decision. This they were perfectly entitled to do, but what would the country and the party opposite have said if the Labour Party had casually jettisoned, on the eve of a General Election, a specific pledge to the electorate which had been repeated times without number?
Anyhow, what was the censure debate on 2nd February about if it was not about alleged breaches of election pledges by the Labour Government, pledges which were considered to be broken because they had not been redeemed within the first 100 days? This is a specific pledge, redeemed and in full operation 15 weeks after our taking office.
Further, we do not, and we did not, share the only coherent reason which has been given by the doctors themselves for reversing their attitude, namely, the fear of increased work load and of widespread abuse by patients. These fears were reiterated with increasing force amongst doctors as 1st February approached. I said then that I thought they were exaggerated and that I did not share them. Little has been heard of these fears since 1st February. There is no evidence so far of any substantial increase in prescriptions over the country as a whole and no evidence whatever of abuse by patients.
1206 This issue has been raised by and on behalf of general practitioners because somehow they seem to think that, but for this decision, £22 million would have been available to increase their remuneration. The fact is that no remuneration has been withheld from them because of this expenditure on behalf of their patients, any more than it has been withheld on account of the increase in old-age pensions. The only circumstance that might have made this point relevant and anything more than a red herring would have been if the Government had rejected the award of the independent Review Body. Instead of that, we accepted it.
I want now to turn to the main problem and I want, during the course of my remarks, to try to clear away a number of dangerous misunderstandings about the present position. I cannot regard it as anything but somewhat ironical that it should be on my head that the wrath of the family doctors is being visited because, like the right hon. Member for Enfield, West (Mr. Iain Macleod), who, about 10 years ago, held the office that I now hold, I am the son of a family doctor. Although, perhaps, I had no valid judgment at the time, I have plenty of evidence that my father was a good general practitioner. At least I know that he loved his work and that he worked hard at it. No doubt he worked too hard, because he died of a coronary thrombosis at the age of 42. That was over 40 years ago, when conditions were very different and perhaps even in some respects hard for the G.P. than they are today.
But, young as I was, I absorbed the atmosphere of a family doctor's home which was also his surgery, and what one absorbs in the first dozen years of one's life stays with one for life. So I do claim first-hand knowledge of what is involved in being a family doctor and any prejudices I may have are likely to be in sympathy with the family doctor rather than to the contrary.
I think, also, that I can claim to have shown some awareness of the serious situation which for some years has been developing in general practice. Of a number of articles that I wrote and speeches I made while in opposition perhaps I need only mention my speech in the debate to which the right hon. Gentleman referred, the debate I initiated on 1207 27th July last year, on the family doctor service. In that speech I referred to the many warning signs over the years which had been ignored by a succession of Conservative Ministers of Health, until the profession erupted in 1963. Let the House face this fact. Here is one more critical situation inherited from the previous Government which had been festering through years of neglect.
Shortly after taking office I wrote a personal letter to all family doctors, the first time, I understand, that any Minister of Health has done this. I wrote it in an effort to convey to them my good will and my concern that good family doctoring should flourish. The letter included the statement that I wasready to discuss more radical reforms in general practice, either through the medium of the Working Party or in any other way that may be thought appropriate".The response to this letter from the profession was a mixed one. Of the very many doctors who wrote in reply to me, the majority at least showed appreciation of my intentions and some desire to co-operate constructively. Some replies and some comments in the journals were cynical, suspicious and even downright abusive. For my part, I can only say that I wrote the letter in complete sincerity and that I stand by every word of it. At least, the replies encourage me to believe that there are enough family doctors willing to work constructively for the genuine partnership between profession and Government that is essential for the future of the Health Service.
Now there has been another and more violent eruption. Perhaps the right attitude to adopt to this is that it was bound to come sooner or later without a considerable change in the general practice set-up—that the situation was unstable and must reach this crisis before a remedy could be found. Whether the eruption would have been quite so violent and bitter under a Conservative Government is a question on which there has been some speculation in the Press and elsewhere. One can only wonder. However that may be, the crisis is upon us and out of it can come an opportunity which the Government are willing to seize, if the profession will do the same.
1208 I would be the last to deny that there are very real problems connected with general practice that the medical profession and I have to face and tackle today. Some of them go far deeper than levels of remuneration, though pay and methods of pay must certainly loom large. The detonator of the latest explosion, if I may so describe it, was the award of the indepent Review Body, of which I shall say more later, but to understand it I must try, as I promised the right hon. Gentleman, to explain the basis of the pool system which is now the focus of the family doctor's discontent.
The pool system, in essence, goes back more than half a century, far beyond the beginning of the National Health Service, to the old National Insurance days. There are two elements which go into the pool. The first is the agreed average net income for all official services of G.Ps., multiplied by the total number of G.Ps., broadly speaking. The second element is the total practice expenses of all those G.Ps. as agreed by the Inland Revenue, for tax purposes. That is the global total.
From the global total is deducted all separately remunerated payments to G.Ps. from public services—for example, hospital and local government work—and then the balance that remains is distributed amongst G.Ps. on a capitation basis, that is a fee, with certain loadings, for each patient on each G.P's. list. I have simplified what is an extremely complex system. I hope that I have not misrepresented it in any way in so doing. It is a system which is fully understood by few doctors and by even fewer members of the public.
One undesirable result of this system to which I called attention long before either the leaders of the profession or the previous Government got around to discussing it, is that, though 100 per cent. of practice expenses are repaid to the profession as a whole, they are repaid not according to what each doctor incurred but on an averaged basis as part of the capitation fee. Thus, a doctor spending a great deal on ancillary help or maintenance of his premises in order to give a better service to his patients does so by encroaching on what should be his net income, while at the other end of the scale the doctor who is content to spend the very minimum on his practice is able 1209 to pocket as net income a large proportion of what is intended to be reimbursement of expenses.
Thus, it can fairly be said that the second category is being subsidised by the first; or perhaps I can put it in another way. There could hardly be a bigger financial disincentive to improving and modernising the standards of general practice.
The pool system is not anything that has been imposed on the profession by machiavellian Governments or Ministers of Health, as many doctors appear to believe today. The profession has always accepted it willingly, and it made no attempt in evidence before the Royal Commission on Doctors' and Dentists' Remuneration, which reported in 1960, to seek any change. The Royal Commission's Report endorsed the system in these words:Because of the practical advantages … and because the profession is accustomed to it and on the whole likes it we recommend a continuance of the pool system.Now the profession considers that these latest developments—and I quote again—demonstrate … the improbability of ever securing justice for family doctors so long as the present pool system remains the basis of remuneration.But I have already expressed my willingness to discuss methods of remuneration, and I cannot understand why it should be necessary to demand such discussions as the profession is now demanding with the truculence that is being exhibited. There is a similar demand for a new contract of service, on which it has always been open to the profession to make suggestions. I have not shown myself difficult of access to the profession. Since I took office, in four months I have had at least half a dozen meetings with B.M.A. leaders on such questions as immigration, compensation and prescription charges. There is only one subject on which there is a request for a meeting at present outstanding, and that is on free drugs for private Patients—
§ Lord Balniel (Hertford)
I interrupt purely to clarify a point. Has the right hon. Gentleman directly approached the medical profession, suggesting negotiations with them?
§ Mr. Robinson
One of the purposes of my letter of 1st January was to make it 1210 perfectly clear that I was ready to discuss with the profession any basic changes in the structure of general practice. The claim for remuneration at this time was before the Review Body. I must tell the noble Lord that if I had put forward any constructive suggestion at this time, in this atmosphere, it would have been met automatically with hostility and suspicion. I was awaiting, as I was bound to await, an initiative from the profession.
§ Lord Balniel
I am sorry to press this point, but I think that we ought to be clear. If I understand the right hon. Gentleman aright, he has not, in fact, made any direct approach to the British Medical Association or other representatives of the profession. Does the right hon. Gentleman not feel, in the atmosphere which exists at the moment, that it might help the atmosphere were he directly to approach the profession?
§ Mr. Robinson
Perhaps the noble Lord will allow me to proceed with my speech. I think that he will find satisfactory answers to his questions in the course of it.
I was saying that there is only one subject on which there is a request outstanding and it is free drugs for private patients, which it is difficult to see as a proposal crucial to the family doctor's future. If the pool and the present contract are, indeed, so intolerable, it is hard to see why changes have not been put forward earlier, beyond the change in the pool which was proposed to and in part accepted by the Review Body, and why the British Medical Association has not even sought an approach to discuss them with me.
The truth may well be that the causes of the present crisis are more deep seated and can be traced to the family doctor's feeling of insecurity about his place in the world of medicine.
§ Sir Keith Joseph (Leeds, North-East)
The right hon. Gentleman referred to changes which were proposed. Proposed to the Review Body by whom?
§ Mr. Robinson
These were changes in the pool proposed by the evidence committee of the doctors to the Review Body. I hope that my speech will not become intolerably long, but perhaps I might interpolate an answer to a point made by the right hon. Member for Bridlington, 1211 who said that he thought that the Review Body was concerned with the levels of remuneration and not the method. I think method is much more appropriately discussed direct with Ministers, and I said this when in opposition. The fact is that the profession itself asked for a change in method by making this demand of the Review Body and putting forward this claim.
Medicine is very much more complicated than it was when this pattern of general practice was established, long before the Health Service. It becomes progressively more doubtful, as medicine advances, whether the family doctor can fill the place that he ought to effectively under the traditional pattern, working to a great extent in isolation and unsupported. He needs premises, staff, equipment and these things that can usually only be secured by working in groups. He needs time for continuing education to keep himself up to date, and this is also easier to organise in group practice.
There are many general practitioners—and they are, in general, those who suffer most under the present system—who are gearing themselves for this forward movement, but the profession as a whole is still a collection of individuals isolated from each other and from their negotiators. The result has been a lack of collective initiative from which much of the current frustration must derive. This frustration is then projected on to the Minister and to the Government as the obvious scapegoats. The waters are deeply troubled, and it is not surprising that destructive elements like the Fellowship for Freedom in Medicine and the Communist Party are fishing in them, exploiting and trying to maximise the dissatisfaction.
Perhaps in all this turmoil too little is heard from the ordinary hard-working G.P. who is devoted to his job and his patients and has no time—and perhaps little inclination—to engage in medical politics, or even to take part in local meetings of the British Medical Association. Occasionally, one or other of them writes to the Press. There was a letter in The Times on 15th February, and six Birmingham doctors wrote to the British Medical Journal on 13th February. Many of them have written to me. 1212 Many of them have asked me to discount much of the bitterness and anger that is more widely expressed. But the bitterness and anger is undoubtedly there, sincerely felt by many G.Ps, and I certainly would not wish to under-rate it in any way.
It is quite wrong to say that no initiative has come from the Government to meet these problems. True, many locust years were wasted, but belatedly, less than a year ago, a Working Party was set up on which representatives from the profession, sitting down with officers of Health Departments, considered a wide range of problems affecting general practice. I am glad to pay tribute, as I did then, to the right hon. Member for Altrincham and Sale (Mr. Barber) my predecessor, for that initiative.
The problems which the Working Party was to discuss had been largely identified by the Annis Gillie Report on the Field of Work of the Family Doctor, from a committee set up on Government initiative. I regret as a sad fact that there were no corresponding initiatives from the profession itself and, even sadder, that the profession has made so little response and has failed to recognise the sincerity of our desire fundamentally to improve general practice.
A number of improvements have been discussed and proposals made to the profession. If little progress has so far been made this can hardly be laid at the door of the Government. It is very much more due to the cumbersome machinery for consultation and decision within the medical profession itself. A further obstacle to change has been the doctor's status as an independent contractor, a status on which he has insisted ever since the beginning of the National Health Service. If he were an employee, premises, staff, and equipment would automatically be provided by the Government, just as they are for hospital doctors, and he would be paid a net salary according to his grading.
But because of the doctors' obsessive insistence on this independent status I could not now introduce a salaried full-time service, if that was what the profession as a whole wanted, without new legislation. Aneurin Bevan was compelled by the profession to incorporate a specific prohibition of this in the 1949 National Health Service Act.
1213 It is on this account that we have the present pool system of remuneration and that we have so much difficulty in agreeing on arrangements to pay some of the expenses direct. We have had to find a formula for direct payments that would give real help to the doctor who wants to provide himself with better facilities, without depriving him of personal financial responsibility for what he provides. We have proposed to the profession, and their leaders have agreed to recommend it, a direct payment of a proportion of the wages of ancillary staff. It is this view which, in a sense, is at the core of the present troubles.
It was conceived at first as a limited redistribution of expenses already paid in full. This inevitably meant that if some doctors with high expenses were to receive more pay, those with low expense ratios would receive rather less. Most people may think this equitable, but the profession, whilst welcoming the principle, wished to avoid any scheme that would result in a fall in net income for any doctor. This could be avoided only by placing additional money in the pool, because die pool already contained 100 per cent. of all expenses incurred.
Now this is precisely what the Review Body award has made possible. Indeed, it has made possible not only the introduction of this ancillary scheme in this way, and another scheme for providing direct payments in respect of practice premises, but also a small increase in the capitation fee from which all will benefit. In percentage terms, for a doctor with an average net income this means increases ranging from 2frac12; per cent. for those G.P.s who do not employ or intend to employ ancillaries, to around 14 per cent. for those who employ one full-time helper, and to around 20 per cent., or some £550 a year, if he is employing a full-time and a part-time helper, as many do.
The overall additional cost to the Exchequer is about £51 million a year, or about 10 per cent. if averaged over all general practitioners.
§ Mr. Lubbock
Did not the Review Body, in its recommendations on the ancillaries, say that the financial means to do this would be provided from the surpluses which would otherwise have been distributed to doctors as soon as the pool calculations were completed? 1214 Are not the doctors now going to lose that?
§ Mr. Robinson
It is the precise opposite. Under the Review Body proposals, the balances would be paid out in full to the profession and the greater part of the new £5½, million would be devoted to launching the ancillary scheme.
I have described the effect of this, and to use such words as "snub" and "insult" to describe such an award, coming on top of a 14 per cent. increase two years ago, which was intended to last for three years, must seem to many trade unionists a strange use of language.
Since general practitioners' pay is settled on the advice of an independent body, it is not for me to express a view as to whether G.P.s are adequately paid or not, but I must put it on record that if this award is included their increases since the Royal Commission was appointed eight years ago have aggregated to around 50 per cent. Their present net average income is £2,765, to be increased by this award to rather over £3,000. The present gross average income is rather over £4,200 a year, which would rise to very nearly £4,500 a year if this award were accepted.
I must now say a few words about the Review Body itself. This body was appointed following the recommendation of the Royal Commission with the enthusiastic support of the profession.
§ Dr. Wyndham Davies (Birmingham, Perry Bar) rose—
§ Mr. Deputy-Speaker (Dr. Horace King)
Order. If an hon. Member wishes to seek to intervene he must ask whoever is speaking whether he may intervene. It is not enough merely to stand.
§ Mr. Robinson
I have given way rather frequently and I still have a good deal to say. I do not wish to take up too much of the time of the House and I hope that I shall be allowed to proceed.
