HC Deb 09 February 1966 vol 724 cc416-81
Mr. Richard Wood (Bridlington)

Mr. Speaker, I am sure that the House is extremely grateful to you for the Ruling which you have given, and perhaps grateful, also, for your pointing out that if we had done our researches adequately we would have had 73 years' notice of your decision today.

As you have reminded us of it, it fills a number of hon. Members who had intended to take part in the debate with a certain amount of trepidation, and I shall do my best to relate the remarks that I make about the Ministry of Health and the Scottish Office Estimates as closely as possible to the Estimates themselves; and it is those Estimates to which we are anxious to give particular attention in the early part of today's debate.

I should like to deal particularly with the consequences and implications of the decision to abolish prescription charges which the right hon. Gentleman the Minister of Health announced just before Christmas, 1964. It would be quite improper for me or any of my hon. Friends to complain that the Government have honoured an election pledge, because in health matters that seems to have a certain scarcity value and is something of a collector's piece.

Out of the galaxy of promises in "The New Britain", the Government seem to have selected one pledge, or, to be more accurate, half a pledge, which has made the honouring of all their other promises more difficult than it was before.

We would certainly have given the Government every support in an attempt to improve the system of charges which they have now abandoned. It was certainly not a perfect system, and perhaps none of our systems is perfect. As the right hon. Gentleman knows, my right hon. Friend the Member for Altrincham and Sale (Mr. Barber) had worked out an important modification of it when he was Minister.

I am suggesting today that the right hon. Gentleman could well have examined that first, but, as far as I know, no further discussions took place between his officials or himself, when he was in charge of the Ministry of Health, and the medical profession. He might also have re-examined with our entire approval and support the whole system of exemptions from the charges. He could have examined another problem which no doubt gave a considerable amount of trouble, that of general practitioners in country districts who do their own dispensing. We should also have supported an examination of the advisability of making a distinction between drugs which are necessary to save life and others which are less essential.

The fact is that the right hon. Gentleman and his colleagues had no interest at all in making any such examination.

I have had the opportunity over the last 18 months to observe the right hon. Gentleman at fairly close quarters, and on fairly frequent occasions, and I am sorry to say that I find him much more of a doctrinaire politician than his benign appearance, his courteous behaviour, his diplomatic statements, and his general pragmatic approach would suggest. I find that he drinks more avidly from the pure fountain of Socialist doctrine than either Lord Attlee or Mr. Bevan.

Last week, during the debate on the Second Reading of the National Health Service Bill, I expressed disappointment at the right hon. Gentleman's unwillingness to experiment by allowing doctors to charge fees which could be wholly reclaimed by those in certain categories of need. The right hon. Gentleman was very shocked and told me, rather loftily, that this was alien to the whole idea of the National Health Service.

It was presumably for the same reason, that, two months after the election, the right hon. Gentleman hurried towards total abolition of the prescription charges, thus relieving, as I pointed out on that occasion, hundreds of thousands of people well able to pay them. He described his move as the first major step towards restoration of the free Health Service which the Labour Government introduced after the war."—[OFFICIAL REPORT, 17th December, 1964; Vol. 704, c. 584.] The right hon. Gentleman told me on that occasion that the anxieties of the doctors about an increased work load were exaggerated. He later estimated—I think that it was in April of last year—that the abolition of these charges would cost about £25 million in England and Wales. My right hon. and hon. Friends and I decided to wait and see. We waited, and we have now seen that the estimates which he gave were wholly wrong. In the year 1963–64 the then 2s. prescription charge, with the exemptions which existed, brought in about £22 million. Since the charge was removed, and, presumably largely because of its removal, the number of prescriptions dispensed has greatly increased.

In the first seven months after abolition, that is, from February to August inclusive, the number in England and Wales went up by 19 per cent., and the cost by 22 per cent. As the total cost of prescriptions in the previous year was £105 million, I estimate that the increased cost may be more than £20 million; and if one adds this to the loss of revenue, it comes to between the £40 million and £50 million which has been quoted with some authority during the last few months.

I find it very hard to understand why, when announcing the abolition in December, 1964, the right hon. Gentleman thought that habits had so changed in the 15 years which separated his statement from that of Lord Attlee in October, 1949, when he announced the Government's intention to take powers to make a charge, and explained that its purpose would be to reduce excessive and, in some cases, unnecessary resort to doctors and chemists, of which there is evidence.…"—[OFFICIAL REPORT, 24th October, 1949; Vol. 468, c. 1019.] Three weeks after that Mr. Bevan spoke of the "ceaseless cascade of medicine pouring down British throats", but his cascade was a trickle compared with the flood which the right hon. Gentleman seems to have unleashed.

The right hon. Gentleman says that that is evidence of a pent-up demand, and in some sense it is. A great many potential demands are released by a decrease in price. But if, as in this case, a demand is released at the expense of other demands, it is not necessarily wise to release it, and to us the important question is: has the added benefit to health which has been secured by giving this demand complete freedom outweighed, first, the added burden on general practitioners, secondly, the greatly increased cost to the National Health Service, and, thirdly, most important of all, the postponement of improvements and expansion in the Service which would otherwise have been possible? After all, we are today discussing sums which represent a sizeable proportion of the total capital expenditure on hospital building last year.

The Parliamentary Secretary to the Ministry of Health very kindly wrote to me last night explaining that he could not be here at the beginning of our debate. I replied to tell him that I wanted to quote some words which he had used during the course of a debate on the cytological service, which I attended. On that occasion the hon. Gentleman said: …in the short period in which I have held office I have never been really satisfied with any of the services we give, although I recognise that our Health Service is by far the best in the world."—[OFFICIAL REPORT, 26th January, 1966; Vol. 723, c. 367.] That seems to me—and I explained to the hon. Gentleman that I should be making this comment—an honest statement, free from complacency, which might have come from any Minister connected with the right hon. Gentleman's Department ever since the National Health Service began. But the natural and proper dissatisfaction of the hon. Gentleman might possibly have been abated if £50 million, or even a proportion of that sum, had been available to his right hon. Friend to improve and expand the Service. We can all think of needs—I daresay that one or two hon. Members will be pressing them today—across the whole spectrum of the National Health Service where even a small proportion of that £50 million would have been able to bring considerable relief.

The right hon. Gentleman announced last December that one of the regional hospital boards had had to suspend recruitment of nurses because of lack of money. The Royal College of Nursing, which is not, in the experience of many of us, generally given to using strong language, criticised as ludicrous the promotion by the Government of a publicity campaign to project the attractions of modern nursing, and the simultaneous decision to put a brake on recruiting.

I turn from that to a small, but to my mind important, human example of the difficulties caused by this financial pressure. Only last week I asked the right hon. Gentleman about the provision of hearing aids for the small number of people unable to benefit by the aids provided by the Service. The right hon. Gentleman replied that he would have to consider relevant priorities between improvements in this respect and improvements elsewhere in the Health Service."—[OFFICIAL REPORT, 31st January, 1966; Vol. 723, c. 677.] Perhaps he will be able to find a place for this priority, but this is only one of the real human problems which has undoubtedly been pushed further away from solution by the costly abolition of the charges, and the kind of question which my hon. Friends and I would like to ask is whether it can really be a priority to leave florins in the pockets of the affluent, rather than to give back to a man the ability to hear.

Socialism, as we have been told on many occasions, is the language of priorities, but to us the language is becoming increasingly incomprehensible. To abolish charges for those who can well afford to pay, in the face of the other needs of the Service, surely makes nonsense of the language, especially when those unable to afford them did not have to pay them.