The Review Body was described by a leading general practitioner asa method of removing, for all time, the recurring disputes with the Government on pay.Those are slightly ironical words today. The body comprises seven distinguished 1215 and wholly independent men, under the chairmanship of Lord Kindersley. Its existence confers on doctors and dentists a privilege denied to all other Health Service staff. The Chairman of the General Medical Services Committee, Dr. Cameron, who is one of the key figures in this dispute, told the British Medical Association Council a month ago:It would be regrettable if the profession were to take up a militant attitude which might be construed as a threat to the Review Body and its work.Dr. Cameron added that the profession would have given anything for arbitration in the dispute with the Government before the Royal Commission was appointed. He said that one of the great benefits which had come out of the package deal was undoubtedly the setting-up of the Review Body and added:You can call it anything you like, but basically it is a form of arbitration, and it is something the profession must have. We cannot conduct our affairs in a state of threat and counter-threat with successive Administrations.A week later, the same Dr. Cameron told his own committee:The profession itself suggested to the Royal Commission that a Review Body should be set up which could consider the profession's case from time to time. One of the great results of the Royal Commission was the setting up of the Review Body, which, in fact, is a form of arbitration".Another leading general practitioner, who is a most prominent and militant leader in the present dispute, quoted the following words with evident approval:If one accepts an arbitration, one is almost in duty bound to accept its verdict".I take just one more quotation, which, with the indulgence of the House, I should like to read in full. It is a short letter written to the Permanent Secretary of my Department, and published, I may say, by the Secretary of the British Medical Association. It was dated 17th December, precisely two months ago today:Thank you for sending me a copy of the Joint Statement of Intent on Productivity, Prices and Incomes and its accompanying letter addressed to Sir Thomas Holmes Sellors and Dr. Cameron"—they are, respectively, Chairmen of the Central Consultants and Specialists Committee and of the G.M.S.C.— 1216After consultation with them and the Chairman of Council of the B.M.A., and on behalf of all the members of the Joint Evidence Committee, I am instructed to say that we have full confidence in the independent Review Body procedure as recommended by the Royal Commission and accepted by the Government, Parliament and the profession. We are equally confident in assuming that the Government will accept and act promptly upon any recommendations which the independent Review Body may make".Dr. Stevenson's confidence was not misplaced. The Government did precisely what the leaders of the profession had asked. We accepted the award, and it was not altogether easy in the context of this time. We accepted it promptly and in its entirety.
The doctors were disappointed. They had asked for £18 million and they had got £5½ million, and it was not recommended as a straight percentage increase but, for the greater part, as a method of helping the more hard-pressed general practitioners with higher expense ratios. The Review Body had examined the case put before it by the doctors, and, in paragraph 46 of its Report, had written:Although we do not question the sincerity of the conviction of general practitioners that remuneration has been seriously inadequate ever since 1948, we find no evidence to support it and do not share it.That was the view of the Review Body, frankly and clearly stated.
Disappointed as they were, it is very hard to exonerate the leaders of the B.M.A. from the charge of misleading their members as to the effect of the award, which even now is utterly misunderstood by many doctors. Instead of an objective factual statement, the B.M.A., in its letter to members, chose to describe the award in the most derisory possible terms, as no more than 1d. per consultation. If they really needed an average, it would have been more accurate, and far less tendentious, to cite the figure of £250 per year increase in net income, which is what the award, in fact, represents.
§ Mr. Robinson
I am sorry, but I cannot give way at the moment.
The entire presentation of the case by the leaders of the profession to its members smacks more of a competition in militancy between the various warring 1217 factions than of any attempt at a constructive approach to a solution.
Does the profession think that the Government were right or wrong to accept the award? Does it think that we should have rejected it, and, if so, how is it imagined that the Review Body could have remained in being? Has the profession lost confidence in the Review Body, and, if so, what does it suggest putting in its place? These are questions which require answers.
I have been asked whether I stand by assurances given by my predecessor and myself that the scheme of direct payment for ancillaries will not be imposed on the profession against its wish. I do not regard the acceptance by the Government of this award as in any way inconsistent with those assurances, but I must emphasise that, in my view and that of my advisers, the proposal is in the best interests of general practice.
But it is for the doctors to decide. We have still to learn whether or not the profession accepts the recommendations. In spite of the sharp reaction, they do not appear to have been rejected. Once they are accepted, £5½ million of Exchequer money will be put into the pool; but to put this money in for a flat-rate increase in capitation does not constitute acceptance, as paragraph 59 of the Review Body's Report makes clear.
Now, one or two general words in conclusion. I think it a pity that the profession should feel the need to express itself so strongly to get negotiation on methods of remuneration and the form of the contract, but, so long as negotiations can take place with a sense of urgency, perhaps it does not matter how they come about. This, of course, is on the assumption that there is no question of negotiation under duress. There has been talk of resignations and of necessary preliminaries to negotiation. But I cannot imagine that this means that I am expected to agree to this or that, on pain of resignation of doctors from the Health Service, before negotiations can begin. Clearly, no Government could be expected to do that, or to negotiate under threat of withdrawal by a specified date.
I have clearly said, and I repeat now, that I have always been willing to discuss basic charges in the structure of general 1218 practice, in the terms of service and methods of remuneration. There is no need of threats to get me to negotiate. Perhaps the profession might be reminded that it is never wise to hurl oneself at a door which is already open.
For the last time, I quote Dr. Cameron again, speaking only a week or two ago:So long as we are the responsible body dealing with general practitioner affairs, it should be our policy to negotiate, and to continue to negotiate, and only after negotiations fail to consider any other course of action".If that is the spirit in which the profession will enter these discussions, and if the doctors will concede my good faith and put aside their suspicions, then, I believe, we can reach a successful conclusion.
I said at the beginning of my speech that the right attitude to adopt in the present crisis might be to regard it as something which was bound to come sooner or later and, having come, even to be welcomed, perhaps, for the opportunity it gives for advance. I have been obliged to speak to the House in plain terms about the reasons for the crisis, as I see them, and about the responsibility which the leaders of the profession must bear. But I hope that nothing I have said will suggest that I am reluctant to seize this opportunity for advance or unhopeful about what might come out of it. On the contrary, I am now more than ever convinced that the Government and the profession must get together to grapple with the deep seated problems of general practice which go far beyond remuneration.
We have now come to a point where there are only two alternatives, as I see them. They are reconstruction of general practice within the Health Service so as to allow the family doctor to play his proper part in the future development of medical care, or the disintegration of general practice and the erosion of the whole concept of the family doctor, which we in this country specially cherish and which here as nowhere else in the world plays so vital a part in the whole medical scene. There can, surely, be no doubt which of these alternatives we must strive for.
§ 4.59 p.m.
§ Mr. R. H. Turton (Thirsk and Malton)
As one who for a short time held the 1219 responsibility of the right hon. Gentleman and, during that period, engaged in the preparatory work which eventually saw the Review Body set up, I wish to say a few words in the debate.
First, I regret the tone of the right hon. Gentleman's speech, which, I believe, will not be helpful in a very difficult situation. We have to accept the fact that there has for some years, unfortunately, been great disappointment among general practitioners with the working of the Health Service.
I thought that the right hon. Gentleman was very unwise in saying that he had inherited great problems. When I became Minister, I also inherited the malice between the general practitioners and Mr. Aneurin Bevan at that time, but I never mentioned it in the House. It was a great mistake for the right hon. Gentleman to try to play party politics about something which is far beyond that.
§ Mr. A. Woodburn (Clackmannan and East Stirlingshire)
As one of the Ministers with Aneurin Bevan in the negotiations with the doctors, I must point out that there was no foundation for this feeling at all. Mr. Willink, a predecessor of the right hon. Gentleman's at the Ministry of Health in the Coalition Government, had the same experience with the doctors. "Nye" Bevan was entirely reasonable—we both were. The trouble was that the doctors never got down to the problem of how the Service was to work and wasted a great deal of time on inessentials.
§ Mr. Turton
That reinforces what I said. I inherited a great deal of malice, but I do not believe that in such a matter it is wise to try to play party politics. [HON. MEMBERS: "What is the right hon. Gentleman doing now?"] If hon. Members opposite will listen to me, they will hear what I am doing.
There has been a great decrease in the number of principals in general practice—74 in the year ended last September. I am quoting from the Kindersley Report. I notice the right hon. Gentleman shaking his head. Does he wish to correct me?
§ Mr. K. Robinson
The right hon. Gentleman's figure is not wrong. I would suggest that that was not a great decrease. 1220 In fact, it was the first decrease ever.
§ Mr. Turton
Also, about 25 per cent. of doctors are emigrating. These are serious problems which the House must tackle. I agreed with the right hon. Gentleman when he said that it was not remuneration in particular with which general practitioners were dissatisfied but conditions of service. But there has been a great deal of misunderstanding about the system of remuneration, and it should be cleared up. I did not feel that the right hon. Gentleman's speech cleared it up.
Our intention when we set up this body was to take the difficult question of arguing about the total quantum of remuneration, the total amount of the pool, away from argument between the Ministry and the profession and put it into entirely independent hands. That was done in the case of both the Pilkington Royal Commission and the Kindersley Committee. I should have thought that there was no argument that both those Committees had discharged that duty well and satisfactorily. Both of them came to conclusions about the right increase in remuneration for the profession at the respective times. The Pilkington Commission recommended a 9 per cent. increase, and this time the increase recommended is £5½ million.
I have always understood that the working out of the details of distribution should be left to the profession and the Minister. That is what I understood by the pledge given by my right hon. Friend the Member for Altrincham and Sale (Mr. Barber), that he would not impose any system of reimbursement of practice or ancillary expenses, and equally from the pledge repeated by the right hon. Gentleman. Therefore, I should have thought that if we could reach a more friendly situation between the doctors and Parliament—both parties in Parliament—it should be possible to avoid the tragic step of doctors withdrawing from the Health Service, and we might be able to try to get agreement about how the £5½ million will be distributed.
I agree with the recommendation in the Kindersley Report—I have always thought this absolutely right—that the payment for Executive Council services should be taken out of the pool. I 1221 should have thought that was the fair and right way to deal with the matter. That also happens to have been part of the evidence of the general practitioners to the Kindersley Committee. That recommendation would appear to take £5,300,000 out of the pool, and yet, as a result of the bringing in of the Working Party's proposals for the reimbursement of ancillary and practice expenses, that will involve about £3 million to £4¼ million of this sum.
I should have hoped that the Minister would make it clear when he makes his second speech today by leave of the House that he is not imposing any of these machinery aspects of the Kindersley Report on the profession and that all that he is saying is that he accepts the recommendation that there should be awarded to the general practitioner service an extra £5½ million and that he will work out with them in friendly session—rather different from the attitude that we found in his speech—how it is to be distributed.
§ Mr. K. Robinson rose—
§ Mr. Turton
Perhaps I might finish first, and then I will give way.
One sees that paragraph 59 of the Kindersley Report would not be out of line with what I am suggesting. I refer to the recommendation for an increase in average earnings of general practitioners to £2,775 with the exclusion of the Executive Council payments. Paragraph 59 says:If (as we think desirable) the schemes for partial direct reimbursement of certain practice expenses are introduced from 1st April, 1965, some £4 million to £5 million will cease to be reimbursed through capitation fees …In other words, the Report is saying that if there is agreement between the profession and the Minister, certain consequences will follow. It is accepting the Minister's pledge, which has been repeated, that there will be no imposition of this on the profession.
Therefore, I hope that the Minister will make it clear that the way is open now for negotiation, not on the total sum of £51 million when the doctors ask for £18 million, but on how the £51 million will be distributed. If he did so, that would help to ease a very difficult situation throughout the country. The dissatisfaction is far more widespread 1222 than one would gather from what the right hon. Gentleman has said.
I ask him to make two other statements in the near future. One he has already done today—that he will look again at the whole system of remuneration to try to make it less complicated. It is extremely involved. I ask him to do that in consultation with the medical profession.
Secondly, in recent years we have had both the Gillie Report and the Porritt Report. I believe that the time has now come when we should review the whole structure of the Health Service. There are a great many wise suggestions in the Porritt Report which I hope the Minister will consider. There is far too much duplication and waste in the Health Service at present. There is far too little co-ordination between those who are working in the hospitals, those working in general practice and those concerned with the prevention of disease.
I do not look upon health as a party matter, and I never have done so. The Health Service was conceived by the National Government at the end of the war. We are all jointly responsible for the introduction of the Service, and we are all jointly responsible for its advantages and its shortcomings. I certainly take my share of the blame as well as the credit. It is against that background that we should attempt to make the Health Service work better and more efficiently than it has done in the past. I believe that if the Minister grasps the opportunities and seeks the good will of all those working for the profession we can succeed in getting this dispute settled without bitter acrimony.
§ 5.10 p.m.
§ Mr. James A. Dunn (Liverpool, Kirkdale)
I rise to introduce myself to the House as Member for Liverpool, Kirkdale, and, as usual, to ask for the indulgence of hon. Members for my maiden speech—although I appreciate that any medical diagnosis of my facial appearance would deny the word "maiden".
I follow in the footsteps of many worthy and illustrious representatives of the constituency. They range from the famous family of Baden-Powell to Elijah Sandham and William Keenan and last, but not least, to the most recent of my 1223 predecessors, Mr. Norman Pannell. Each in his own way made valuable contributions to the debates of this House with independence and authority. I hope, in some small measure, to follow in their footsteps.
It would be wrong of me to attempt to deal with subjects that have been introduced by right hon. Gentlemen so far in this debate, because I am the first to appreciate that this could never be accepted as non-controversial, so I shall try to deal with the issues that face the Kirkdale constituency, one in particular.
Kirkdale is in the middle belt of the city. Its housing ranges from urban renewal to the "two up, two down". Predominantly, however, Liverpool housing, and especially the housing in Kirk-dale, is of the small, terraced type of high density. We have a large population and many large families.
A constant problem is that of hospital accommodation and, unfortunately, we suffer from the lost opportunities of yesteryear. At present, we are confronted by the proposed closure of the Stanley Hospital, which has been in existence for over 100 years—even before the famous family came to represent the constituency which I now have the honour to represent. The Stanley Hospital serves a dockland area which also has other industrial and commercial activity in the first belt of the city. It also serves the neighbouring constituences of Scotland and Bootle. The catchment area is very large. It is quite a closed community and the intended closure of the hospital will cause—is causing already—consternation throughout my constituency. For our people it is a catastrophe and it is being said that it will endanger the future well-being and health of the residents of Kirkdale.
The hospital itself is a small unit. It has about 110 acute beds, a first-class emergency and casualty department and an out-patients' department that has more than served the needs of the community. Last year, about 21,000 people passed through the out-patients' department and that figures does not reveal the high proportion of the under-14s taken there for emergency treatment. It is very convenient for a mother with a small family, living close to the main arterial road to the North from Liverpool, to be able to take a child, hurt at 1224 home or at school or in a children's game, to the emergency service at the hospital.
The emergency service for the dockland workers has always been immediately available. The removal of that service from the geographical centre which Stanley Hospital provides could cause great hardship. It is said—and I agree—that if the planners were looking for an ideal site on which to build a small, compact, modern general hospital they would probably pick the site on which Stanley Hospital now stands. Yet they propose to close the hospital that is already there.
I appreciate that the intended closure in the first instance was proposed as the closure of a teaching hospital but, nevertheless, the regional hospital board could have declared its intention to continue with the service as it already existed. I am asked by my constituents to voice their anxiety, and I do so, as well as my own. I live in Kirkdale and although my home is a fair distance from Stanley Hospital it has been a source of security and guarantee to me and my family. To remove the hospital will cause concern to each and every person in Kirkdale as well as to those in the neighbouring constituencies I have mentioned.
During the past year, about 2,000 inpatients have been treated at the hospital. This is not a high figure by any standards, but it does not reveal that the occupant of an acute bed very often became a geriatric case. We have not sufficient hospital accommodation for geriatric cases and most of those who found themselves in the Stanley Hospital with an ailment that needed further medical attention for a prolonged period were advised not to return home, for the simple reason that home conditions were very often so bad that they would retard recovery. There would be little opportunity for exercise and fresh air, while the cramped situation would cause nursing difficulties. Many of these homes are sub-standard. Running hot water is often not available at all while cold water is very often drawn from an outside tap.
All these factors have made the imminent closure of the Stanley Hospital a serious threat to our community. It is causing a great deal of anxiety 1225 now. It will cause a great deal of inconvenience because the hospital is easy of access in our area. Relatives visiting patients have no difficulty in travelling. I ask my right hon. Friend to reconsider the decision to close the hospital.
Kirkdale has many things of which I am proud, not least the Stanley Hospital. The late Cardinal Godfrey was Kirkdale boy, and, on a lighter note, the ground of the Liverpool Football Club is in the heart of my constituency, and some hope that 1965 will be a year of attainment for that club. Still being lighthearted, an old friend of mine used to tell the story of a Liverpool supporter who saved up for many years to see Liverpool win the Cup, but who, unfortunately, died a millionaire. I hope that most people in Kirkdale will not die disappointed with the service offered at the Stanley Hospital under the control of my right hon. Friend.
§ 5.20 p.m.
§ Sir John Vaughan-Morgan (Reigate)
There are few greater pleasures in the House than congratulating an hon. Member on his maiden speech. I should like very sincerely to congratulate the hon. Member for Liverpool, Kirkdale (Mr. Dunn) on his contribution this afternoon. There are always certain traditions of a maiden speech which should be observed, although they have been somewhat breached in many instances in this Parliament. They should not be contentious and they should preferably deal with local affairs. A particularly attractive feature is when some reference is made to the hon. Member's predecessor, particularly when he comes from another party. The hon. Member fulfilled all the true traditions of the House in his maiden speech, including his reference to Norman Pannell, who is a good friend of many of us on both sides of the House. I am sure that we were all delighted to hear the hon. Member. He has done credit to Kirkdale and we look forward to hearing him in future, perhaps on less contentious issues and perhaps less local issues, but we shall, none the less, look forward to hearing him.
I should like to congratulate the right hon. Gentleman on his office. No right hon. Gentleman has ever come to that office having made so many speeches on the subject with which he was to deal. 1226 I am sure the right hon. Gentleman will understand that his past speeches will form a gold mine of research on matters on health policy for hon. Members on this side of the House.
I have to declare an interest in this debate in that I am the chairman of a teaching hospital. I have to be somewhat circumspect in my remarks, because I am a creature of the Minister, appointed by him. My appointment is due for renewal in about a year's time, but I have every hope that it will not be the right hon. Gentleman himself who may renew it. Perhaps in passing I may pay tribute to a colleague whom we have just lost both from the House and from the Board of Westminster Hospital, Llywelyn Williams, a very much loved colleague here and on the Board and a very dear friend of mine.
Most of the debate has been about the general practitioners, as is understandable in present circumstances, but I should like first to draw attention to a fact of which the right hon. Gentleman will be fully aware. It is that there are other difficulties, particularly in the hospital service. Everybody knows about the shortages of medical and ancillary staff, but few people appreciate the increasing problem of the difficulties which are beginning to arise with non-medical staff. It is becoming very difficult to recruit good, young administrative staff, secretaries, clerical and domestic staff. This even now applies to what are sometimes called the prestige hospitals.
I want to draw the Minister's attention to one of the reasons for the difficulty and the dissatisfaction in the hospital service. It is a certain dichotomy of approach within the Ministry of Health. All hospitals have these staffing difficulties. The Ministry of Health officials listen very sympathetically to the tales of woe which are told, but then point out that these are matters for the Whitley Council. The boards of the hospitals then get in touch with the management side of the Whitley Council at the Ministry of Health and are told that these matters are under discussion. Somehow—and this applies whatever party is in power—if and when the discussions come to fruition, they do so far too late to assist in a solution of the problem.
1227 The current position of pharmacists in hospitals is a classic example. Outpatient dispensing is having to be abandoned in many hospitals and, as a result, on the other side the Ministry is faced with a large extra bill for the completion of prescriptions on EC 10. There is a sort of dichotomy of responsibility, for all these problems eventually come under the responsibility of the Minister, who somehow manages to give managements and boards the appearance of having a slightly split personality.
I hesitate to suggest yet another Royal Commission, but I wonder whether there could not be some inquiry into the whole of lay staffing in the hospital service. The net result of such an inquiry might be, as I would hope, the scrapping of the Whitley machinery and possibly even the substitution of a review body on the lines which have become almost notorious in another connection. This may seem an odd moment to advocate such a change, but I believe that it would be welcome, particularly if it would give the boards and the teaching hospitals access to the review body so that they could put their case. I only throw that out as a suggestion for consideration.
I want now to turn to the subject of the general practitioners. I am tempted to say that this is where I came in, because eight years ago I was very briefly at the Ministry of Health when Dennis Vosper was Minister, now my noble Friend Lord Runcorn. He, too, was faced with a crisis and angry doctors, and when doctors are angry they are very angry indeed. Like all angry people, they sometimes get a little irrational and liable to damage their own cause, however good it may be. I say that while deprecating some of the remarks of the right hon. Gentleman today, because it is no answer to the irrationality of the doctors to speak in the tone which the right hon. Gentleman sometimes employed in passages in his speech. Eight years ago, the crisis ended in the appointment of the Royal Commission, and it is the fifth Report of the Review Body which came out of the Royal Commission which has created the current rumpus.
We must appreciate the difficulty which doctors have as negotiators. In- 1228 side the profession there are always inherent conflicts of interests which break their unanimity and weaken them as negotiators. There is the basic potential conflict of interest between the general practitioners and the consultants which, in a sense, is one of the causes of the present malaise. Out of the review there is now a further conflict between those who employ ancillary staff and those who do not. This is a conflict which has been exploited by the Report.
In this dispute, I have some sympathy with the B.M.A. Against the B.MA. it can be said, as the Minister said, that we are only half-way through an agreed standstill period of three years. That might have been an argument for a rejection of their claim by the Review Body on the grounds that in another year a complete review would be taking place. But the Review Body did not do that. In fact, it accepted part of the claim, and I concur with my right hon. Friend the Member for Thirsk and Malton (Mr. Turton) in feeling that there is a curious illogicality within the Report between the reasons for the decision and the nature of the award.
Paragraph 55 of the Report of the Review Body says quite plainlythat the present system of remuneration does not recompense doctors for additional work resulting from an increase in the proportion of patients to doctors unless average net income is increased on that account.In other words, the quantum has increased and the amount of the award, in the circumstances and pending a review very shortly, does not seem to me to be unreasonable.
What is unfortunate is that strings have been tied to the distribution of the award which must seem to many illogical and unfair. We all agree, perhaps, that it is high time to review the whole matter of pay, and it is certainly time to revise the expenses and review the use of ancillaries.
§ Mr. K. Robinson
I am most grateful to the right hon. Gentleman for giving way. Would he say whether in his opinion it is equally illogical and unfair for the Review Body to have recommended certain payments to be taken out of the pool which were part of the payments which the profession wanted taken out of the pool? There seems to be an analogy here.
§ Sir J. Vaughan-Morgan
I think one could claim that as a logical point of view, and I am sure that we could find others. I am only pointing out what I consider to be illogicalities which have caused the present discomfort. I am not trying to drive a coach and horses through the Report of the Review Body, and I think that the right hon. Gentleman is quite right to accept it. However, I am bound to find cause for the discomfort in the medical profession. I think that this should have been done, therefore, in quite separate negotiations. Imagine an industrial award which gave an increase in wages and which specified how that increase was to be spent. That, really, is the nub of the issue. I think, therefore, that there has been a mistake by the Review Body in that illogicality, and, perhaps, in others too, and a mistake which the right hon. Gentleman has not seen fit to point out.
§ 5.34 p.m.
§ Mr. Arthur Blenkinsop (South Shields)
On the whole, I welcome the fairly rational atmosphere in which we are discussing this matter and, in particular, I would like to welcome the speech of the right hon. Member for Bridlington (Mr. Wood), who opened the debate in a cool, reasonable and dispassionate way. I think that, without unfairness, one might welcome the right hon. Gentleman as yet another new face in this field of health debates. The benches opposite are littered with past Ministers of Health who were not speaking officially on this occasion, but I do not think that we lost anything on that account. I am sure that we welcome the new views of the right hon. Member for Bridlington.
I must say that I found some of the strictures made by one of the other right hon. Gentlemen opposite on my right hon. Friend the Minister of Health rather amazing. It seems to me that my right hon. Friend, in making his initial speech, put forward the general problems which we are facing in an extremely moderate and careful way, and it is amazing that it should be said that it is perfectly proper for the professional body to use any kind of language it likes in reference to the Minister, and, indeed, to the whole Ministry, and not expect a few modest and factual statements to be made in reply.
1230 I would not have thought that the profession itself was quite such a tender body as to be incapable of taking a little reasonable and modest plain speaking. I have had an acquaintance, partly direct and partly indirect, with the medical profession in the past, and I have certainly never found its members unable to express their views very vigorously indeed. Therefore, I do not see why if they do that there should not be a certain amount of honest speaking in return. To suggest that there should be this difference of treatment as between one body and another is extraordinary.
The tragedy of this whole affair is clearly that there have been so many missed opportunities over the years. I think one can say perfectly fairly that they have been missed both by the medical profession and by the Ministry. The new development of the National Health Service, which was started by the late Nye Bevan, offered when it was introduced some exciting opportunities for the development of general practice. Perhaps one of the great tragedies is that these opportunities have never been taken. There has been very little leadership either from the medical profession or, perhaps in the past, from the Ministry itself, with a view to really keeping clearly in the minds of members of the profession the exciting possibilities offered to them.
For example, there are opportunities of advancing the standards of the medical profession, of improving the quality of its work and the status of its members, which I know is a matter of very real concern to them. There has been this unfortunate lack of leadership throughout. I think it is a pity that for 13 years we had so many Ministers of Health. Without making an attack on them individually, this fact has inevitably meant a lack of continuity.
I think it was unfortunate that there was no opportunity for the medical profession in the Health Service field to feel that it was part of an important developing service. In fact, that service has been relegated as something of a dead end. This is something which we must correct, and I am sure that my right hon. Friend is only too anxious to seek to correct it. We must seek to give the general practitioner and other workers in the Health Service a clearer view of the prospects 1231 ahead for the benefit of the whole country and of the contribution which they can make.
In most parts of the world our own peculiar system of general practice is not accepted. Perhaps this is one of the few countries left where we have general practice in this form. Specialisation is developing nearly everywhere in the world and, in most parts of it, it has wiped out what we consider to be a general practice. Let general practitioners beware that in their present form of pressure they do not themselves precipitate what I am sure they do not want, and what none of us wants—the ending of this peculiar and perhaps unique service. This they could very well do if they pressed their claims in too irrational a way.
Let us look at some of the problems which have emerged. I, like others who have spoken recently, have had some experience of this matter in the past. Of course, one can well understand this general feeling of dissatisfaction about their future expressed by the doctors, which I know my right hon. Friend is only too eager to put right and which I think can be put right, but, of course, as other hon. Members have said, they like most of us have been confused about the working of the methods of remuneration. The system which was devised, the pool system, with all its refinements, is an extremely complicated system.
But let us be fair. Whose responsibility is that? It is the general practitioners' professional representative body itself, the British Medical Association, which insisted, in early negotiations in the Health Service, that somethng of this form should be established, and many of the practitioners themselves have insisted upon this in the past. This is what some of us feel to be so illogical about the present situation.
I do not want to dwell unnecessarily on this, but, for example, there was the Danckwerts award, which I remember well because I was myself at the Ministry of Health at the time. One of the features of this package deal which was welcomed by the doctors because it involved a very substantial financial payment into the pool was the principle, which was accepted then, that the multiplier should be the number of doctors, the number of doctors serving the general 1232 public within the Service. This has now turned out unsatisfactorily for them, but though in fairly recent years it was the Ministry which made suggestions about altering this, suggesting that the multiplier should be the number of patients, the number of those the doctors were serving, which would have been much more beneficial to the doctors, this proposal was turned down.
As one goes through the history of this it is astonishing to see that on almost every occasion when benefits would have accrued to the doctors it was their own representative organisation which tended to be on the other side, tended to oppose the proposals. For example, let us take the whole question of practice expenses. It is now, I understand, agreed by the joint committee, in making representations to the Review Body, and in discussions with the Ministry, that there should be some way of dealing separately with practice expenses. My right hon. Friend has outlined the absurdity of the present position, but the Ministry is not responsible for that absurd position, the absurdity that where a doctor does his best to improve the standard of his services he is likely to receive a smaller, not a greater, amount. Obviously this is a gross injustice. This was raised when the Royal Commission sat and heard the evidence, and, amazing as this may be, it was indeed the B.M.A. which insisted that it wanted to retain this system of including practice expenses within the pool. It is only during the last year or two that, one understands, it has in direct negotiations with the Ministry now agreed that some other, more sensible, measure should be adopted.
I find it, therefore, quite absurd, that the British Medical Association should now be attempting to load coals of fire upon my right hon. Friend's head for something which it has in the past largely been responsible in arranging. For this, in fact, is the truth.
Again, look at the point, mentioned by several speakers, and very properly, of the increased load on doctors, which we appreciate, because of the reduced total number of practitioners as against the number of patients. This is true. It is the relative increase in the number of doctors compared with the much greater increase in the population. That has happened; but then, if one looks back 1233 a little way, and it is not all that far past, one sees it was the medical profession itself which insisted upon the Ministry setting up the Willink Committee, which, of all things, recommended a reduction of entry into the medical profession. It was that Committee. Many of us objected to the Willink Committee's recommendation of that temporary 10 per cent. cut in entry to the training colleges at the time. Many of us thought it was an absurd suggestion, but the Government of the day—my right hon. Friend has not a scrap of responsibility for that—accepted it, temporarily—I agree they would not boast of it now—and aggravated the problem which faces the doctors.
I appreciate that difficulty. I appreciate the problem that doctors are having to serve rather more patients, overall. This is something we should take account of, but then let us fairly look at the responsibility for this, to try to make sure we do not make decisions of this kind in the future. I appreciate that we had these difficulties in the negotiations with the medical profession, and I am merely saying now that it is really time when on both sides—for this is not really a party political matter necessarily at all—we invited both the Ministry and the profession to look seriously at the exciting prospect which there is still for the general practitioner in the future.
As I see it, we can really devote some of the energy which has been displayed in the past in rather unnecessary namecalling to the point of how we can best improve the quality of the service for the benefit of the doctors themselves, and of their patients, because that is, after all, what we are concerned about: not only the doctors but the people they serve; it is the standard of the service we are really concerned about. Should we not now devote our attention to that matter of how best to improve the quality of the service? There we surely have a number of important suggestions which could be made, including the need today, I would have thought, to accept the fact that if we want the highest quality and standard of service we must think in terms of doctors working together in groups, and making the fullest possible use of ancillary help, as, increasingly, they are undoubtedly doing, such as that of health visitors, nurses, and, indeed, welfare staff. 1234 With this aid there is no doubt that a great deal of their problem could be very much eased.
Of course, in the long term we must tackle what we have delayed far too long, the speeding up of entry of students into the medical profession, increasing the size of our existing medical colleges and, indeed, providing new medical colleges. I am thinking of some perhaps quite revolutionary ways of training doctors in future, looking at the way in which doctors are trained, to make sure that general practice is not regarded as a blank end, so that doctors in training should not be encouraged to think of it as a blank end but as an exciting and valuable prospect. These are possible, practical things which can be done.