Mr. Will Griffiths (Manchester, Exchange)

Was not the policy of the Government of which the right hon. Gentleman was a member one which took the florins from the public and did nothing to provide the hearing aids about which the right hon. Gentleman is speaking?

Mr. Wood

I shall come to that point, because it is very important, and I thought that perhaps an hon. Gentleman or an hon. Lady might raise it. I promise to deal with it before I conclude my speech.

Mr. Deputy Speaker, I hope that you will allow some general reflections on the mistaken choice of priorities which we believe the Government have made, because I think that they are closely related to the Estimates which we are discussing.

I start with the Parliamentary Secretary's lack of real satisfaction with any of the services provided. Probably, if we were honest, most of us would agree with him. But if this is true of the mid-1960s it looks like being a great deal more true in 10 or 20 years' time. We are all aware of the fact that the proportion of old people in the population will increase, and that the sum total of need will accordingly increase fairly considerably. Need will increase in that proportion of the population which is always most subject to illness.

Looking ahead at the advances in medicine—and the skill of the medical profession, in a sense, is always making its job harder—we can be sure that the medical profession will open the door to the possibility of far greater expenditure than we have to meet at present. If—as I hope is not impossible—the medical profession finds answers to the problems of cancer, circulatory diseases, and so on, we shall find the field for medical attention far wider than it is at present, and a greater need for medical care. People will live longer and, other things being equal, will need medical attention for a greater proportion of their lives.

Thirdly, in this very general sense, there is the question of preventive health. The right hon. Gentleman and the Parliamentary Secretary have explained the progress which their Department is making in the direction of cytological screen- ing. I have no doubt that many other possibilities will open up in the years ahead. I shall not attempt to overstate the case and pretend that a significant expansion would have been possible in all directions if only the Government had maintained the prescription charges. It would be foolish to put forward that argument. What is true, however, is that we can push forward more effectively into these new fields only if we have a really firm base to start from.

The question is: to what extent have we this firm base? I must keep clear of detailed matters, because the Estimates are not concerned with them but, in general, the human resources of the National Health Service now seem to be overstretched. Buildings and equipment are inadequate, and many patients have to wait a very long time for hospital treatment. A number of examples have appeared recently in the Press. It would not surprise me if an exceptionally bright hon. Member or hon. Lady opposite—or the hon. Member who raised the question just now—asked what we were doing in the 13 years when we had responsibility. I want to make the point for them.

Throughout this period we were trying to make the most effective use of a very large but limited sum of money—which now amounts to over £1,000 million a year—mostly contributed by taxpayers but some drawn from National Health contributions, with a relatively small but significant addition from the users of the Service. By their decision in December, 1964, the Government have made expansion more difficult, because they have at the same time reduced the inflow of money from the users of the Service and increased its cost.

Therefore, whatever future priorities the Government choose, the choice of this first priority—the abolition of the prescription charges—has inevitably made it more difficult than it was, even under our Administration, to find the money for expansion. I therefore, ask the right hon. Gentleman where the money for this necessary expansion is to come from.

Dr. Shirley Summerskill (Halifax)

In view of what the right hon. Gentleman has said, and since there was a prescription charge throughout the 13 years of Conservative government, is it intended that if ever there is another Conservative Government the charge will be reimposed?

Mr. Wood

That is quite a fair question to ask. I think that the hon. Lady was here at the beginning of my speech, when I suggested that what I hoped the right hon. Gentleman would do, rather than abolish the charges, was to carry out an examination of the various possibilities that I have mentioned, which, in my opinion, would have resulted in our being able to maintain this system while removing the inequities in it. That is what we shall try to do when we are next responsible, especially if, as I assume is only too likely, unfortunately, the resources available to the National Health Service, are still much smaller than we would like.

I was asking the right hon Gentleman where, in the absence of revenue from the prescription charges and of the increased cost of the Service, he will find the necessary money for the expansion which I have no doubt he wants to see more than any of us—which is saying a considerable amount. Surely one of the sources cannot be a massive increase in taxation—because at the election we were told that the expansion of our social services would be financed out of greater production and not from general increases in taxation. The proportion of the gross national product which is to be devoted to health and welfare services looks like being slightly smaller in 1970 than it is today.

The second alternative is substantially to increase National Health contributions so as to offset the loss of revenue involved in the abolition of prescription charges.

Mr. Arthur Woodburn (Clackmannan and East Stirlingshire)

Is the right hon. Gentleman aware that at the same time as his Government doubled the prescription charges an almost equivalent amount of money was handed back quite unnecessarily to Surtax payers, who did not ask for it? It is clear that other sources are available, without considering the possibility of increasing the contributions.

Mr. Wood

Perhaps the right hon. Gentleman will make some of these points to his right hon. Friend. All that I am asking is whether the right hon. Gentleman will tell us from what sources the Government now intend to find the money in order to push on with the necessary development of this Service in the absence of revenue from prescription charges.

I was in the middle of asking whether it was the intention, if not to impose a massive increase in taxation, substantially to increase National Health contributions. Certainly, to hon. Members on this side such an increase would not seem to accord very closely with past pronouncements of the Labour Party. But if there is to be neither a massive increase in taxation nor a substantial increase in National Health contributions, how do the Government intend to make progress towards the twin objectives of improving the existing services and moving into new medical fields which will become increasingly important in the future? Every hon. Member will agree that these two aims are highly desirable, but they will inevitably be pushed that much further away by the decision which the Government reached at the end of 1964.

There is apparently no magic short cut out of the difficulties which have been created by this decision. The Government have set their faces against any system of charges, which were thought, by an earlier Socialist generation, nonetheless, to have a certain respectability. The Government seem in no mind to encourage individuals to insure themselves for private medical care, whether in or out of hospital. Whenever this question is discussed—and it was mentioned the other day—there is a confusion of growls behind the right hon. Gentleman. On the last occasion he was kind enough to interpret them as adding up to two words—"queue jumping".

The right hon. Gentleman kindly interpreted the babble of barking for us. No doubt, as the queues get longer, the barks will get louder. Having decreased revenue and increased costs by the decision of 1964, are not the Government face to face with this straight choice—either to raise higher revenue from taxation or from contributions or from both, or to postpone in some degree the kind of expansion of our hospital building and the improvement in the service generally which I and my hon. Friends believe that everyone in the House would like to see? The purpose of the debate is for us now to hear the kind of choice which the right hon. Gentleman has made.

4.30 p.m.

The Minister of Health (Mr. Kenneth Robinson)

As the right hon. Member for Bridlington (Mr. Wood) has done, I propose to confine my speech in general to the Supplementary Estimate which relates to prescriptions and the pharmaceutical services. I would remind the House that, in abolishing prescription charges over a year ago, the Government were redeeming a specific pledge. What fun the Opposition would have had if we had failed to redeem that pledge! This pledge was contained not only in our election manifesto of 1964, but also in that of 1959. I had attacked charges in principle in the House on many occasions and, in particular, in 1961, when we moved a censure Motion when the right hon. Member for Wolverhampton, Southwest (Mr. Powell) doubled the prescription charge to 2s. per item.

During the last election campaign, I referred to this pledge on platform after platform, as did my right hon. Friend the Prime Minister and many other Labour candidates. I would remind the House, also, that it was not only the Labour Party, but the doctors themselves, who had, for years and years, opposed prescription charges as a matter of principle. As long ago as 1957, in giving evidence to the Hinchliffe Committee on the Cost of Prescribing, the British Medical Association reiterated its opposition to such financial barriers between the patient and the treatment which he needs.

The Hinchliffe Committee did not like the charges and said that they were resented by patients and doctors as a tax on illness. The British Medical Association consistently opposed the charges right up to the annual representative meeting in July, 1964, at Manchester, where it suddenly reversed its policy. Certainly, it is perfectly simple and in no way unreasonable for a professional organisation to register a vote reversing its previous policy; but, of course, there was no certainty that the original policy would not have been reaffirmed at a subsequent annual representative meeting.

However, it was a very different matter for the Labour Party on the eve of a General Election, claiming rightly to be the alternative Government, to abandon, even if it had wished to do so—which was not the case—a specific and many-times-repeated pledge to the electorate. Why did we make this pledge in the first place? I am sorry if the right hon. Gentleman thinks that I am doctrinaire. All Conservatives think that anybody who does not share their political philosophy—such as it is—is doctrinaire, but the Labour Party does not believe that taxing people when they are sick is an appropriate method of financing health services.

So far as the charges themselves are a source of finance, their abolition amounts only to a method of redistributing amongst the community the burden of a fraction of the drug bill—far less than a quarter—and shifting what was, in effect, a poll tax on sick people to the taxpayer in general. After all, the money has to be found somewhere. I have said many times that the Government believe in a free Health Service at the time of need. These charges, without any question, had a deterrent effect and that, I think the right hon. Gentleman will be honest enough to admit, was the purpose for which they were originally imposed.

But they had a deterrent effect at: the very moment of need on those who genuinely required medical advice and treatment. I am aware that some doctors believe that the charges deterred the patient with a trivial ailment, but even if this were so—I certainly do not accept it as a general rule—there are plenty of other doctors who are particularly anxious not to deter such patients, on the grounds that only the doctor himself can decide what is and what is not a trivial ailment.

We were in no doubt that the charges meant hardship for many of those who could not avoid going to the doctor and were forced to pay the charges or, as many of them did, went to the doctor for a prescription and neglected to have it dispensed by the chemist because they could not afford it. Whatever the right hon. Gentleman may say—he was reasonably fair about this—the scheme of reimbursement through the National Assistance Board introduced by the Conservative Government was quite inadequate to meet this kind of hardship.

The right hon. Gentleman asked why I did not pursue the investigations which the right hon. Member for Altrincham and Sale (Mr. Barber) was making to try to find a better method of reimbursement. My first reaction to that is to ask why it took 13 years for a Conservative Minister of Health to begin to look for a better method if the existing one was a bad one, which I firmly believe it was. The answer to why I did not pursue this investigation any further, quite apart from the fact that we were pledged to abolition, was that it was not leading anywhere.

I accept that efforts might have been made to find a better system, but they would have been without success, because there would always have been a grey area of unidentifiable poverty which simply meant that people were either being deterred from going to the doctor when they needed to do so, or were being called upon to pay sums of money—not measured always in single florins, particularly among the chronic sick with multiple prescriptions—which they could ill afford.

I should like to remind the House that, in trying to calculate the cost of abolition, hon. Members should not forget to deduct the sum of nearly £3 million which, if the charges had remained, would have been spent last year in reimbursement through the National Assistance Board.

The right hon. Gentleman did not actually say, but indicated that people had not benefited very much from or noticed the abolition of the charges. This is not my experience. A very large number of people, particularly the elderly and chronic sick, have told me how extremely glad they are to have this burden lifted. There is another category, which is not often mentioned, that of the dispensing doctors, those who do the dispensing themselves. Almost without exception, they loathed having to collect the florins from their patients when they had given them medicine and many have gone out of their way to tell me how grateful they are that they do not any longer have this burden.

The right hon. Gentleman made a good deal of play with the effect, in money terms, of removing the charges. I want to be completely frank here. We always expected that there would be an increase in the number of prescriptions and I freely admit that the numbers which have eventuated are higher than was anticipated and that, in consequence, the drug bill, in money terms, is higher. There are so many factors entering into the cost of the drug bill that it is impossible now—I believe that it always will be—to estimate with any accuracy the cost of the abolition of prescription charges. Certainly, not all the extra costs in 1965–66 are due to abolition.

I will give some rather later figures than those which the right hon. Gentleman was able to give. I have them for the first 10 months since 1st February, 1965, when the charges were abolished. The number of prescriptions has increased by 18.8 per cent. over that period, which is equivalent to far less than one additional prescription per person in a year. I mention this only to get it into perspective.

Mr. Bernard Braine (Essex, South-East)

The right hon. Gentleman has given the percentage. Can he give the total increase in the number of prescriptions?

Mr. Robinson

I could give the hon. Gentleman the figure, but, rather than scramble through my figures here, I will ask the Under-Secretary of State for Scotland to give it later. I would rather not guess. I can, however, tell the hon. Gentleman that the cost of the drug bill in the 10 months has risen by £18 million, or just over 20 per cent. more than in the previous year.

I believe—I have said this before in the House—that we underestimated the deterrent effect of the prescription charge and, as a corollary, we underestimated the good which abolition would bring about.

I should like now to try to analyse the possible causes for the increase in the number of prescriptions. I have gone into this very carefully. I believe that there are five possible contributory causes. There is some evidence that prescriptions for items costing less than 2s., which, while the charges remained, would automatically have been bought over the counter at the chemists, have increased in number, but I have made it clear many times to the medical profession, and publicly, that it is not intended that patients should visit the doctor simply to get household remedies which they would normally buy over the counter. I told the doctors that I would always support a doctor who refused such an unnecessary prescription.

The second factor is that the drug bill has risen year by year since the National Health Service started. Hon. Members may be interested to know that the average cost per prescription has risen from 3s. to 10s. in 15 years. The cost of the drug bill has been going up all the time because there have been advances in medical practice and in the development of drugs. Drugs are very different in their therapeutic effect now from those which were cascading down the British throats in Mr. Aneurin Bevan's day. The development of the new drugs inevitably brings with it higher costs, and contributes to the increasing cost of the drug bill.

Since charges were abolished in 1965, the actual increase in cost per prescription has turned out to be less than we expected it to be or than we estimated. There is some evidence that doctors are prescribing smaller quantities, which is what I asked them to do when I wrote to them about the time of abolition. In that way the increase in prescription numbers has been partly offset because the cost per prescription has risen less than was forecast.

The next factor is, or should be, an obvious one. Prescription numbers, and, of course, the costs, reflect the amount of illness that there is about. Compared with the previous year, 1965 was undoubtedly a year of heavier sickness. We have certain statistics from my right hon. Friend the Minister of Pensions and National Insurance, and in the same period that I have been dealing with—February to November, 1965—the number of first certificates for sickness benefit was up by very nearly 5½ per cent. over the corresponding period in 1964. This does not take into account sickness among the old or the very young, who are, of course, the two heavy demand groups who would probably need more prescriptions in proportion than those who are at work and whose numbers are reflected in certificates for sickness benefit.

Apart from those four factors, the only other explanation for the rise in prescription numbers must be that doctors are prescribing more freely, for whatever reason. As for those who suggest that there is an abuse of the service in relation to prescriptions—I am glad that the right hon. Gentleman did not make this point, but it has been made—this is simply to attack the medical profession, since it is the doctor, and not the patient, who writes the prescription.

But, whatever conclusions one can draw from these possible explanations which I have given the House, it is certain that the increase is by no means solely due to the abolition of the charge. The other certain thing is that it is impossible to calculate with any accuracy what the cost was of that decision.

What about the effect on the doctor's work load which the right hon. Gentleman mentioned? It is very difficult to estimate the effect. I think that there was probably some effect. I am not happy to see any increase in doctors' work load in these difficult times, but I think that the increase was a good deal less than many doctors believed.