As a sideline, I would suggest that we should not rule out the possibility of the Ministry itself providing premises for group practice in suitable areas, and, indeed, although this requires an alteration of the Act, offering full and adequate salaries to those willing to serve and taking part in such centres. This could be done by the initiative of the Ministry as part of the negotiations with the medical profession.
I only mean that there are exciting prospects ahead, in which we can combine for the benefit of everybody. And is it not high time we got down to this? Here we have a Minister who is, I believe, only too eager to undertake this job and to work with the general practitioners. I feel that the issues which they have raised are utterly irrelevant in fact to the big and exciting problems which, I very much hope, they and my right hon. Friend will join together to tackle.
§ 5.50 p.m.
§ Mr. Frederic Harris (Croydon, North-West)
Many of us were interested to see the hon. Member for South Shields (Mr. Blenkinsop) back in the House, and we appreciate that he speaks with considerable knowledge of the past. As time is limited, I shall not follow the tone of what he said, save to comment that I do not agree with his view of the tone of the Minister's speech.
The Minister complimented my right hon. Friend the Member for Bridlington (Mr. Wood) on the modest way in which 1235 he made his remarks. I agree with the Minister on that, but I doubted—and I say this quite frankly, because I have respect for him and I listened carefully to the polite way in which, as always, he made his points—whether the Minister's speech helped the atmosphere at all. I found his speech rather dictatorial—[HON. MEMBERS: "Nonsense."] Yes, definitely. It made me feel that if there were a number of people who were finding things disturbing and they were addressed with that kind of speech, they would not be prepared to calm down very easily. It is essential for us all, as far as possible, to create the kind of atmosphere which will do away with misunderstanding.
§ Dr. David Kerr (Wandsworth, Central)
In view of the hon. Gentleman's repeated accusations that the Minister was abusive to doctors, would he be kind enough to specify the particular complaint that he has about the Minister?
§ Mr. Harris
I did not say that the Minister was abusive to doctors at all. I said that he did not help to create the atmosphere which is so essential at the moment to lead us to a reasonable settlement of this unfortunate dispute which may become very serious in the long run.
As the Minister knows, I am one of three Members privileged to represent Croydon. It has a population of 250,000, and, on 1st April, because of the reorganisation of Greater London, will have a population of about one-third of a million. I might, therefore, claim that the views which emerge from Croydon invariably represent the sound views of the commonsense people of the nation.
§ Mr. Harris
That is true, and the hon. Gentleman ought to know that what I have said is correct.
We are discussing the manning of the Health Service, and because of the present impasse with the doctors, I must tell the Minister that the doctors from Croydon have reached boiling point. Their feelings are very strong indeed. The Minister referred to letters in the Press, but he did not mention the communication which appeared in the Daily 1236 Telegraph on 1st February, signed by 24 Croydon doctors, in which they set out their concern about events within the Service. This letter did not deal solely with their own personal remunerations. It dealt with many other aspects, some of which the Minister touched on in his speech this afternoon.
General practitioners are a vital element of our National Health Service. This applies to other branches of the Service, too, but, as we know, it would be impossible to run the Service without the doctors. This is a fact which we as Members of this House have to face in the present situation. I am the first to appreciate, of course, that if a large number of doctors withdrew from the Service because of the present dispute there would still be quite a number who would carry on, but at the moment G.P.s are under extreme pressure of work, and it is therefore not realistic to think that a smaller number could keep the Service solvent. The attitude of mind of the Croydon doctors at the moment is symptomatic of the rest of the country, and nothing but ill can come out of the present situation unless it is quickly resolved, and I ask the Minister to consider this as a matter of urgency—[Interruption.] I listened to the Minister. I ask hon. Gentlemen opposite to listen to what I have to say.
We are now faced with the threat of mass resignations by G.P.s who consider that the dispute is due to the considered breaking of a promise, not only by the present Minister, but by previous ones, too. As my right hon. Friend the Member for Thirsk and Malton (Mr. Turton) said, the doctors were given an assurance that no scheme would be imposed on them involving conditions set upon awards recommended by the Review Body. The doctors consider that this promise has been broken by the present Minister.
§ Mr. K. Robinson
Perhaps the hon. Gentleman would be kind enough to repeat the assurance which he says was given to the doctors.
§ Mr. Harris
The assurance was that no scheme would be imposed on them involving conditions set upon pay awards recommended by the Review Body.
§ Mr. K. Robinson
At no time has any such assurance been asked for or demanded of me or my predecessors. The assurance to which the profession refers concerns a particular scheme for direct payments for ancillary help. The assurance was that this would not be imposed on the profession against its wishes.
§ Mr. Harris
That illustrates the confusion which exists, because I assure the Minister that what I have said represents the view of the bulk of the Croydon doctors. After all, Dr. Cameron is also a Croydon doctor.
If the G.P.s go ahead with their three months' notice to the Minister of Health, it will mean that the Government will not have answered the strong complaints of the profession, and the Ministry will be faced with a critical situation. The Ministry could not provide a satisfactory service simply by mobilising other doctors from the Service or by attempting to use the already overcrowded outpatient facilities. Such a situation is, of course, quite unthinkable.
We must all recognise that at the moment there is a serious shortage of medical manpower. I submit that in the long term this can be remedied by increasing the number of medical schools, and by increasing the number of places in the existing ones. In the short term, one practical remedy is to stop the tide of emigration which at the moment is averaging 400 doctors a year. This can be stemmed by making conditions much more attractive for them. After all, 400 doctors represent a quarter of the annual output from our medical schools.
§ Mr. Lubbock
Is the figure of 400 gross or net? Does it take into account the fact that many of these doctors come back after serving overseas for a period?
§ Mr. Harris
I appreciate that, but I understand that at the moment 25 per cent. of the doctors who come out of our medical schools go overseas. This is a high percentage, and obviously these doctors are leaving because they consider the profession here to be not as attractive as they would wish it to be.
§ Dr. David Kerr
Can the hon. Gentleman say what percentage of doctors emigrated in 1935, 1945, and 1955 respectively?
§ Mr. Harris
As Ministers say, without notice I cannot possibly answer that question. The hon. Gentleman is a doctor, and no doubt he knows the answer. The Minister could easily answer the question. All that I claim is that at present the country cannot afford this drain upon its newly-qualified doctors. Our population is increasing at a time when the number of doctors is decreasing and the viability of the National Health Service is at stake.
Only this morning I was advised of a questionnaire sent out to Croydon doctors before the findings of the Review Body were known. It contained a question asking them whether they would encourage their children to enter general practice as it is today. Out of 70 doctors only 10 said "Yes". In answer to another question whether they would actively discourage their children from entering the profession 42 out of 71 said Yes", which again regrettably confirms the strong feelings which they hold about the present situation within the National Health Service. In my view their feelings are symptomatic of the feelings of doctors in the rest of the country.
§ Mr. Harris
This is not a matter that can be treated lightly. Where are the recruits to come from in the future? Furthermore, Croydon hospitals are undermanned, especially among the junior staff, and particularly in the registrar grades, who provide the consultants for the future. This aspect of the problem needs careful watching.
On 4th June last I raised the question of nurses' remuneration, for nurses are also an essential part of the National Health Service. It is all very well to maintain that we can get nurses to volunteer on the basis of vocation, but there is a competitive demand for the service of girls today—so much so that this is just not on, especially to the extent of recruiting the great number of nurses which the Service requires today.
Let us consider the extent to which we depend on nurses from overseas. Contrary to what the Minister said, there 1239 is no doubt that the aboltion of prescription charges, coming at the time it did, when the doctors' legitimate complaints were not being met, acted as a red rag to a bull for the doctors. This added, and will continue to add, to their already heavy burdens.
Like other hon. Members, I have a heavy postbag. I interview people every week and have plenty of meetings. Yet in all the years that I have done this I have never had a specific request for the removal of prescription charges. I am sure that many other hon. Members, if they are sincere, will know that that is an absolutely correct statement. On the other hand, my attention has often been drawn to our considerably overworked doctors. The action of the Government in removing prescription charges when they did was without question done to gain more political support, but it also aggravated what was an already difficult situation.
As long as we take care of people who cannot afford to pay—and this can always be done by reimbursement, when applicable—nominal charges in the National Health Service are quite justified, because human nature is such that people never completely appreciate something that is given for nothing. They respond much more if some charge is made, however small.
The Labour Party seems to be determined that everything shall be free for the people, but this always leads to flagrant abuse, even from people coming here from overseas. Who suffers in the end? The public. Because of this it is deprived of the best National Health Service that can be provided. This question of charging or not charging is of vital importance. It should be kept in proper perspective, and viewed against the necessity adequately to remunerate for their contribution those who are an integral part of the Service, such as doctors and nurses.
In my opinion it is almost impossible for everything to run satisfactorily on a completely free basis. There is no bottomless pit in the Treasury to draw upon, and from which to pay for everything. Contributions, in one form or another, are essential. Many Socialists are now trying to bring to an end the practice—and only a very small percentage of people are involved—whereby 1240 people who are prepared to do so can pay for private hospital beds. This is a negative approach. It will not help to solve the problems of the Service.
In view of the unfortunate impasse that has now arisen between the Minister and the doctors, I ask him to take a new and considered look at the present Service and to aim at creating a fresh, efficient and harmonious pattern in the family medical care services of this country. As my right hon. Friend the Member for Thirsk and Malton said, this is a matter which should transcend party politics.
§ 6.6 p.m.
§ Mr. Laurence Pavitt (Willesden, West)
About the only thing that I agreed with in the contribution which we have just heard from the hon. Member for Croydon, North-West (Mr. Frederic Harris) was his remark that the doctors in Croydon are in some state of confusion. If it is of any consolation to him I can assure him that a lot of other doctors are equally confused. The main point I want to make about what I considered to be his unhelpful speech is that he should look a little more closely at what my right hon. Friend said and what his right hon. Friend the Member for Bridlington (Mr. Wood) said, because, in my view, both those speeches did something to create the right kind of atmosphere. I wish that I could say that same thing about the hon. Member's speech.
§ Mr. Frederic Harris
Is it a problem for the hon. Gentleman that perhaps I was too realistic in my remarks?
§ Mr. Pavitt
I realise that many other hon. Members wish to speak, and although I would dearly love to be able to debate, point by point, the number of misconceptions under which the hon. Member seems to be suffering, I must go on to make my own speech. Hon. Members on both sides of the House realise that medical manpower embraces medical womanpower, and that we are discussing other things than general practitioners, although that will be the main burden of my comments.
The House must face the fact that although we are discussing manpower within the National Health Service, the basic problem with which we are grappling is within the realm of incomes 1241 policy, because there is developing a wide discrepancy between the way in which we are rewarding people in commerce or production as compared with those who provide services like doctors, nurses, physiotherapists, radiographers and so on. That question goes wider than the debate, but it is basic to the problems which my right hon. Friend is having to tackle. In the Health Service there is a shortage of manpower in many sectors, not least with the professions supplementary to medicine.
For example, in 1955 there were 3,907 physiotherapists. Seven years later the number had risen by exactly five, to 3,912. The House probably recognises that in connection with these ancillary sources of service within the National Health Service my right hon. Friend faces a considerable problem. Fortunately, I have every confidence that he will be able to tackle it. What happens in hospitals is that after we train radiographers they leave because of inadequate pay. They are employed by private contractors who send them back and we have to pay the contractors three times the amount we would have paid to retain their services. This kind of thing will not be solved in 100 or 200 days, but I am grateful that the Government are aware of the situation and are seeking to do something about it.
The hon. Member for Croydon, North-West made some comments about nurses. I am most grateful for the fact that in the hospitals in my area, the Central Middlesex Group out of 828 nurses no fewer than 278 are Commonwealth immigrants. Without them our services would not be able to continue. In the light of the overall extreme difficulties of manpower, the hon. Member for Croydon, North-West and many other hon. Members are guilty of short-cut thinking when they say that prescription charges are an alternative to the question of whether or not doctors should get more pay. There is no analogy here. In a service spending £1,000 million a year one could find many sectors where a saving might be used to vend elsewhere as well. One could also say that for every doctor £112 per annum is spent by the drug companies on sales promotion for which we the taxpayers ultimately pay. There is also a good deal of advertising of 1242 medicines and drugs, for which we also pay. We might seek to get these and other kinds of expenses cut, and the saving diverted to doctors' pay.
In my view, the redemption of the pledge on the abolition of the prescription charges was in health matters the absolute No. 1 priority. This was a situation in which the sick had to pay the most; the more sick one was, the more one had to pay. If one was over 65 or under 5, one went twice as often to the G.P. and had to pay twice as much. If one lived in South Wales one had to go three times as often as one had if one lived in Surrey, and therefore had to pay three times as much. On sheer grounds of equity, this was the right priority. It was also right in order to ensure that the G.P. gave his patients an early diagnosis and prevented them having to go to hospital so often and thus presenting the nation with a heavy hospital bill. Any financial barrier between patient and doctor is wrong.
Nevertheless, in spite of the fact that we have reached a climax as far as the general practitioners are concerned—this has been sparked off by the recent pay award—I think that the House should give credit to the Government for the speed with which they accepted this pay award. They received it on 25th January, and by 8th February the Prime Minister was making the acceptance plain here in the House. When we look at the record of previous Administrations in dealing with doctors' pay, we see that a claim for a 24 per cent. increase in June, 1956, lasted a year until the Royal Commission was appointed in March, 1957. It was three years later—though there was an interim award—before that Commission finally reported, in February, 1960. The Government accepted it three months later, in April. Two years then went by before the review body was established.
I think that in all fairness it should be said that the doctors' pay claim in 1963 was for 14 per cent. I asked the right hon. Gentleman who was then Prime Minister, Mr. Harold Macmillan, how he reconciled this 14 per cent. with the guiding light maximum, laid down by the Chancellor of the Exchequer, of 3½ per cent. He told me to divide the pay claim by three as it would have to last until 1966. Yet already, before the 1243 end of that time, we have another increase, which the Government are prepared to accept.
I cannot see that my right hon. Friend the Minister has any other option when the doctors have insisted that their claims should be taken out of politics. When there is a Review Body, he can only do one of two things—accept its findings or reject them, and if the doctors are not satisfied with the review body award of £5½ million, they have the same option. My right hon. Friend has made equally clear today that if they decide to reject it, that is all very well, but at least they have a considered offer of £5½ million. This is a considerable increase for some of them—though not for all—which I think they could quite well accept and still continue their further negotiations for alteration in the Service.
I accept the proposition which has emerged from any speeches in this debate that the central pool is no longer the best method of paying general practitioners. This was forced on the Government as was pointed out by my hon. Friend the Member for South Shields (Mr. Blenkinsop), who was involved much more in those days. This idea of a doctor being a private entrepreneur under contract was the doctors' idea. The Government of the day accepted that this had to be done. The central pool today is no longer relevant to the conditions of practice today. It is not only we who find it difficult to understand; there are 99 doctors out of 100 who have not a clue how their pay is made up. Any system where there is no communication or understanding of its working must be a bad system, so it is time that we relinquished this idea.
I hope that, as a result of negotiations, it may be possible to have a two-tier system in general practice, under which doctors who insist on the capitation plan can keep it, but new doctors coming in can be offered the kind of rights which a hospital doctor, including a consultant, gets. The consultant has a set salary and he knows, if he is away, that a locum will be provided. The new doctor should enjoy precisely the same kind of contractual relationship as the consultant does. I think that the feeling of the general practitioner is that there is no such animal as the average general prac- 1244 titioner. When he sees an amount referred to as the average amount received by a doctor, it bears no relation to the facts as he knows them. He does not know that there are 10 separate payments which are included in the "average" whether or not that general practitioner has access to that sector of income.
I think that the question of the central pool is one which, inevitably, whatever is the outcome of the present crisis, must be negotiated afresh and some method of payment which is more logical and which is more easily seen to be just should be given to the general practitioners. One of the anomalies which the layman has difficulty in understanding is that we pay on the per capita basis for more patients than there are in the population. In 1963, there were 451,000 more patients than there were in the population; the difference had gone up to 528,000 in 1963; it went up to 640,000 in 1964. In other words, there are over half a million floating patients. Some of them must be on two doctors' lists at the same time, and there must be an element of unfairness in this.
I was interested in the point raised by the hon. Member for Croydon, North-West about differentials. I am afraid that all doctors are qualified, but some are more qualified than others. A consultant at his peak with an A award gets £8,995, a senior registrar who may do appendectomies and a number of important operations gets £2,050 after four years. In a borough about the size of Croydon, with 200,000 inhabitants, a Medical Officer of Health gets £3,070, with a maximum of £4,170. But the average general practitioner gets £4,215 gross, out of which he has to pay for his car and his laundry and anything else. After all his payments, he gets about £2,765.
It is not for us to lay down how the pattern of payment shall go, but I am certain that the key rests in organisation. With an inevitable shortage of manpower for the next seven years, the only way in which general practice can make sense is as a team job. Instead of giving lip-service to the G.P. as the leader of a social welfare team we should make it a reality by the organisational methods which are needed. A doctor should work with receptionists, midwives—if he is engaged on obstetrics—social workers, 1245 psychiatric social workers, if he aeals with people who are emotionally upset, and all the other people who are needed to make this a team job. I suggest that if the doctors and the Ministry would combine to make general practice a greatly improved service, it would be much easier to find the answer to the pay problem.
It is absolute nonsense to talk of a doctor working 365 days a year and 24 hours a day without time off. He cannot do it. There is at the moment no feasible and organised modern way of catering for him when he wants time off. I notice that in London, out of 2,237 G.P.s there are 1,305 who have contracted out of their evening and weekend work by deputy service, emergency night calls and that sort of thing. Has the Minister considered this? If a doctor contracts out from, say, 5.30 p.m. one evening until 8 o'clock the next morning and from 12 o'clock on Saturday until the Monday morning, should he then get a reduction in the amount we pay? I think that the Minister could save money by paying the annual fee of a G.P. to the Emergency Night Call Service—about 100 odd guineas—and then deducting a pro rata hourly rate for the time the G.P. no longer contracts to give. The doctors cannot have it both ways. They should he prepared to work in a reorganised system with all kinds of modern methods using equipment and personnel to provide coverage for patients.
I echo the words of my right hon. Friend and, if I may, I will extend his metaphor a little. He talked about doctors trying to rush through an open door. I am worried about whether, in order to do so, they are using the patient as a battering ram and that when they get through the door the patient may find himself flat on his back and in need of their aid. As has been shown by speeches from both sides of the House, and especially by the right hon. Member for Bridlington, there is much good will here, in the Ministry and among patients who are grateful to general practitioners. We must avoid the situation where this becomes some kind of a contest, a battle, where doctors score off a wicked Socialist Minister or the Minister scores off the obstinate doctors. We must see what we can get from this struggle, and secure the kind of service that we want for the 1246 patient. It is the patient, after all, who is the important factor.
In my view the only way we shall begin to move from a purely curative service to preventing people from becoming ill is by keeping the general practitioner right in the centre of medical activities. In order that this may be done, there must be proper organisation, and I hope that my right hon. Friend will secure the support of hon. Members on both sides of the House in his efforts to provide it.
§ 6.21 p.m.
§ Sir Richard Thompson (Croydon, South)
It was inevitable and predictable, in the circumstances in which this debate is taking place, that the gravamen of the Minister's speech should be the regrettable impasse which has been reached, or looks like being reached, in relation to the family doctor. I welcome some of the things which the Minister had to say, particularly what he said about keeping the door open for further negotiations. He must recognise as clearly as anybody else that the first priority among the great responsibilities which he has assumed is the need to tackle the question of the general practitioner service which, for most of us, represents the medical care which we need in the course of our lifetime. Thousands of people go through their lives without entering the portals of a hospital but practically none go through even a single year without having cause to call at a doctor's surgery or have the doctor come to their house.
In the innumerable health debates at which I have been present in this House during the last 10 or 15 years we have said that the family doctor is either the cornerstone or the Cinderella of the National Health Service. Whichever description may be true—perhaps both are true—I am sure that now we have reached the stage where we must try to do something effective to reform the conditions—I refer particularly to financial conditions—under which the general practitioner works. I do not believe that a succession of pay awards, which might have had a better reception in the profession, strikes at the fundamental question. I was glad that the Minister and my right hon. Friend the Member for Bridlington (Mr. Wood) recognised that, basically, this problem was not necessarily wholly one of finance.
1247 There is a sort of malaise in the profession which appears to be deep-seated. The question of professional status, or the apparent whittling down of the status of the general practitioner, helps to make apparent the presence of a "chip" on his shoulder. I think that the general practitioner is one who would be very reluctant to match the militancy of the "big battalions" when trying to secure better conditions for himself. He feels that he is being edged more and more into an attitude of militancy by what seems to me to be a pay structure which does not really apply the rewards in the right places. This malaise is something which is serious for the future of the profession.
I quote figures with reluctance because some have been quoted already and almost all have been challenged, but my information regarding recruitment and wastage is that although on paper there is a substantial surplus of new doctors every year over those leaving the Service, dying or emigrating, nevertheless the lines on the graph are converging uncomfortably closely and the numerical surplus which appears to exist is not as real as it seems. The reasons for this are the number of doctors who emigrate—I believe that emigration is at a pretty high level—and the fact that there are a number of foreign and Commonwealth doctors who acquire their qualifications in this country, and who work here for a time, but do not necessarily stay here. There is a considerable number of women doctors and many are lost to medicine because they get married, or cease to practise for some other reason, and all this must be set against a background of a population increase.
What can we do to stop the rot and restore the confidence of the general practitioner in his great profession? I am sure that the restoration of confidence in his future and his status in society is just as important for the general practitioner as the mechanics of a particular pay award. The Minister has said that doctors need not fling themselves at the door of his Ministry because that door is wide open. I do not think that such a statement can be made too often or too loudly. I have been appalled during this impasse by the apparent gap between the vast majority of general practitioners and their leaders. It occurs to me that the doctors and their leaders do not always 1248 talk the same language. I do not seek to apportion blame. I do not know who or what has gone wrong, but it seems fantastic that quite recently the British Medical Association should have said certain things while a large number of doctors apparently believed quite different things. There is an internal job of reorganisation to be done so that doctors may feel that the body which represents them is talking in a manner which represents what doctors think and feel. There appears to be a need for a meeting of minds. Some of the decisions of the British Medical Association have caused genuine anxiety and concern to doctors, and that does not seem to me to help the situation.
I am sure that one of the central matters in our discussions—many speakers have mentioned it—must be the need to use our ingenuity, or at least for the Minister and his advisers to do so, in conjunction with the doctors, to devise a better system than the present central pool with its capitation fee. It was interesting to note that the Minister spelt out how it works as simply as he could, for the benefit of many hon. Members who are not fully conversant with the details of that complicated structure. I am quite certain that this kind of information is not appreciated by large sections of the medical profession.
A system which is so hard to explain to the people who are operating under it, and which causes so much misconception about the expenses allowable and so on, is a system which cannot work well. If it is so complicated to define we should not worry very much about who started it, who wanted it or who insisted on having it. It all happened many years ago and the passage of time has shown that it is too cumbrous to fulfil the job it was designed to do.
Once we accept that, without bothering about saying "You wanted it" or "You would not change it", the Minister's task of sitting down at the table with representatives of the profession and saying, "We are all agreed that the present deal does not work, so let us get down to one that does", will be greatly simplified.
Both the Minister and my right hon. Friend the Member for Bridlington were right to pick out the disadvantages of the scheme. It is, shortly, a system which 1249 gives precious few incentives to good medicine and implies no penalties for slack or inefficient medicine. That is at the bottom of a great deal of the general practitioners' complaints. A conscientious doctor soon finds that he is being overworked, which is of no financial advantage to him. The only way to increase his remuneration is to take on more patients, but he conscientiously knows that he cannot give them good service. If, as a good doctor, he does not take on more patients, his practice remains at the same size and he gets no benefit from the extra fees he would otherwise have had.
Conversely, a doctor who thinks that he must reduce his list of patients if he is to serve them properly is in the difficulty that, if he does, he receives much less money for being conscientious. Equally, there are doctors who are prepared to take on more patients than they are able to manage because that means a better financial deal for them, although they probably know that they are unable to look after them all as well as they should.
We must, in these circumstances, find a new basis for remuneration. There is always the alternative, which I do not support—I know that some hon. Members would plump for it; although I do not think that the profession as a whole would support it—of a full salaried service. I reject this idea. Most members of the profession would reject it and I feel that there must be a middle way between the rather chaotic situation we have got into and the full salaried service which some would advocate as the best alternative.
For the immediate future I suggest that the profession has everything to gain and nothing to lose by announcing its acceptance of an award which, after all, is the finding of a body which it wished to set up. which was set up with its agreement and to which the whole of this matter was referred. The profession need not regard that as the end of the day, but it would be wise for it to accept the award and to say, "Having done that, we are now really going to have a go at the Minister and settle among ourselves what we consider is a viable way of preserving a doctor's clinical independence in future, coupled with a more rational distribution of the 1250 available public money for this kind of service". I hope that the profession will do this and say, "Now we will sit down at the table with the Minister and hammer out a better scheme". If that could be done, not in an attitude of bitterness and recrimination—the sort of situation which has suddenly boiled over, for reasons I can well understand—I am sure that only good would follow.
Many doctors have written to me in recent years saying that they regard themselves as Cinderellas—as the forgotten people. If they can approach this matter in a reasonable atmosphere I believe that today's debate, and the crisis which has forced us all to take cognisance of these difficulties, will not have been wholly in vain. It may, in the end, lead to a much better situation for medicine and patients.
§ 6.35 p.m.
§ Mr. A. Woodburn (Clackmannan and East Stirlingshire)
I apologise to the House for not being in my place during the speech of the right hon. Gentleman the Member for Bridlington (Mr. Wood). I was called out of the Chamber by a constituent who thought that I could be of some help in regard to a contract worth some millions of £s which he hopes to get from abroad. I could hardly have refused him.
What I have heard of the debate has been extremely interesting, and I was glad that my right hon. Friend the Minister of Health made it clear to the medical profession what this is all about. I agree with the hon. Members for Croydon, South (Sir R. Thompson) that the great majority of doctors have not been keeping in contact with the political arguments of their leaders or even with the negotiations. As a result, this has all come to them rather like a bolt out of the blue and they do not know what it is all about.
It is in these circumstances that they have become misinformed and have got the impression that the Minister has done something to them, whereas he has merely been carrying out a pledge. As a doctor wrote in the Daily Telegraph the other day, after insisting on the Review Body doing this job, it is a breach of honour that the medical profession should not accept its findings. I have not quoted the exact words used, 1251 but certainly the other complaints are matters for negotation with the Minister and should not be hinged to the Review Body's decision.
I agree with the right hon. Member for Thirsk and Malton (Mr. Turton) that the difficulties we are discussing should not become matters of political cricket. The hon. Member for Croydon, North-West (Mr. Frederick Harris), after also agreeing with this view, proceeded to introduce his own King Charles' head—prescription charges. They have nothing to do with the matter under discussion, and even the medical profession has been misled on the prescription charges issue.
People have had free prescriptions since 1912. They continued to have them right up to the introduction of the National Health Scheme. We never heard anything about abuses during the years of the National Insurance Scheme, and I never myself used to pay for prescriptions at any time. I did not find that doctors either abused their position, or their patients; this whole business of so called abuse is a completely new idea. Doctors are entitled to prescribe as they always have, according to the needs of their patients. Women and children were not included in the old National Insurance Scheme because to have included them would have made the scheme too expensive. It was cheaper to restrict it to the wage-earner and leave the women and children to depend on charity and wait in the long queues at hospitals.
When the National Health Service was introduced women and children were included so that they would receive full medical care—to which they should have been entitled all along. It should be recalled that throughout the country women went to their graves prematurely, because, to save the family budget, they would not go to the doctor. When the National Health Scheme was being drawn up every doctor said that one of the great calamities was that women and children, and there were others, were not going to the doctor at the first sign of illness. In many cases they waited until the disease had gone so far that it was incurable.
When we introduced the National Health Scheme we insisted that every person should be able to go to the doctor at the first sign of illness. Now we are 1252 told that people should indulge in self-medication. "They must rub themselves with boracic ointment"—until the disease has gone too far—we are told. Time and again we hear that people should not go to see their doctors with frivolous complaints, but how does the average patient know whether or not his or her complaint is a frivolous one? Either people should go to their doctors before they become too ill or they will delay until it is too late. Surely it is much better for the doctor to have the happiness of telling a patient there is nothing wrong with him than it is to find that the patient has waited until he cannot be cured at all. The doctor gets satisfaction from helping and curing his patients. Fortunately, most doctors take that view, and only a minority of them grumble.
The prescription charge was introduced, first, as a contribution to the Health Service and, as such, Is. a prescription might have been justified. Then, because a Tory women's conference wanted free prescriptions for private patients, the charge was raised to 1s. per item, and then to 2s. per item, which debarred old people and many people with families from getting their prescriptions.
The hon. Member for Croydon, North-West said that the old people could recover the charge, but in many cases they had to pay nearly as much in bus fares to go to the National Assistance office. If he knows them, he must know that many of them would never go through all the rigmarole. The Conservatives knew it, and knew that money would thus be saved. Some of these people would rather starve or do without some of their medicines. One pharmacist told me that the old people used to come to him every week and ask him, "What can I do without on this prescription?" He then had to telephone the doctor to get that information.
Did the doctor put on the prescription something that the old person did not need? If not, was there any reason why that old person should not get what was prescribed? Why should old people be humiliated in order to get a repayment from the National Assistance? I am sure that the hon. Lady the Member for Tynemouth (Dame Irene Ward) would not agree that they should go through such an ordeal to get their medicine, because I know that she fought for women to get these services.
1253 It was a bit of meanness, and of political meanness, just as is this talk of foreigners getting free medicine. I remember that long before the Health Service existed, the Royal Infirmary at Edinburgh, and infirmaries elsewhere, gave free service to everyone, whether they came from Timbuctoo or anywhere else. Now that the nation has taken over the job, it seems that we are supposed to be meaner than were the charitable institutions of those days. People can pay if they want to. In fact, they do pay—the bigger their income the more they pay through Income Tax. When the next Budget is presented perhaps hon. Gentlemen opposite will remember that those who have most already pay their contributions to the National Health Service.
I was one of the two Ministers involved when the Service was introduced, and I remember that the doctors insisted that there must be no obstacle between patient and doctor; that nothing must prevent the doctor from prescribing what the patient needed. Anything that breaks that rule is a crime against the health of those who are not prepared to go through all sorts of circumlocution departments to get repayment. There is no justification for interfering between patient end doctor. If a patient goes to hospital no one ever dreams that he should save a means test before the doctor or a nurse can give him his medicine every day. To think otherwise is nonsense.
The hon. Member has introduced politics into this and would like doctors to believe that hordes of patients will turn up for free medicine. That reminds me of the Scotsman who looked into the chemist's shop window when there was a sale on and said, "What a pity there's no one ill at home". The idea that people want medicine just because they get it for nothing is nonsensical. If the hon. Member knew the effort it is for some people to sum up the courage to go to the doctor he would not say that, and if he were to look at Boots' counters he would recognise the number of people who still indulge in self-medication and he could reflect on how much how many people save the Health Service by doctoring themselves. I am sure that every hon. Member doctors himself most of the time, and Members of Parliament are just as economical as anyone else.