What has really contributed to the increase in the work load of the general practitioner has been the falling number of family doctors combined with the rising population and, again, and particularly, the extra rise in the numbers of the very old and the very young—those who, as I have said, make high demands on the family doctor. Nothing contributed more to the falling number of general practitioners than the gross neglect of general practice by successive Conservative Governments over a dozen years; a dozen years in which they allowed discontent to grow without even seeking the causes, let alone looking for remedies; a dozen years when they were content to sit back complacently while fewer and fewer newly-trained doctors chose to go into general practice, and the morale and the self-confidence of the family doctor ebbed steadily away.

I have reminded them before, and I do so again, that their decision to accept the recommendation of the Willink Committee to cut the intake into the medical schools by 10 per cent. was a blunder of the first order. But, of course, the chickens are only now coming home to roost, seven and more years since the decision was taken, because of the length of time it takes to train a doctor. So by their action, and by their inaction, they managed to create a vicious circle in which too few general practitioners were having to look after too many patients with inadequate support, and that, in turn, led to still fewer entering general practice.

The right hon. Gentleman spoke about competing priorities. The Government have not been inhibited by the cost of the drug bill from taking action to make good the shortage of doctors that was made worse, as I have said, by the disastrous policies of the Conservative Party. As we announced a week or so ago, it has been decided to undertake, starting this year, building at existing medical schools in Great Britain which will increase the intake of students by 250 a year. We expect by this means to raise the annual intake of British-based medical students from the present figure of 2,283 to more than 2,500. This increase is broadly the equivalent of the intake of three new medical schools.

That is my answer to the right hon. Member for Bridlington, who seldom misses an opportunity, although he missed it today, of reminding me of what I said on this subject when we were in opposition. Meantime, planning of the new teaching hospital and medical school at Nottingham, which will provide at least a further 100 places a year, is making good progress.

Mr. Raymond Gower (Barry)

I hope that the right hon. Gentleman will concede that some valuable steps had been taken towards increasing the number of places in medical schools before he took over his Department; in other words, that the policy had already largely been decided upon.

Mr. Robinson

It had been decided to take some action to get rid of the cut which was imposed by a previous Minister, but the action that was taken and even the action contemplated was totally inadequate to deal with the very serious shortage of doctors which we are facing now and which we will be even more serious during the next few years.

The right hon. Gentleman suggested that because we had taken this decision we had made it more difficult to honour other pledges we had made, presumably in relation to the National Health Service. I will consider the other priorities in the Service, and I do not think that anyone can complain that the rest of the Service has suffered as a consequence of the removal of charges. Like my hon. Friend the Parliamentary Secretary, I am not fully satisfied with the services that we can provide. Still less am I in any way complacent. I will merely say that at least the record of the last 15 months will stand comparison with any similar period in any of the previous 13 years when the party opposite was in charge of the National Health Service.

Consider the question of staff. All pay increases recommended by any body have been honoured. There have been very many of them and some of considerable size. Consider hospital building. We were able to provide an extra £5 million in 1965–66 over and above what was planned by the previous Government to be spent in that year. The House will not have failed to notice that hospital building was wholly exempted from the general deferment of capital projects announced by my right hon. Friend the Chancellor of the Exchequer last July. I turn to current expenditure in the hospital service. Expenditure in this sphere was held down for a very long time by the party opposite, to an annual increase of 2 per cent. This is now rising at more than 2½ per cent. and hospital boards have been told to plan ahead on the basis of a 2¾ per cent. increase in real terms. These increases provide increased funds to run the new hospitals and to ensure expanded and better services in existing hospitals.

Nor is this by any means all. I am able to announce a major step forward on the important subject of health education. I have been considering the Report of the Joint Committee of the Central and Scottish Health Services Councils under the chairmanship of Lord Cohen of Birkenhead which has made far-reaching recommendations for the future development of health education.

Mr. Deputy Speaker (Sir Samuel Storey)

Order. I think that the right hon. Gentleman is getting somewhat wide of the Supplementary Estimates we are discussing.

Mr. Robinson

I agree, Mr. Deputy Speaker, but I hope that it is only the same difficulty in which the right hon. Gentleman found himself.

The right hon. Gentleman enumerated a number of things which, he said, because of abolishing prescription charges, we might not be able to do. I am sure that I am able to rebut, if I am allowed to do so, his charges by pointing out some of the things we have done and which the previous Government did not do. I have very nearly come to the end of my list and I hope, Mr. Deputy Speaker, that I will be allowed to deal with this one rapidly.

I was paying tribute to the members of the Committee and the Chairman for the time they devoted to their task. The Government accept the conclusions of the Committee and agree that increased effort is needed in health education and that the first priority is a new and stronger central organisation. I propose, therefore, to establish a new health education council, the functions of which will be broadly those proposed in the Report. The details are being worked out as quickly as possible, in consultation with the local authorities and other bodies concerned.

We have done all these things despite the economic difficulties which hon. Gentlemen opposite bequeathed to us.

Sir Keith Joseph (Leeds, North-East)

The right hon. Gentleman is, of course, accepting the Report of the Committee which was set up by the previous Government. It is fairly cheap to accept the recommendations, but would the right hon. Gentleman say what budget he is proposing to allow for the expenditure recommended by the Committee?

Mr. Deputy Speaker

Order. Not on this occasion.

Mr. Robinson

It would obviously be out of order for me to do so on this occasion. Certainly, the Committee was set up by the previous Government, but that Government failed to come to any decisions on its recommendations.

As I was saying, we have done this in spite of the economic difficulties, and we have said all along that putting the national economy on to a sound footing must be the prerequisite of the advances we intend to make in the health services and the other social services. The National Plan sets out what we hope to achieve and, in the area for which I am responsible, the Government plan to increase total expenditure on the health and welfare services in England and Wales by more than £260 million between 1964–65 and 1969–70, an increase of more than 23 per cent., rising to a total expenditure in 1969–70 of about £1,370 million. That is my reply to the right hon. Gentleman's suggestion that, somehow or other, we will have to starve the National Health Service because of the decision we took a year ago.

If the right hon. Gentleman and his colleagues are so critical of this decision, then I end my remarks by asking them why they did not table a Prayer against the Statutory Instrument which brought this about. Why did they not even seeek to debate it, even if they were not prepared to vote against the decision?

Mr. Wood

We did not pray against those regulations because we were given wrong information, though I am not suggesting that that was done intentionally. The right hon. Gentleman admitted that he under-estimated the effect of this. We decided to wait and see on the basis of the information the right hon. Gentleman gave. We have waited and we have seen—and we have seen that it was wholly wrong.

Mr. Robinson

I understand the right hon. Gentleman to be saying that he would have supported the abolition of prescription charges if it had cost only the amount which it was estimated to cost at the time of the decision. It turns out that we underestimated the hardship and deterrent effect of these charges, and, because the cost is greater, the right hon. Gentleman is opposed to the decision.

I would very much like a clearer answer from the right hon. Member for Leeds, North-East (Sir K. Joseph) than we got from the right hon. Member for Bridlington to this question asked by my hon. Friend the Member for Halifax (Dr. Summerskill): in the event of the Conservatives forming another Government would they reintroduce these charges? The implication of what the right hon. Member for Bridlington said was that perhaps they would reimpose some kind of charge, but that it would perhaps be at a lower level than that fixed by the right hon. Member for Wolverhampton, South-West (Mr. Powell). If that is the policy of the party opposite, we and the country would like to know. We are entitled to a clear answer to that question tonight.

4.59 p.m.