1254 I very much regret the way in which the doctors have reacted. I do not think that most of them mean to be irritable or that they resent this offer. Most of them do not know what it is all about, and when the Minister's statement gets round no one will be more surprised than many general practitioners. That was the case when the Health Service was introduced. The right hon. Member for Think and Malton (Mr. Turton) referred to the fact that I was engaged in those negotiations—hon. Members would not believe how difficult it was to get the doctors' representatives to consider how the Service was to work and the problems it would have to face. It nearly broke the hearts of Tom Johnston and Mr. Willink, as he then was.
We had more co-operation from the Scottish doctors, of course, but there were many prejudices. For instance, doctors would have nothing to do with local authorities and medical officers of health. They wanted to get themselves out on a limb. They would have nothing to do with that, and said that they had to be separate. In Scotland, for this reason the doctors were brought under the Secretary of State and not connected with local organisations.
In a way, they also separated themselves from the hospitals, because they did not negotiate in the same way as did the consultants. They never got down to practical terms. The consultants behaved quite differently—they got down to considering practical problems, and how the Service was to work in relation to hospitals. As a result, they got very good terms—in the minds of some general practitioners they got away with murder—and established themselves with all the facilities of the profession, with proper salaries, and a certain amount of liberty.
The doctors acted otherwise and were cut off from the hospitals and the local authorities. They have been left out on a limb and, as the hon. Member for Croydon, South (Sir R. Thompson) said, that has as much to do with the present problem as any question of salary. The G.P.s feel that they are outside; that they have no connection with the scientific side of the profession. Because many of them have no way of doing the tests in hospital that they used to do, or of dealing with their patients there more 1255 completely, they feel frustrated and irritated, but that situation has largely been brought about by the doctors themselves.
One of the cures is to reverse the process, and that has been done to some extent by group practices and by doctors associating themselves with hospitals, and in one or two cases we were able to build health centres. I know of two such health centres. In the bigger one, the one more fully equipped, the doctors simply use the rooms as consulting rooms and do practically no other work there at all. They make no real use of all the scientific facilities provided and act as individual doctors and do not co-operate much with each other. In the other, the doctors co-operate as they would in a group practice; they work in a scientific way and are much happier as a result.
Some group practices are unable to have all the necessary facilities, but in other cases the doctors build what is almost a small health centre. I remember offering as a prototype health centre a hospital in a small town which was just ideal for doctors to work in. It could accommodate the ideal number of doctors—six or seven—but the doctors refused to co-operate with each other. I have a suspicion that it was because one of them was a woman. They did not get the health centre. There is no way in which people can be forced to work with each other. One of the troubles is that so many doctors are individualists and believe in doing their own empire building.
One of the problems which has arisen and which causes much irritation in relation to capitation fees is that this empire-building makes doctors in some cases behave improperly to get more patients. A woman went to a doctor friend of mine and said that she wanted penicillin for a child of hers who was cutting his teeth. The doctor refused. The woman said, "If you do not prescribe it for me, I will go to the other doctor who will do it". The woman went to the chemist's next day and, sure enough, she had taken the whole of her family of five from my friend's list and the other doctor had prescribed penicillin for her child. No Government or Health Service can control such behaviour amongst doctors. If such competition continues, it is bound to lead to improper practices. No doubt in many 1256 cases patients are allowed to dictate their prescriptions. In some cases doctors are inclined to prescribe expensive prescriptions to show how much better they are than the doctor next door. This is wrong. Fortunately, only a small minority of doctors do this, but it causes mischief and irritation in the profession and gives rise to big lists.
One of the matters which irritates the private practitioner is the Review Body's recommendation about merit awards. I dare not repeat some of the strong comments some medical practitioners have made about what are called the prima donnas. There are the prima donnas among the consultants. What they get is a mystery to the ordinary doctor. Now doctors see the prima donnas system coming into force for general practitioners. They are absolutely furious to think that there are to be prima donnas among themselves. They naturally think that the body which does the negotiating will become the prima donnas.
The point is: how are the prima donnas to be selected? The general practitioner feels that he himself is so far away from these decisions that the money will go to the prima donnas and he will have nothing to do with it. This is just as irritating to the general practitioner as is the fact that, for example, apparently extra money is to go to those who employ secretaries.
The status of doctors is undoubtedly a very important matter. Much work has been taken away from the doctor. We hear about the doctor being overworked, but it should be borne in mind that he has been relieved of a tremendous amount of work. Much of his ante-natal and post-natal work has been taken over by local authorites. A great deal of geriatric work has been taken away from the general practitioner. This may to some extent have reduced the general practitioner's interest in his profession. It has certainly reduced his work.
Many doctors whom I know work too hard. It is ridiculous that doctors should have to work so hard. When I was Secretary of State I saw this for myself. I offered the practitioners to establish an office in each town to which their telephone calls could be transferred when they wanted to go out with their wives. This was a reasonable offer, because I know that doctors' wives have to sit by 1257 the telephone and that doctors and their wives can seldom go out together. This is a very human and important point. Nothing was done about my offer. It was not accepted because most doctors feared that if their patients' telephone calls were transferred to another office somehow or other those patients would drift on to another doctor's list.
So long as this kind of atmosphere exists, no progress can be made. There are lone scouts who insist on being on tap for 365 days a year, 24 hours a day, which is a physical impossibility. It is difficult to get things changed in the profession. In the hospitals young students on the wards are sometimes there for 36 or more hours, on duty all the time. If a lorry driver was found to have driven for more than 11 hours he would be put in gaol or certainly fined. A doctor is expected to be able to treat a patient after 36 hours without sleep.
What is the answer to this? The chiefs sly, "We did it when we were students". We are also told that the students like it and want to remain over the next day to report to their chief about what they have done. Could anything be more nonsensical in these modern days than that a man who is dealing with the most delicate machinery in the world—the human body—should have to work 36 or 40 hours at a stretch? No trade union would stand for it. But, instead of objecting to it, doctors seem to welcome and accept it. These are matters which should be examined. The whole National Health Service should be reviewed on the basis of all these experiences. Somehow or other we must get past the politicians on the negotiation body.
There is another handicap. There are two bodies. They are competing. If one body accepts the award without criticism, it will look soft compared with the other body. So there are rival bodies to prove that each one is the more militant on behalf of the doctors. This makes it still more complicated for the Minister to get any satisfactory acceptance on a reasonable basis.
Above all, the negotiating bodies are not in touch with the ordinary doctor in his profession. The ordinary doctor does not have time to go to committee meetings; he is too busy. He does not feel 1258 that he is interested in the political side. Therefore, a very few people, who may have no real appreciation of the feelings of their colleagues, decide these things and suddenly plunge the profession into a crisis, such as there is today.
I therefore hope that my right hon. Friend the Minister will not regard this doctors' revolt, as it is, as being a considered action by all doctors. It is a reaction against the surprise they received when this announcement was made, about which they had heard nothing or to which they had not paid attention until they suddenly found it on top of them. It is a very natural kick-back. They feel that they are having a raw deal. They see other people off on Saturdays and Sundays, working a five-day week, while they go on slogging and can get no time off.
It may be true that this is partly due to the fact that they will not make arrangements with the doctor next door. It may be true that it is partly their fault. But doctors are like the ladies. They are kittle cattle and not easy to handle. They do not necessarily follow logic in all these matters. They must be handled delicately. They must be persuaded. They have to be nursed a little. If any man went home and talked cold logic to his wife, the chances are that there would be a break-up of his home. It must be realised that doctors are a little like this. They are sensitive people who know nothing about politics. They are ignorant on any subjects except their own profession, in the main. They are so engrossed in their profession that it is very difficult to get their intelligence shifted on to any other topic.
I therefore hope that we shall try to bring about a new deal. This crisis may well be a blessing in disguise. It may be that this up-turn will make doctor's minds receptive to trying to get a new organisation of the Health Service. As I see it, the doctors should be connected with the hospitals. They should be connected with the medical officers of health. In my own constituency when they built a child clinic they built a doctors' consulting room attached to the clinic. This gets rid of some of the slum surgeries where people queued out of doors, where there was no lavatory and where there was no washing accommodation, for consultation in some old shop with a dirty 1259 blind which nearly made ill people even more ill to go near it. We want nice surgeries. It should be the responsibility, not of the doctor, but of the community, to provide such surgeries through the agency of the local authority. There should be surgeries and consulting rooms so attached. Already nurses are connected with the clinic. A whole lot of services are already laid on by the local authority. It is almost like a miniature health centre. This is one way of linking the doctors up with preventive medicine and with the medical officer of health.
Doctors must also be allowed to get into hospitals and be associated in the treatment of their patients. They want the opportunity to use their skills in a more widely diversified form. They do not want merely to be welfare officers who decide whether their patient should go to a hospital. They want to use their skills. Some way must be found of associating doctors with hospitals.
These are some points on status, which are much more important in the long run than salaries. I do not want to go into details on the dispute. The doctors now know that the Minister is willing to hear what they have to say and to sit down and consider a complete reorganisation of the Service. I hope that the doctors will now be in a mood, which they were not when the Service was formed, to think about the difficulties and consider the best way of solving them. Somebody—I do not mind whether it is the medical profession or not—should prepare a new scheme so that all these matters can be integrated and we can have a comprehensive scheme. But I hope hon. Members opposite will not introduce red herrings, like prescription charges and political prejudices, and thus interfere with the creation of a properly integrated scheme by which people may receive treatment according to their illness. No doctor would agree that people should receive treatment according to the contents of their pockets. People should be treated according to their illness, and the doctors should have the means to do it so far as their skill permits.
The National Health Service, with all its faults, is the greatest organisation of its kind in the world. Even the Americans realise that. President Truman sent one of his representatives to investigate it, 1260 and he said to me, "Mr. Woodburn, we should love to have a health service in America, but we cannot. Many people in America do not have the normal hygienic amenities and we envy you your Health Service, but we have not the basis on which to build one." I am sure that in spite of all the money that the American doctors earn, they do not get the satisfaction which our doctors in the National Health Service enjoy.
Stories about the emigration of doctors are a myth. Doctors have emigrated from this country for the last 50 years at least. If we saw the percentages of doctors who have emigrated from Scotland most of us would collapse, fearing that we had been left without a single doctor in the country. I am certain that ours is one of the best-served countries in the world, medically speaking—I certainly have no difficulty in finding a good doctor in Scotland—and we are proud of that fact. In the Highland medical service doctors travel hundreds of miles, rather like the flying doctor service operates in the Australian bush. This is not a matter of £. s. d. Let us give the profession the pride of doing the job according to its ability, and let us be proud of the Service.
§ 7.2 p.m.
§ Mr. Eric Lubbock (Orpington)
During part of his speech the right hon. Member for Clackmannan and East Stirlingshire (Mr. Woodburn) appeared to be attacking the doctors, and then he started on the women. To make an accusation about the whole of the profession and then to attack the fair sex on their illogicality comes ill from a politician, because I have always felt that politics was the most illogical of all professions.
I am glad that the Minister began his speech by referring to the recruitment of nurses. We should not lose sight of that situation merely because of the general practitioner crisis which faces us. I was pleased to hear that recruitment is going well, but I wonder whether the figures would look so rosy if they were set against the need for more nurses in our hospitals and the question of a reduction in working hours.
The Minister might be interested to hear that a front-page article in my local newspaper last week, the Orpington and Kentish Times, carried these headlines:Voluntary helpers kept hospital wards open. Acute shortage of nurses.1261 The article then said:Voluntary helpers, many of them housewives, have been called upon to work in a number of wards at Orpington Hospital because of an acute shortage of nurses. In the last month an unusually heavy crop of illness among the nurses coupled with the slow rate of recruiting new stag have caused such a difficult situation that the matron has sent out an urgent call for help to voluntary organisations in the district.I do not think Orpington is alone in this. We cannot view with equanimity a situation in which a 'flu epidemic or a sudden call on the number of beds in the acute wards of hospitals will create a crisis in which matrons have to send out S.O.Ss to voluntary organisations to make up the deficiency. I ask the Minister, when considering the recruitment of nurses, to bear in mind this important requirement for additional nurses to cover the reduction in working hours, which has not yet come into effect in many hospitals but which, when it does, will make the situation increasingly worse as time goes on.
There are many areas in the Health Service where there is a shortage of staff. I have a letter from the Secretary to the Orpington Mental Health Association stating that there is an acute shortage of psychiatric workers in the hospitals and local authority organisations. Coming back to the question of G.P.s, they are unable to cope with patients suffering from psychiatric disorders. Much more could be done by the recruitment of trained mental workers to relieve the work load on G.P.s.
I agree with the Minister's main thesis that he cannot negotiate with the profession under the threat of withdrawal from the Health Service at some unspecified date. I have told friends of mine in the profession that I thought it was unwise that this threat should have been made, and that they may regret it at some future date when there may be in office a Government who find the recommendations of the Review Body unacceptable for economic reasons. We do not have to go back many years when this happened with a Whitley Council award. I warned the doctors that this action would set an unfortunate precedent.
The Minister has made a useful gesture in his speech in saying that the door is always open and that he will be 1262 prepared to talk to the doctors. Doctors in my constituency have said that they want the discussions to proceed, and it the Minister is prepared to meet the profession this will go a long way towards alleviating some of their anxieties. They asked me to put it to him that he should seek a means of meeting the profession as a matter of urgency. In my view, the profession would be well advised to accept the recommendations of the Review Body and get together with the Minister as he has offered to do this afternoon.
There are several matters in the Review Body's Report which have been left open for discussion. These include the question of compensation for loss of practice goodwill, the calculation of the return on capital which is to be credited to the pool, and seniority or merit payments. I agree with the profession that it would be very difficult to devise any satisfactory system of merit awards. I think the Minister would be well advised to have another look at the question of seniority payments to G.P.s.
Another question left open by the Review Body's Report was the exact form of schemes for ancillary workers and practice premises. The Minister said that there were a number of misconceptions on the Review Body's recommendations, and this is one of the items to which that observation applies. I found it difficult to ascertain exactly what form this scheme would take. I have read through some letters that the Minister's predecessor wrote to Dr. Cameron last year, but they do not specify in detail how a doctor shall qualify for the payment of the contribution towards ancillary help. I was asked to find out from the Minister whether it would be possible for a scheme of part-timers to be considered. Many doctors employ married women to help and, of course, some employ their wives in this capacity. I think it would be unfair if the rules were drafted so as to exclude wives from qualifying for some of these reimbursements.
I agree with those who have stated that the real crux of this matter is the shortage of staff in the general medical service and that the ultimate answer is the building of new medical schools. This is something that we said in our Liberal election manifesto, as the Labour 1263 Party did. I notice that the Minister did not refer to this matter in his opening speech. Will he say what has happened about the promises made by the Labour Party during the election campaign? Were these promises not precise in stating how many new medical schools were to be built? I agree with those who say that the new universities which are projected give us an opportunity of taking this step.
The right hon. Gentleman talked about improving the conditions under which general practitioners work. This can be done only by reducing the size of their lists, and obviously that must depend on increasing the numbers coming out of medical schools. There are some minor ways in which the situation can be improved in the short term—measures to encourage married women to come back into the medical profession and perhaps experiments with health centres, which have never really got off the ground. There may be some areas where smaller hospitals closed under the ten-year plan would be suitable for health centres. Some experiments might be tried with these, even though it is generally accepted that, with general practices having grown up as they have, it would be impossible to impose the solution of health centres all over the country.
I deplore the way in which some people have tried to stir up this dispute between doctors and the Government for political ends. This can be most disastrous not only from the point of view of doctors themselves but that of the patients. They are the people who will suffer in the long run. Let us take the heat out of this argument. Let the Minister get round the table with the doctors, and let us discuss this question in a calm atmosphere in which sensible solutions may be reached.
§ 7.12 p.m.
§ Dr. Shirley Summerskill (Halifax)
I feel that I should state first of all that I am a medical practitioner and have been for four years and that before that I worked for a year in a hospital. But I am also speaking in this debate because as long ago as I can remember I have supported the National Health Service as a service to give the sick free treatment and impose no financial burden on people when they were ill.
1264 The debate so far has been extremely well mannered and cool. The right hon. Member for Thirsk and Malton (Mr. Turton) said that this was not a party issue. I think that Aneurin Bevan was right when he said that health is at the heart of politics, and this issue today of manning the Health Service cannot be divorced from politics. Ever since 1948 when the Health Service was established it has been a party issue. I am sure that many of my hon. Friends remember that hon. Members opposite opposed the introduction of the Health Service.
§ Dame Irene Ward (Tyneside)
If the hon. Lady will forgive me, I do not think that she needs to go into that, because what she has just said is nonsense.
§ Dr. Summerskill
I was not in the House at the time but I am sure that there must be some of my hon. Friends who were here who remember that the Conservative Party opposed in the Division Lobby the very setting up of the National Health Service.
§ Mr. Maurice Edelman (Coventry, North)
I was in the House and I can confirm, and it will be within the knowledge of hon. Members, that the Conservative Party voted against the Third Reading of the Bill.
§ Dr. Summerskill
I bring up past history because it pays hon. Members opposite to make health a very gentlemanly subject about which one does not have a great deal of argument. This has been their attitude to the Service over the last 13 years. We are today discussing a crisis in the manning of the Service which I believe has been brought about by 13 years of Conservative government. We are inheriting a situation in our hospitals, in general practice and in the local authority services which is the result of the complacency and neglect of hon. and right hon. Members opposite who formed the previous Government.
§ Dr. Wyndham Davies
Would the hon. Lady not agree that many reputable medical authorities would say that the troubles in the Service stemmed from its inception rather than from the last 13 years?
§ Dr. Summerskill
My hon. and right hon. Friends feel that with the right Government, right leadership and the right attitude towards it the Service can be made to work. In the few months in which we have been in power, and despite inheriting a severe economic crisis, we have brought in three major measures to try to resuscitate this Service which has been so neglected. We have kept our pledge and have found £22 million to relieve people from prescription charges. We have provided an extra £5 million for hospital buildings, and the Review Body is providing £51 million for the doctors.
Any blame that may be apparent in the bad manning of the Health Service, in the lack of G.P.s, of nurses, of occupational therapists, of radiologists and so on, is on successive Ministers of Health from the benches opposite. The right hon. Member for Enfield, West (Mr. Iain Macleod the right hon. Member for Thirsk and Malton, the right hon. and learned Member for Hertfordshire, East (Sir D. Walker-Smith), the right hon. Member for Wolverhampton, South-West (Mr. Powell) and the right hon. Member for Altrincham and Sale (Mr. Barber) were all in power during the last 13 years as Ministers of Health. Therefore any judgments that are made today and directed at our own Minister of Health should be applied instead to those right hon. Gentlemen.
§ Mr. Geoffrey Howe (Bebington)
Would not the hon. Lady agree that it is quite contrary to the justice of the case to condemn the Ministers of a Government who presided over a threefold expansion of the amount of money being spent on the Service as being responsible for its shortcomings? Would not she agree, rather, than the shortcomings are inherent to any Service striving for higher standards and are not easily resolved when any expenditure on the expansion of the Service has to come out of the taxpayer's purse? These are problems which are built into a nationalised service and it is not right to blame any deficiency on a Government who presided over a massive expansion of it when they were in office.
§ Dr. Summerskill
If when they were in power the Opposition felt that there were built-in difficulties, why did they not denationalise the Health Service? They 1266 opposed it in the beginning, but they took it on and it was their job to make it work.
This disgruntlement which we all agree exists among general practitioners did not start in the last few months. It has been there for years. There were grumblings of dissatisfaction and the volcano at last erupted when the Review Body announced its decisions. The findings of the Review Body have not been accepted or rejected by the doctors as yet, but I believe that the discontent does not rest solely on that score. This discontent has existed ever since the excellent Annis Gillie Report in 1963 which showed a picture of frustration, dissolution and depression among general practitioners. The Report showed that they were overworked, that they had too many patients on their large lists, that there were not enough general practitioners, and that they had inadequate access to hospitals. These are the things about which doctors are grumbling today, not just the Review Body announcement.
Mr. Vic Feather, Assistant General Secretary of the Trades Union Congress, recently deplored the threatened withdrawal of doctors from the National Health Service. He said, quite rightly, thatIf trade unionists had broken a three-year agreement in the same way as G.P.s were being advised to do and had rejected out of hand the findings of the review body which they had requested, they would have been widely attacked as representing the worst iniquities of the trade union movement. The Review Body was no different from an independent tribunal.I think we should all agree with that, but I must put this point to hon. Members on these benches as well as on the benches opposite. How many trade union leaders would tolerate their members working in the middle of the night after they had already done a day shift and, in fact, having no fixed hours of work at all? How many trade union leaders would tolerate their members having to supply locums when they were away sick or went on holiday and, in addition, having to pay those locums as well out of their own pockets?
For these reasons, I believe that the position of the general practitioner today cannot be compared with that of someone in any other job or profession. As it is at the moment, the general practitioner's job is unique. It is up to us to reorganise the whole mode of life of the 1267 general practitioner. He has just as much right to regular hours, to the same amount of sleep, to holidays and leisure as anyone else. Here lies the basic cause of dissatisfaction among doctors, quite apart from the Review Body award.
Various answers lie within the scope of the Government. First, health centres. I consider that in the health centre the future of the family doctor lies, particularly the younger doctor qualifying from hospital who is tempted to go abroad when he sees the situation here at home. Four to six general practitioners working together in a health centre could have full facilities for pathological examinations, X-rays and ancillary help. The Gillie Report tells us that this is the most satisfactory form of general practice not only for doctors but for patients. In such a scheme there would be the possibility of fixed hours, a national locum service, the opportunity to take refresher courses or do post-graduate studies, and the possibility of much needed married women doctors coming in to do part-time work attached to centres.
The Government should undertake an urgent review of the method of remuneration. As has been said in the debate, the doctors' leaders have not been at all helpful in this matter. They did not approach the past Government on the question and it has fallen to the lot of the present Minister of Health to cope with the sudden demand to consider a new method of remuneration. The capitation method is falling out of favour, particularly with the younger doctors, because it is designed to placate the patient. An interest in quantity of patients not quality of work is what it inspires in the doctor.
The pool system has been shown to be unfair and unpopular. The alternative method of remuneration is by a salaried service, and I believe that younger members of the profession are more sympathetic to the salaried service than to any other method. My right hon. Friend has told us that it would require legislation, but remuneration in a salaried service would, for the first time, give doctors security. There would no longer be a rat-race between family doctors to try to score up as many patients as they can on their lists, even to the extent of giving people drugs which they do not 1268 need so that they do not leave one's list.
Under this system of payment, expenses and salary would be entirely separate. There would be security and, at the same time, increments according to age, seniority and, for instance, the high morbidity in an area where doctors practised. These things could all be initiated. Under such a scheme, doctors could move freely from general practice to hospital, to research work or to the World Health Organisation. There would be far more mobility among doctors.
The third way to solve the crisis is to recruit more doctors. Patients are now demanding better medicine. There are more elderly people living to a greater age. The emphasis in future must be on preventive medicine. All those things will call for even more doctors than we have already. In Halifax 90 per cent. of the doctors resident in the hospitals are from the Commonwealth. The day will come when they will have their own hospitals to work and train in and we shall not have these people coming to us. We shall have to staff our own hospitals. At present, we are relying on nearly 4,000 doctors from abroad to staff our hospitals. The Robbins estimate was that, by 1981, we shall need 3,000 more medical students. This has now been found to be a gross underestimate and it has been calculated that we shall need 12,000 more medical students if we are to cope with the increased demand.
It is urgent that we plan now for at least six new medical schools. I should like these medical schools to be in the industrial north of England, because it is near where they train that doctors tend to settle down and we need more family doctors in the North.
All the measures are urgent, yet they will take months or years to implement. Under a Labour Government and a Minister of Health who really believes in the National Health Service, they are far more likely to be brought in quickly and, we hope, with the support of general practitioners. As my right hon. Friend said, the average general practitioner is not a political animal. He simply wants to get on with his job and do it well. It is up to this Government to inspire in him the feeling that he has the confidence of the Government and that the Government 1269 really mean to do something about his life and work and will give his profession a lead.
It is for this Government to institute as soon as possible a thorough inquiry into the method of payment, the establishment of health centres and plans for greater recruitment. In this way, the manning of the Health Service will no longer be the cause of crisis that it is.
§ 7.28 p.m.
§ Lord Balniel (Hertford)
I think it will probably be for the convenience of the House if I intervene at this stage to put forward some views in reply to points which have been made and to put a number of further questions to the Minister. The whole House will agree that the choice by the Opposition of this subject, the manning of the National Health Service, has proved very well worth while.
It has proved not the least worth while because it has enabled the hon. Member for Liverpool, Kirkdale (Mr. Dunn) to take the opportunity of making his maiden speech. The hon. Gentleman spoke with a special knowledge of his city not only as a Member of Parliament but as a city councillor. He referred to the important matter of hospital accommodation, which is highly relevant to the debate but which, because the debate has concentrated on the general practitioner service, has not otherwise been mentioned. The hon. Gentleman spoke also of another matter which was highly irrelevant, the Liverpool Football Club, but which, nevertheless, because of his enthusiasm, warmed the debate considerably. Having heard him speak for the first time we should like to say from these benches that we hope that he will take part in many debates on the National Health Service in future.
The debate has given the Minister the opportunity to state clearly where he stands in this extremely unhappy situation which has arisen between the Government and the great mass of general practitioners. We have also had a number of speeches which have been temperate and constructive but which at the same time have expressed, quite rightly, the sense of frustration which is 1270 felt by the general practitioners, a sense of frustration which I quite accept has continued for a substantial length of time but which has been precipitated by the decision of the Government in the last few days to accept the Review Body's Report. Also, we have had a series of questions to which I hope clear and specific answers will be given by the right hon. Gentleman when he winds up the debate.
Inevitably, as this debate follows so closely after the publication of the Review Body's Report on doctors' remuneration, and as it follows so closely after the explosion of anger among general practitioners, it has been dominated by the question of doctors' remuneration. This is, of course, predominant in our thoughts at the moment. But the debate is concerned not only with doctors' remuneration but with the manning of the National Health Service in general. The purpose of the debate has not been merely to discuss doctors' remuneration; its purpose has been also to discuss the working conditions in which doctors have to undertake their task, and, indeed, the future of the general practitioner service in the National Health Service, The purpose has been to discuss not only the general practitioner service but the manning of community care services and the hospital service.
My right hon. Friend the Member for Bridlington (Mr. Wood) referred in some detail to the question of doctors' remuneration, and I shall be referring to it also in my remarks, but I shall also be referring to the equally important subject of the working conditions of doctors in the general practitioner service. The Minister has asked the doctors to take a long, cool look at the Report of the Review Body. It seems to me, though, that the Government have taken a long, cool look at their election pledges, and so cool has the look been that those election pledges have evaporated into thin air almost overnight. It is a very bitter irony for those who work in the National Health Service that, after all the promises to improve working conditions in the National Health Service, hardly 100 days have elapsed before the Government at their first review of a pay claim come into such sad conflict with the mass of general practitioners.
§ Mr. K. Robinson
I should like to correct the noble Lord. The first claim was for the student nurses, and that has been satisfactorily settled.
§ Lord Balniel
I was about to refer, and with pleasure, to the fact that that claim has been accepted by the Government. The right hon. Gentleman objects to what I am saying, but he must not do this. We were told that the Labour Party was poised to go into instant action. Hon. Gentlemen opposite must understand that some of the disillusion which exists in the National Health Service arises from the failure to implement some of the promises made so airily just before the General Election.
As the right hon. Gentleman has encouraged me, perhaps I might refer him to the Labour Party election manifesto. It was called "New Britain". It ought to be renamed "Never-never Land". It says:Labour will press ahead with a revised hospital plan… Labour will greatly increase the number of qualified medical staff. We shall train more doctors and dentists … by increasing the number of students admitted to existing medical school …".I would ask the right hon. Gentleman whether there have been more pledges broken in so few words. [Laughter.] Hon. Gentlemen opposite laugh, but they said that they would press ahead with their revised hospital plan, and the first major step which has been taken by them is not to publish a hospital plan. They said that they would greatly increase the number of qualified medical staff. My right hon. Friend has already asked the Minister what steps the Government are taking to increase the intake to the medical schools, and we have not had an answer yet. The Labour Party also in the manifesto on health talked about consultation with the unions concerned. One of the troubles about the existing dispute is that the Minister has not yet had consultations with the professional representatives of the general practitioners.
It seems to me that the problem of general practitioners is not only a question of remuneration. It is an almost inextricable knot of which the main strands are a sense of overwork, a sense of underpayment and a sense of uncertainty about the status of the family doctor in the National Health Service both today and in the future.
§ The Under-Secretary of State for Scotland (Mrs. Judith Hart)
Perhaps the noble Lord remembers that three years ago when we were debating the pay of nurses he said exactly the same thing. He said at that time that the National Health Service was underpaid, understaffed and overworked. I wonder what steps he took to bring the attention of his right hon. Friends to that need in the three years that he had compared with the three months that we have had.
§ Lord Balniel
The best answer that I can give the hon. Lady is to suggest that she should read that speech of mine, and she will then find the constructive comments that I made. I hope that during the course of my present remarks I shall be able to put forward some constructive suggestions because we most certainly are not happy about the dispute which has arisen between the doctors and the Government.
On the question of pay, I should first like to welcome very warmly indeed the Minister's decision to invite the profession to discuss the whole question of the pooling system, the system of paying the family doctor. I believe the right hon. Gentleman is right to take this step. I certainly hope that the profession will take advantage of his invitation and be able to enter into negotiations. As he reminded us, it is only right that we should remember that the broad concept of the pooling system was established to meet the wishes of the general practitioners themselves, and only relatively recently it commanded their support. It has one great advantage. It is a means of payment which enables doctors to take part in the National Health Service without at the same time being salaried employees. It also has the advantage that it gives doctors security irrespective of the number of doctors who come into the Service. It also has the advantage from the country's point of view that it creates a fixed, budgetable sum of money to be allocated to the family doctor service.
On the other hand, it seems to me that the disadvantages of the pool system as it exists are very considerable. It is immensely complex. The right hon. Gentleman once said that given 15 minutes he could explain it to the House. I would not make such a claim. I am sure that the great mass of the public simply do not understand the pool system, and I think 1273 it is equally true to say that the majority of doctors cannot understand the system by which they are paid. The 1963 Report of the Review Body gave rise to widespread misconceptions, and although the last Report has gone out of its way to avoid misconceptions and, indeed, has actually proposed a simplification of the pool system, the fact remains that the pool is an immensely complex structure. I think that for all those reasons alone it should be re-examined.