Sir John Vaughan-Morgan (Reigate)

It is a matter of some regret to me that the Chair has ruled out of order the matter of health education being discussed at any length, because I am furnished with a cutting from the New Statesman of 15th May, 1964, under the startling sub-heading: The Devil's Orchestra. Kenneth Robinson M.P. writes which deals with the recommendations of the Cohen Report and says that the Committee's recommendations are a little on the thin side. It writes in very contemptuous terms—not the right hon. Gentleman; he is never very contemptuous; he has the perfect bedside manner. It is a little derogatory of the sum which it was decided to spend. No doubt we shall have another opportunity of quoting from "The Devil's Orchestra", or whatever particular composer the right hon. Gentleman chooses.

In speaking on the matter of hospitals, which I wish to do today, I declare, as I have in the past, my interest as the chairman of a teaching hospital. I trust that nothing I say may be used in evidence against one particular hospital. Perhaps in polite parenthesis I may say how much I personally appreciate the interest that the Minister takes in the teaching hospitals and in my own in particular. This is not quite the place for either brickbats or bouquets for the Minister on this score, but at the moment I have reason to be very pleased with the Minister about two things and absolutely hopping mad with him about something else. I will keep that for a more suitable occasion.

Before I come on to the question of hospitals, may I deal with the question of charges? As I have already proved to the House, I was always a great student of the right hon. Gentleman when he was in opposition. I always read all his writings with great interest. I have with me a most interesting article published in Socialist Commentary in February, 1964, by the same Kenneth Robinson whom I mentioned earlier. It is an excellent article. It is an anthology of pious aspirations, many of which I think are common ground to us all. It is only fair to say that it contains an absolutely specific pledge about the abolition of charges. I will read the particular passage, because it has some relevance to what I shall say later: All charges to the patient…will be abolished, and the original basic principle of a free Health Service restored. Not only do we regard this principle as the keystone of the Bevan Act, but we agree with the view expressed by the British Medical Association that the prescription charge…represents a barrier between the patient and the treatment he needs". That is the pledge which the right hon. Gentleman has defended himself for implementing.

I must disclose to the House that I have omitted two parentheses. The article really read: All charges to the patient (such as those for prescriptions, dental treatment, dentures and spectacles) will be abolished… The second parenthesis which I omitted read as follows: the prescription charge (and the objection applies almost equally to the other charges) represents a barrier between the patient and the treatment he needs. Does not this show a slight anomaly in priorities? Are we not entitled to ask the right hon. Gentleman this question? If the abolition of prescription charges is right and stands in the scale of priorities higher than more money for medical research and hospital building, why does the abolition of these other charges stand lower in the scale? There would have been a reasonable case, on the basis of implementing the pledge, for implementing the whole lot. Why not the whole lot? Are not we going to have exactly the same arguments about the other charges for appliances? We are entitled to ask the right hon. Gentleman where in the language of priorities the abolition of the other charges stands in his scale. All the arguments he used today could have been used equally on the other charges.

Mr. K. Robinson

I am delighted and very flattered that the right hon. Gentleman pays so much attention to my writings, but if he would look also at the Labour Party manifesto for the last election he will find the answer to his question.

Sir J. Vaughan-Morgan

I read that, but I prefer the ipsissima verba of the Minister of Health on a subject dealing with the Health Service. In defence of the right hon. Gentleman, it must be realised that he is in fact faced with the same dilemma that faces everybody in dealing with the Health Service—which does come first?

Today I want to deal much more with the question of expenditure on hospitals. In case I am ruled out of order, I point out that I am dealing with Class VI, 14, Expenditure: Increased rates of pay. Provision is made for the whole of the increase in respect of pay awards agreed to date. The problem of all hospitals is to get enough money to maintain the services. We must have some sympathy with hospitals generally in their efforts to get their own priorities correct. It is just as difficult inside the budget of a single hospital management committee to get the priorities correct as it is nationally. It is equally hard to find the correct yardstick by which to judge the priorities. Those of us who come from the harsher world of industry sometimes miss the discipline that the need to make a profit imposes when one is deciding which comes first.

This is something of a dilemma which faces many hospitals, not only with capital expenditure but also with revenue expenditure. I stress this, because it must be realised that 75 per cent. of the average revenue expenditure in a hospital goes on salaries and wages. There is very little scope for economy in the rest. There is very little scope for reduction in that sum. The sums are decided in the main by Whitley Councils outside and the hospital has no choice.

It therefore becomes essential for hospitals to have more guidance than they get at present on the efficient use of manpower. People think of hospitals only in terms of doctors and nurses. They forget that in a fully established teaching hospital—and, indeed, in any fully established hospital—the ratio of staff all told to patients is anything up to 3 to 1. The ratio of nurses to patients is 1 to 1, the rest being ancillary workers. This is a very large number indeed and a very high ratio. I am speaking of acute general hospitals, not of those where the care is more custodial than medical or nursing.

We have not done nearly enough research into some of the major facts, such as the fact that the average length of stay in a British hospital is about twice that in an American or a Scandinavian hospital. I mention Scandinavian hospitals, because probably anyone commenting on this would say that the charges are so high in American hospitals that the patients want to get out as quickly as possible. This does not apply nearly so much in the case of Scandinavian hospitals. In the sphere of the efficient use of manpower there is enormous scope still for a reduction. I cannot but feel that if some of the money which we might have spent had been spent on more work studies it would have brought us very great dividends.

I move to another question related to the salaries of nursing staff, namely, the question of the Whitley Councils. In that same article, the Minister said this: Possible subjects for investigation would be…the Whitley Council system of pay negotiation. This is such an important matter to hospitals that I hope that the Under-Secretary will give us some information as to how far the Minister of Health has got on that.

Most hospitals could be more efficiently run if they had more of the ancillary staff that they need. I am not talking of nurses and doctors. One of the shortages everywhere is in domestic staff, which means that in many cases the overworked nursing staff have to do jobs which could be better done by unskilled domestic staff. Throughout the hospital service we find the complaint that the Whitley Council machinery operates in general very slowly and the staffs are always miles behind rates of pay and conditions in the outside world. This is quite wrong and I hope that the right hon. Gentleman will be able to do something about it.

Most of us know, for example, that there has been an acute shortage of pharmacists in the hospital service. This has meant very often that out-patient dispensing has been abandoned and the dispensing of drugs on EC10s has been carried out at greatly enhanced cost by outside dispensing chemists. This is only due to the fact that the Whitley machinery worked so slowly that by the time we got round to giving the necessary awards it was almost too late to save the destruction of the dispensing service inside hospitals. Much the same applies to other kinds of ancillary work.

I hope that the right hon. Gentleman will consider a suggestion which I made in the debate last year when we were faced with the crisis over the doctors. I said, on very much the same point, that I thought it was high time that we looked at the possibilities of having the same kind of review body for the pay of these staffs as the doctors have for their salaries. I cannot but believe that a body like that would act more quickly and at the same time would be more effective in keeping rates of pay and conditions attuned to the outside world. I emphasise again that the efficiency of the hostel depends, of course, upon the doctors and nurses but it depends on the other workers as well.

After my brief experience inside the Ministry and my now rather longer experience outside dealing with hospitals, I am still convinced that we could get much better value for money provided that the money is made available for modest expenditure on work study and the other matters which I have mentioned. I would prefer to see money spent on these things to make the hospital service as efficient as it ought to be than have it spent on some other things that have been mentioned.

5.13 p.m.

Mr. Laurence Pavitt (Willesden, West)

I was interested to notice that the right hon. Member for Reigate (Sir J. Vaughan-Morgan) started by talking about the common ground on this subject. This has been typical of the last few years, but when the Act was being passed hon. and right hon. Members opposite not only voted against the Second Reading but had 469 Amendments down. Although we have achieved common ground now, it has taken them a long time to get to this stage.

I should have liked to follow the right hon. Gentleman's remarks about hospitals because I, too, serve on a hospital management committee and on a regional hospital board, but at the moment I would prefer to continue the argument where it was taken up by the right hon. Member for Bridlington (Mr. Wood). The basis of his comments or the core of the debate is the question whether the Government kept their priorities right or wrong in making the decision to abolish prescription charges.

I come out firmly and distinctly on the side that they were right. I bear in mind all the things that the right hon. Member for Reigate has said. I have been demanding from the previous Government and pressing on the present Government steps to meet the many needs of the hospitals, including auxiliary and ancillary workers, the greater needs of the local health authorities, decent pay for porters and engineers to keep the hospitals running, and the whole question of the nursing service, and I have been bearing in mind all the urgent things that the National Health Service needs and which a Labour Government eventually will have to give. But I still say that in the circumstances the decision taken by my right hon. Friend represented the right priority.

I say this because the sum of money, which unfortunately has been larger than was estimated, affects the people who need it most and affects the most people. My right hon. Friend made the point that the prescription charge was a tax on the sick. It was not only a tax on the sick but it was a tax which meant that the more sick one was the more one had to pay. In terms of equity this was the most unfair tax put on any community in any civilised country.

On average we see our general practioner 5.5 times a year, but if a person is over 65 or is under five years of age the figure is 11. In other words, the prescription charge meant that mothers of young families and our elderly citizens paid twice as much as people in the middle-age range. Those of us like you, Mr. Deputy Speaker, and I who are comparatively young and healthy, at least we were before we came to this House, probably spent only 2s. a year, but a person who was chronically sick and had the misfortune to have cancer of the bowel and faced a most unpleasant and difficult situation, and had to live for the rest of his life with part of the bowel taken away, had to have medicine costing 12s. every fortnight whether he could afford it or not. Geographical situation was also a factor leading to unfairness. If one happened to live in South Wales one paid three times as much as someone who lived in Surrey, because the morbidity rate in South Wales is that much greater.

Apart from the inequity, the fact that we were prepared to tax the sick was a complete negation of the whole principle and understanding on which our late colleague Nye Bevan built the Health Service. The basis of the service is that those who are well are prepared to look after those who are sick, and those of us who are fortunate enough not to need medicine are prepared to pay for those unfortunate enough to need it. To have to take physic is not a privilege, it is a disability.

On 1st February, 1961, the right hon. Member for Wolverhampton, South-West (Mr. Powell) suddenly swung the charges up. The whole House was in uproar during the following three months, and I remember that at that time the British Medical Association reaffirmed most strongly its attitude to prescription charges. It deplored in particular the doubling of the charges and declared that this imposed increased hardship on those least able to bear it and an increased imposition on doctors who were doing their own dispensing.

There is not only the question of equity. I should like to quote a case very near and very poignant to me. I believe that the person concerned died because of the effect of the prescription charge on his case. Hon. Members will know among their own families and their own circle many people who have had a coronary thrombosis. It is one of the scourges of the 1960s. It is a common complaint which people know all about. One has only to mention coronary thrombosis to call to the mind of one's listeners someone whom they know who has had it or has had to go through the problems associated with it. The usual treatment for coronary thrombosis and the heart condition which remains has been to give trinitrin.

In the case of the man I have in mind, his usual prescription was for 100 tablets, which lasted him for a week or a fortnight. As a result of the doubling of the prescription charges, that patient was paying 2s. for a commodity which cost 1s. 4½d. if purchased at the chemist. He had had coronary thrombosis many years back and had got his disability so well organised, being able to use the tablets correctly when necessary, that he was able to cope with his condition admirably. Then, on one occasion two years ago, when he was unable to get to his doctor, he discovered on going to his chemist that the chemist would supply the tablets to him for 1s. 6d. In this way, he could get his prescribed tablets quite easily without waiting an hour in the doctor's surgery and paying 2s. for them.

In these circumstances, he did what many of us would do. He decided that, in future, he would not waste his doctor's time but would go straight to the chemist for his tablets. Unfortunately, as a result of failing to see his doctor, he failed to have regular check-ups, and the consequence was that, having suddenly to see his doctor in different circumstances later on, he was sent at once into hospital for three weeks. Unfortunately, however, he collapsed and died in the street only a fortnight ago.

I contend that this is one case of many people who may have had a coronary thrombosis but who have not been seeing their doctor regularly because of the 2s. prescription charge. Now, happily, such people will go to see their doctor and receive the right monitoring and the appropriate treatment.

As my right hon. Friend said, there has been considerable pressure on doctors' time. But no patient has yet issued a prescription. If too many prescriptions are being made out, it is surely up to the doctors to make sure that they do not issue prescriptions unnecessarily. By and large, doctors do not issue prescriptions unnecessarily. In the main, they have attempted to work within the framework of the National Health Service to the best of their ability. But the situation is not helped when successive Conservative Ministers have had no understanding whatever of the basic problems of general practice and its importance in the National Health Service.

The right hon. Member for Bridlington asked whether we would criticise what was done in the 13 years of Conservative Government. One of my criticisms is that their last two Ministers of Health were chosen not because of their interest in and knowledge of health matters but because they had both at one time been Financial Secretaries to the Treasury. They were chosen because of their ability to contain within certain limits the amount of expenditure which the Health Service called for.

It is my conviction—the speech of the right hon. Member for Reigate confirmed this—that the whole House realises that, at last, we have in the present Minister someone who is not only intellectually and emotionally keen on the Health Service but has devoted his life to it. I am confident that he has chosen and will choose the right priorities. He is the last person to make the wrong choice in a service of which he, perhaps, has more knowledge than any other Member of the House.

For 13 years, we suffered a good deal from sniping at the Health Service by people who, basically, did not like it. Now we face a new danger from sources of sincere good will in the attempt to introduce a cash basis within the Health Service at some point which, whichever way one cares to look at it, will lead to a situation in which, when there is a shortage of doctors and a shortage of time, those with the money will be able to pay for treatment and those without will have to go without. The danger of introducing any kind of cash barrier at any stage of the Health Service is precisely that. We should create first-class and second-class sections of the Service. In general practice, patients who were able to pay would go in at the front door and receive quick service, while those who were unable to pay would go in at the back door and would have to wait in their usual turn.

Moreover, if we are to move on from the curative service to a preventive service, the same principle, which has been maintained by the present Minister, must be adhered to. The only criterion for treatment is the state of health of the patient. We do not accept the idea that health is a commodity which can be bought and sold in the market-place. We do not accept the idea that people who need glasses, hearing aids or teeth are, in some way, benefiting at the expense of others. Those of us who have the good fortune to have good teeth, good eyes and good ears should thank the Lord that we are able to live without needing these aids, and we should rejoice to play our part in putting something into the community for the benefit of those who happen to be less fortunate.

I hope that we shall be able to move away from these sterile discussions in February of each year. February 1961 saw the imposition of the double prescription charge. On 1st February last year, precisely the same day four years later, my right hon. Friend, fortunately, removed it altogether. This year, however, we are coming back, like a dog returning to its vomit, to discuss the whole thing again. It is time we moved away from this kind of argument. As the right hon. Gentleman the Member for Reigate so rightly said, there is a great deal to be done in the National Health Service. So much needs to be done and there is so much that we can do.