Not only is it very complex. In no way does it provide a career structure for the family doctors. In no way is there a career structure for them similar to the one that exists for the doctors in the hospital service. And—even more important—it in no way relates their pay to the quality of medical care and skill that they provide for their patients. Now the disadvantages loom so large in the eyes of the general practitioners that it is clear that the existing pooling system has lost the confidence of the mass of G.Ps. I therefore welcome the decision of the right hon. Gentleman to open discussion so as to secure reform.
There are several questions one must ask about this decision. Is the right hon. Gentleman prepared to discuss only the administrative arrangements of the pooling system? Is he prepared to discuss only the mixture by which the distribution is made to individual doctors? Or is he opening up for discussion the global sum? Is he prepared to talk with the doctors about the quantum of remuneration? Is he prepared to talk with them about the 5½ million recommended for their pay? If he is not prepared to talk about the overall sum of money, I think both he and the profession are in a difficulty because any alteration in the distribution is bound to mean taking away moneys from what are now being proposed for certain individual doctors.
Much of the difficulty has arisen because it has always been assumed—certainly by my right hon. Friend the Member for Thirsk and Malton (Mr. Turton), by the general practitioners and by me—that the Review Body would decide the overall amount only and that the actual method of distribution would be discussed with the professions concerned by what used to be called the Fraser Committee and what is now called the France Committee—the Joint Committee 1274 of the General Medical Services Committee and the Department of Health.
But what appears to have happened is that while discussions were actually going on between the profession and the France Committee, the Review Body made its recommendations tying three-quarters of its proposed increase to the payment of practice expenses. The Government have accepted this without consulting the profession and without seeing whether it commanded its support. Certainly that seems to be the understanding of the profession. I should like the right hon. Gentleman to disentangle what appears to be a misunderstanding.
§ Mr. K. Robinson
We can clear it up now. Is the hon. Gentleman really saying that one party to an arbitration ought to decide, before accepting, that the award is acceptable to the other side? This is a totally new doctrine. I have never heard it expressed before.
§ Lord Balniel
I was about to say that my right hon. Friend the Member for Altrincham and Sale (Mr. Barber), if I understand the position correctly, gave a promise, when he was Minister of Health, to the general practitioners not to impose a new system of distribution without obtaining first of all the support of the profession. In a statement on 17th September, 1964, my right hon. Friend said:I understand that the General Medical Services Committee propose in due course to put before the profession as a whole the agreed recommendations for the new method of reimbursing expenses.Those were the agreed recommendations within the France Committee. My right hon. Friend went on:… It has never been my intention to impose this new method of reimbursing expenses, which would cost the taxpayer several millions of pounds, if the profession does not like it.We should be quite clear on this matter because it has caused widespread misunderstanding in the profession. The right hon. Gentleman should make clear whether he adheres firmly to the pledge given by his predecessor. I hope that he will be able to give as firm an assurance as that given by my right hon. Friend.
It is quite clear that many in the profession do not like these recommendations at all. That is perfectly understandable. Half the general practitioners do not employ ancillary staff and for 1275 them the Review Body's Report provides an additional 1d. per consulation or 6d. per patient or £50 a year.
Of course, the Kindersley Committee and the Ministry and we on these benches and the medical profession are all anxious to see doctors provided with enough money to spend on ancillary staff and practice expenses. But I think that the Minister is being slightly unwise if he intends to try to secure this by a pay award which ties three-quarters of the award to practice expenses if it does not have the support of the profession.
For the first time since 1948, we have reached a point where we are faced with a practical possibility of the doctors ending their contracts with the N.H.S. Of course, there have been disputes in the last 17 years but I do not think that at any other time has withdrawal been considered as seriously as it is being considered today. I have not, I admit, spoken to many general practitioners since the announcement of the award, but those to whom I have spoken do not give me the impression of men who are bluffing. I think that there is a serious danger now of doctors withdrawing from the N.H.S. unless an accommodation can be reached with the Government.
If the Minister is to retain the doctors in the Service he will have to take this opportunity of looking at the very fundamentals of their contract. He will have to find a way not only to preserve the independence of general practitioners—because they are not seeking to become salaried employees—and also to preserve the security such as is provided by the pool. He must evolve a contract which enables them to be rewarded financially for merit or ability or industry or willingness to provide a better service for their patients. I say this with great emphasis because medicine is, above all others, a service in which quality, care and skill should be encouraged by appropriate rewards.
The second strand of the problem is overwork and one does not have to turn to the mass of reports—the Gillie Report, the Porritt Report, the Royal Commission Report and others—to have that proved. One has only to visit the waiting rooms of so many general practitioners. If we are to help doctors in the burden of work which they have to undertake and if we 1276 are to alleviate that burden of work, then we must try to encourage the development of group practices among general practitioners. I am talking not about financial partnerships but about the grouping of doctors, three or six or eight, in, ideally, purpose-built premises where they can make rota arrangements, where they can employ ancillary staff, dispensers, health visitors, midwives, and where they can operate an appointments system.
We asked the right hon. Gentleman last week what steps he was taking to encourage group practice and he said:Yes, Sir. I am aware of this—that is, the urgency—and I realise that many doctors find difficulty in financing the provision of premises in which to set up in practice, but for the general practitioner to look to public funds for this raises problems about his whole relationship to the National Health Service. This is a matter on which the Working Party on General Practice will no doubt be expressing an opinion."—[OFFICIAL REPORT, 8th February. 1965; Vol. 706, c. 15–16.]This was very different from what the right hon. Gentleman said only just before the General Election. He was not then saying that we must wait for a Report. He was not then saying that this brought into question the position of the general practitioner. He said: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.The right hon. Gentleman has Treasury sanction for an increase of £25 million in the National Health Service. Has he even asked for Treasury sanction to implement this pledge, which is as clear as can be made possible in the English language? Literally his next sentence was:We should also give direct financial assistance towards the employment of ancillary help of the kind that I have described."—[OFFICIAL REPORT, 27th July, 1964: Vol. 699, c. 1017.]Has he asked for Treasury sanction for this?
He has been asked whether he is increasing the intake into the medical schools. Of course, we will not ask him whether he has asked for Treasury sanction for the four new medical schools which hon. Members opposite promised when they were in opposition. But we can ask whether he has requested 1277 Treasury sanction even to increase the size of the existing medical schools?
Finally, I turn to the subject of the status of general practitioners. General practitioners are not asking for a privileged position in society. What they ask is that if we value general practice, then we should develop a sound philosophy towards family doctoring, a philosophy and structure which place the doctor not at the periphery, but at the very heart of the Health Service. They ask that he should be given a position which does not leave him isolated between the community care services and the hospital service but integrated into both.
Of course, we all recognise that an enormous question mark hangs over general practice at a time when all the trends in medicine are towards increased specialisation. Of course, we realise the difficulties, but I fully agree with the sentiments expressed in the Gillie Report and I feel that we should so frame our social policies that the family doctor should become the co-ordinator, the mobiliser and the leader of community care services.
I hope that during his tenure of office the right hon. Gentleman will turn his attention to what I regard as the greatest field for reform in the Health Service—the co-ordination of the excessively fragmented personal family services, the child care service, the family caseworker service, the health visitors, the probation officers, the psychiatric social workers. If he can achieve a coordination of these personal family services, then I hope that he will find there a key place for the family doctor. I suggest that when searching for the key he will find it in those area health boards which were recommended in the Porritt Report.
I believe that the crisis which has developed in the last few days is not merely a normal biennial pay dispute. It is a major turning point, almost a crossroads, in the relationship of the family doctor service with the National Health Service. There are immense difficulties at the moment, but arising from these difficulties we hope that there will now be a profound professional self-examination and that a lead will be given by the Minister to the finding of the new status for the family doctor and a new position 1278 for him in the structure of the Health Service. If he can do that, we from these benches will certainly do our best to assist him.
§ Dame Irene Ward (Tynemouth)
Would my hon. Friend confirm that on the Second Reading of the National Health Service Bill on 2nd May, 1946, the Conservative Party moved an Amendment starting with the words:That this House, while wishing to establish a comprehensive health service …Will my hon. Friend confirm that, so that we can do away with the suggestion of hon. Members opposite that the Conservative Party was not in favour of the establishment of the National Health Service?
§ Lord Balniel
I do not have the records of that debate before me but my hon. Friend's clear recollection entirely confirms my own impression.
§ 7.58 p.m.
§ Mr. K. Robinson
By leave of the House, perhaps I may just complete the picture and state quite categorically that the Conservative Party voted against the Third Reading of the National Health Service Bill, which is an action well recognised in the House to represent opposition to the fundamental principles of the Bill under discussion.
§ Several Hon. Members rose—
§ Mr. Robinson
—but I did not intend to allow the hon. Lady the Member for Tynemouth (Dame Irene Ward) to get away with a half-truth of that kind.
The House will agree that on the whole this has been a helpful and constructive debate. We have had the advantage of hearing from one ex-Minister of Health and three ex-Parliamentary Secretaries to the Ministry of Health, and we have also had the silent presence of one further ex-Minister and one further ex-Parliamentary Secretary.
I must first mention, as did the noble Lord the Member for Hertford (Lord Balniel), the most admirable maiden speech of my hon. Friend the Member for Liverpool, Kirkdale (Mr. Dunn). He 1279 made his speech in a model form for a maiden speaker. He spoke about the Liverpool Stanley Hospital, about which he and I have corresponded at some length and about which we will no doubt correspond again.
The right hon. Member for Thirsk and Malton (Mr. Turton) seemed to think that I was a little rough on some of the doctors' leaders. I can only think that he and perhaps some other hon. Members have not noticed what the doctors have been saying about me and about my Ministry. What I criticised in particular was the presentation of this Report to the doctors and the profession, and I am prepared to repeat and stand by my criticism. I quoted a number of remarks of Dr. Cameron, the Chairman of the G.M.S.C., which I thought showed his most considered and statesmanlike attitude towards the problem, and I contrasted remarks made by an obviously sincere leader of the profession before the award was published with some of the things said by some others since it was published. I thought that that was a point which I was entitled to make.
The right hon. Gentleman's advice to me on the Review Body's award was, it seemed, "Do not reject it, do not accept it. Accept part of it and reject part of it which the profession does not like." This I do not regard as open to me. Here is a Report which I believe the Government could only have accepted or rejected, and we have accepted it. Nor do I regard acceptance of this Report as in any way inconsistent with the assurance given by my predecessor the former Minister, now the right hon. Member for Altrincham and Sale (Mr. Barber), which was read out by the noble Lord in his winding up remarks.
I promised to say a word about the reference by the right hon. Member for Bridlington (Mr. Wood) who opened the debate, about the review I am undertaking of the hospital programme. This is an important exercise, and it is essential that we have adequate time. This is going to involve a realistic study of costs, priorities, population changes, and so on. Certainly it will not be satisfactorily concluded before the end of this year. It may well take even longer 1280 than that, but I certainly give this assurance that once it is finished I shall want to let Parliament and the country know the result of the conclusions which we have reached. We do intend to publish it at the end of that time.
The right hon. Gentleman also referred to the impact of rising costs as the programme is developed. Well, while no Minister could give a categorical assurance about the future, rising costs in the sense of cost inflation have been taken into account hitherto, and consequently he was wrong in his assumption that the extra £5 million we are providing for the next financial year was little more than taking account of rising costs. This is £5 million extra in real terms. The rising costs increase had already been taken into account in the £63 million figure, on top of which we added the £5 million.
The right hon. Gentleman, and, 1 think, some other Members, referred to shortages of manpower, especially of doctors. Of course, I acknowledge that there are too few doctors. I said so when in Opposition. I am not likely to have changed my mind now. There are too few, both in general practice and in the hospital service, but I really would remind hon. Gentlemen opposite that the acceptance by their Government of the Willink Committee's Report which recommended the cutting down of intake to medical schools by 10 per cent., a Report published and accepted in 1957, really did not help and does not help the present situation. So we are considering—my right hon. Friend the Secretary of State for Education and Science who has, of course, responsibility for the establishment of new medical schools is considering—this matter, and I hope that the noble Lord will not add this to the list of alleged broken pledges of the Labour Government if we have not actually constructed new medical schools within 112 days.
§ Dr. Wyndham Davies
I thank the right hon. Gentleman for giving way. May I just ask if he would consider that the acceptance of the Willink Report was an example of an acceptance of a long-term plan, of which we have heard so much from the Labour Party, which went so wrong—of a reputable body of people putting forward a suggestion for a long-term plan which has produced the results we have today?
§ Mr. Robinson
I do not want to speculate on the reasons which led the Government of the day to accept that Report. I only say that its acceptance has not helped the present position.
§ Sir Edward Boyle (Birmingham, Handsworth)
In connection with what the right hon. Gentleman has just said about medical schools, I wonder whether he or his right hon. Friend have been considering the question whether they should come within the orbit of the Council for Admissions of the U.C.C.A. This was a matter which was under some consideration at the end of the last Parliament. I wonder if that matter is still being considered.
§ Mr. Robinson
I think I am right in saying that that is entirely a matter for my right hon. Friend. I will certainly discuss it with him to see what progress has been made since the change of Government.
I was going on to say—and this is the answer to the noble Lord—that we are continuing to expand existing medical schools, but he will not be surprised to know that we have not yet got all the figures relevant to the new Government as against the old.
The noble Lord also asked me whether, when I saw the medical profession, when they came to see me, I would tell them I was only prepared to discuss this thing or that thing. I really thought I could not have made it more clear than I did in my opening remarks. I really am prepared to discuss anything at all with them. I must put in this reservation, however, as to the quantum of remuneration. As things stand at the moment, by agreement between the profession and the previous Government, this is a matter for the Review Body, and as long as it remains a matter for the Review Body obviously it would be improper of me to discuss it with the leaders of the profession.
The only other reference I should like to make to what the noble Lord said is this. He quoted with some glee from a speech I made on, I think, 27th July last on general practice, when I said that we would give grants instead of loans for premises. The position is really no different. Is he really asking me, after all he has said about the imposition of the Review Body's award, that I should impose grants, with all that goes with 1282 it, on the medical profession? It is perfectly true that the acceptance of premises from the Government does basically change the whole relationship with the general practitioners. If I were to try to impose this on them I would be in even worse odour with the profession than the noble Lord seems to think I am at the moment.
I promised to wind up briefly. I want only to repeat what I said before. I regard this crisis as an opportunity I am ready to take, and I am looking forward to an approach from the medical profession.
§ Colonel Sir Malcolm Stoddart-Scott (Ripon)
Would the right hon. Gentleman say a word about dentists? Does he not take the view that the shortage of dentists is even as important as the shortage of doctors? In ten years' time we shall not have enough dentists to carry out the service. Can the right hon. Gentleman say what preparations are being made and whether the new dental school in Wales has been started and whether there are to be more dental chairs in the other teaching hospitals? Could he also say a word about pharmacists? Does the Minister not think there is a shortage of pharmacists? He said that the decision about the prescription charge has not meant a great extra burden on them. Can he say whether we are training sufficient pharmacists, and whether there would be sufficient pharmacists if we were to provide free drugs and dressings for private patients?
§ Mr. Robinson
By leave of the House I would reply to the hon. and gallant Member. I think it is true to say there is a shortage of pharmacists in general over the whole country. There are, of course, pay differentials between private industry and private commerce and the National Health Service and there is a substantial pay claim for pharmacists before the Whitley Council at the moment. On the question of dentists, I think the supply of dentists at this moment in numerical terms is probably a little more promising than he thinks. The intake of new dental students is increasing. However, if the hon. and gallant Gentleman would like some figures about that and would be good enough to put down a Question on the Order Paper I will gladly tell him what information I have.