If the right hon. Member for Bridlington is still worried about how and when we can pay for it, this is my reply. Any civilised community must put as one of its topmost priorities the finding of money for its own health. It is not a payment for something additional in society. Health is fundamental to the well-being of the individual and also of the community. For the economy, the social life and the richness of a civilised society, good health is a basic need, and the Government have a responsibility in meeting it.

The present Minister and his colleagues have this priority absolutely right, and, as the economy grows stronger, I shall hope to see the Labour Government move on to some of the other things we have promised to do and which will be part of the five-year programme.

5.26 p.m.

Mr. John Wells (Maidstone)

British institutions have, in the past, tended to grow gradually. I believe it to be unfortunate that the National Health Service had a sudden birth and has since not evolved at all. The only point of evolution has been the prescription charge, one of the two main items we are debating today, and it has been a political bone of contention, having been invented by the party opposite and now abolished by it. The money the Labour Government have saved the patient might well have been spent in so many different ways to the greater advantage of the sick and the community as a whole.

I deplore the political to-ing and fro-ing over such items as the prescription charge when right hon. and hon. Members opposite might much better have given their attention and their cash—the taxpayer's cash, rather—for the purpose of implementing on a broad basis some of the recommendations of the Porritt Committee; in particular, a closer liaison between the three branches of the National Health Service. This is desperately needed at present. Again, the cash saving to the patient is out of all proportion to what could have been achieved if the prescription charge had been left as it was and the money diverted into the cytology service which both the Minister and other hon. Members have mentioned.

The remuneration of general practitioners could have been attended to. This also is row desperately needed. We are in grave danger of a total breakdown in the supply of general practitioners not only for salary reasons but for other reasons. There is the impending risk of Indian legislation which may cause newly qualified Indian doctors to complete their training at home and obtain their higher qualifications at home. If this were to happen it would reduce the supply of young medical men further. The Minister should have given his attention to these problems and should have used the cash in these directions rather than for the doctrinaire abolition of the service charge.

It is also essential that the Health Service should be streamlined. We have the problem of ambulance boundaries, which smacks of the demarcation disputes in the ship-building industry. The ambulance stretcher carrier can take a person to the hospital door but no further.

Mr. Deputy Speaker (Mr. Roderic Bowen)

Order. The hon. Member is going wide of the Estimates under consideration.

Mr. Wells

I am grateful for your guidance, Mr. Deputy-Speaker. I was seeking to indicate some of the ways in which this money might so much more wisely have been spent.

It is clear that technicians in the hospitals are scarce entirely because of their poor pay compared with their counterparts outside the hospitals. The professions which back up the general practitioners are in equally short supply. The consultants are thoroughly dissatisfied with their remuneration.

I will turn to the south-east of England and deal with the hospitals there, as covered in the first part of the Estimates. Many members of the administrative staff of hospitals and of the administration which backs the hospitals are spending long hours in form filling. I believe that there is a document S.H.3 which it takes hours and even weeks to prepare. The people who have to prepare it have not adequate office equipment. Could not the figures be sent to the Ministry for the Ministry to service these figures? It is difficult for people in the administrative services to deal with these figures when they lack office equipment.

There are many demands on the hospital service to supply statistics of all sorts, not only to the Ministry but also to such praiseworthy bodies as the Nuffield Trust. This is the era of the statistics hunter. Yet when I have asked the Minister for statistics relating to these problems in Parliamentary Questions over the last three or four weeks, time and again I have been told that the figures are not available. But if he is going in for statistics hunting, why are they not available? The people locally have to provide them. Why cannot the Minister reproduce them, particularly when an hon. Member seeks information about what goes on in his own area?

The Minister told me recently that he does not know the population served by my local hospital. I am informed by the people there that they know quite well. It is a population between 120,000 and 140,000, and to cope with that population there are about 146 staffed beds at present. Would not the Minister have been better advised to have spent the money which went for the abolition of Health Service charges on producing a few more beds in my local hospital? I do not want to be bogged down in constituency matters, because that might be boring to the House and I might bring upon my head the wrath of the Chair, but I quote those figures to show that information is available to hon. Members who are diligent. Why cannot the Minister provide these figures for us when, under the Estimates, we are providing considerable sums of money for the hospital service?

With the growth of population in the South-East and the fact that hospitals were built sporadically there before the war, it is not surprising that there is an uneven hospital distribution. Yesterday the Chancellor announced that he was to continue a close scrutiny of every detail of expenditure, which virtually I understand to mean a clamp down on hospital expenditure except in the development areas.

Mr. K. Robinson

The hon. Member must get this right. I repeated in my speech today that hospital building is wholly exempted from any of the special capital development controls introduced by the Chancellor last July, to the continuation of which he referred yesterday.

Mr. Wells

May I get this clear? This includes minor works in hospitals? This is extremely good news, and I am grateful to the Minister for outlining it.

Mr. Deputy Speaker

Order. The hon. Member is beginning to wander once again.

Mr. Wells

In the South-Eastern Region we are among the highest taxed areas of the country. We have very poor hospital facilities. As the Minister said today, there has been a shift of the burden from the patient to the general taxpayer. The people in my area are the general taxpayers, and we are extremely poorly served with bricks, mortar and equipment. I make no complaint about the staff and the personnel, who do a magnificent job in very difficult circumstances, but I emphasise that within the framework of this Estimate we are the taxpayers and we are not getting value for money. I hope that the Minister will bear the problem of the South-East particularly in mind and not put all his money in the development areas.

5.38 p.m.

Mr. Will Griffiths (Manchester, Exchange)

Before I come to points on which the Opposition will be less inclined to agree with me, let me say that I very much agree with some of the comments made by the hon. Member for Maidstone (Mr. John Wells) and the right hon. Member for Reigate (Sir J. Vaughan-Morgan).

They are quite right to point to the shortcomings in the National Health Ser- vice, and, in particular, the right hon. Gentleman was right to criticise the processes of the Whitley Council machinery. He based his remarks on the wage awards referred to in the Supplementary Estimates. I have given the example of pharmacists, who are very scarce in the hospital service and who are very important people. They are able to find much better paid work with multiple chemists outside the hospital service. To take two categories with fewer members than pharmacists, this is also true of ophthalmic opticians and dispensing opticians, both of whom are scarce in the hospital service. One can look at the professional journals every week and see advertisements from all over the country offering jobs for these people which are not taken up because the pay and often the conditions are more attractive outside the hospital service.

I am glad to see this measure of agreement across the Floor, but this situation cannot be blamed on my right hon. Friend and the Government. I have no doubt that these matters will receive my right hon. Friend's attention in his list of priorities. I do not believe that in any way he would seek to disclaim the sentiments quoted in the article which he wrote in 1964. I look forward to the day when my right hon. Friend and the Government will be able to honour the pledge given by the Labour Party to abolish the remainder of the charges.

No one should be surprised that the Government were unable to abolish all the charges immediately. In view of the state of the books when they took over, it was perfectly defensible that abolition of all charges should be deferred. However, the Government have announced their intention to do so at an early date. They have not repudiated the pledge.

The Guillebaud Committee was set up by the right hon. Gentleman the Member for Enfield, West (Mr. Iain Macleod) when he was Minister of Health. It reported in favour of the abolition of charges but accorded a degree of priority. My recollection is that the dental charges were No. 2 on the Committee's list. Certainly they were accorded high priority. The Guillebaud Committee was an independent body set up by a Conservative Minister of Health.

The fact that the Government are not yet able to announce the date when the charges are finally abolished is not to be construed as a departure from the desire to return at the earliest possible moment to the principle of a National Health Service in which no financial barriers remain between the patients and the services they need.

Whenever we discuss this kind of thing—and it came out clearly in the speech of the right hon. Member for Bridlington (Mr. Wood)—there is a deep ideological difference between the approaches of the two sides of the House—differences of principle or prejudice, according to where one sits. All the time I have been in the House, right hon. and hon. Members opposite have regarded the National Health Service as a service which should operate at a two-tier level. They are not without compassion for those who are worse off, but always they seek for special classes that ought to have things for nothing.

This is a characteristic attitude arising from the philosophical background of the Conservative Party. Right hon. and hon. Members opposite believe that there is a section of the community who ought to have charity. They cannot see our view—that we regard the National Health Service as being redistributive of wealth. We regard it precisely the same as we regard payments of the family allowances. Of course, anyone with a high income thinks, when looking at his tax assessment, that he could well do without the family allowance, but it is, like the free National Health Service, a social service designed to make the strong contribute to the defence of the weak.

This is the fundamental difference between the two sides of the Committee. The right hon. Member for Enfield, West once put it very clearly in the House. He said that he supported charges on the National Health Service not only for financial reasons in that the taxpayer had to meet the burden but for social and ethical reasons. He thus put the difference between the two sides very well.

Right hon. Gentlemen opposite have had considerable experience as Ministers. They seek to argue now that the Government ought to devote themselves not to the general abolition of charges but to seeking ways and means of exempting certain classes. Surely they must have realised the remaining deep-rooted opposition that men and women have, particularly the elderly, to anything which smacks of charity. Successive Ministers have urged hon. Members to do their best to make it clear in the community that National Assistance is not a charity, and my right hon. Friend the Minister of Pensions and National Insurance is engaged upon a new campaign to urge people who think they are entitled to National Assistance to apply for it.

We all know that there is considerable resistance to making application, and it is my case that while the prescription charges were in operation, many people did not avail themselves of medical services because they could not afford to pay the charges and would simply not go to the National Assistance Board. I am thinking not only of those receiving only the pension but of the very large number of people who, being in receipt of a small amount of superannuation, are just beyond the reach of National Assistance supplementary benefits. These are the people who felt the hardship of charges, which under the last Government were raised to 2s. per item on the prescription.

Prescription charges became considerable sums to the chronically ill who need regular drugs and so on. I am sure that these people were hurt by the charges, and I am glad that the Government abolished them. The abolition of prescription charges was one of the best things done by the Government, and I am only sorry that they did not take all the opportunities that were perhaps available to them of explaining to the country just what they were doing. They would thereby have got the credit that they richly deserved for this decision.

There have been allegations of over-prescribing. Some members of the medical profession—I do not come across them in my constituency—say that they are inundated with people who are not really sick and who make frivolous demands for their time and service. Such doctors cannot have it both ways. They are the people who very often in days gone by were always warning the general public against self medication, saying that it was dangerous and that people should consult their doctors.

In a service where professional people are custodians of the public purse, it is not in the last analysis, the supplicant patient who is the danger—it is the professional man who does not act up to the highest ethics of the profession. No patient can obtain a prescription unless the doctor thinks that he or she is in need of it. No dental or pharmaceutical service can be obtained unless the professional people operating it say that a patient can have it. Why, if there be abuse, does not the House of Commons pin the blame on those really responsible?

Dr. David Kerr (Wandsworth, Central)

My hon. Friend is being persuasive and I think he knows how much in accord with his views I am. But perhaps he will allow me to make the observation that, although a doctor may know what a patient requires, it is sometimes very difficult to resist a patient's knowledge—which is often wrong—of what he requires in the context of general practice.

Mr. Griffiths

I understand the difficulties of the doctors. If and when we reach that state of social development when the doctors are employed in health centres in full-time salaried service, without the subtle pressures which arise from the system of payment by capitation, there might be more general practitioners with a firmer backbone. Whatever the pressures on the general practitioners, with whom I sympathise, it still remains true that the general practitioner, the dentist and the ophthalmologist are the men and women who decide what the patient can have. If there is over-prescribing, it is because professional people succumb to the demands of the public. Happily, there is only a small minority which does.

The intervention by my hon. Friend the Member for Wandsworth, Central (Dr. David Kerr) has reminded me of a quotation from The Lancet, dated 4th December, 1965, commenting on an aspect of this problem. It says: On the reasonable text of a widespread discontent among general practitioners, the British Medical Association unreasonably preached resignation, alternative services, and non co-operation. Doctors who have been listening to this kind of advice find it all too easy to give a patient everything he may need; and some ill-disposed general practitioners may take pleasure in embarrassing the Minister of Health. I do not believe that there are many such doctors, but we have to do everything possible to protect them from these pressures. I think that we shall gradually move towards that.

I hope that the abolition of the prescription charges will be followed soon by the abolition of the other charges on the National Health Service. To make a quick comment on what my right hon. Friend said about the extra funds which will be made available to the Service if the National Plan turns out as the Government expect; my hon. Friend mentioned the sum of £260 million a year, but I hope that we shall be able to persuade the Government to devote a higher proportion to the Service.

I welcome the end of the charges and I hope that as the Opposition have had another go at it today they will cease this business of not believing in a Service free from the stigma of charity. Having had the debate, I hope that they will appreciate that the global sum being spent on the Service, including the amount arising from the abolition of prescription charges, is greater than anything which they were able to achieve.

The right hon. Member for Bridlington spoke about priorities and asked why the Government did not provide hearing aids for those people for whom the present hearing aid was unsuitable. I interrupted him to point out that right hon. Gentlemen opposite took 2s. out of the patient's pocket, the florin for the presscription charges, and did not supply hearing aids. The Government are not spending as much on the Service as I would like, but at least they are spending more in real terms than their critics did and I believe that they are also embarking on an economic policy which leads me to hope that the increase will be considerably more in the not too distant future.

5.55 p.m.

Mr. Bernard Braine (Essex, South-East)

I must confess at the outset that I have never been enamoured of prescription charges. I do not think that anybody who has held responsibility at the Ministry of Health could have been enamoured of them. The right hon. Gentleman made great play with his assertion that the charges were a tax on ill health. That, of course, was not the view of the previous Labour Government who in 1951, having imposed a ceiling of £400 million on Exchequer expenditure on the National Health Service, went on to impose charges on dentures and spectacles and made provision—

Mr. Pavitt rose

Mr. Braine

If I do not give way, it is because there is very little time left—and made provision for a charge on prescriptions.

Mr. K. Robinson

But they did not implement it.

Mr. Braine

No, they did not have time to implement it. If it is a matter of implementing election pledges now, we shall await with interest the announcement that all pledges of the party opposite in regard to charges are to be honoured.

Of course, as long as a proportion of our population needs to have its income supplemented by National Assistance, unrelieved charges would by simple definition mean hardship. The House will recall that we met the point by exempting all those who drew supplementary assistance and also pensioners who had their basic pension and no other resources.

I could have understood the Government when they came into office, having made these pledges, examining the possibility of abolishing prescription charges as soon as possible, or exempting certain classes from payment. What I cannot understand and what it is difficult for my hon. Friends to understand is why they did so before they had formed any clear idea of what the effect would be, and before there had been any study of the priorities.

The last year has been spent by the Government in examining every conceivable form of public expenditure, scrutinising it carefully, in order, quite rightly, to arrive at proper priorities. They did not do so in this case. I appreciate the force of the argument that pledges have been made. The right hon. Gentleman, whose humanity and knowledge of health matters we all recognise, is the sort of person who would want to honour that pledge, but I hazard a guess that in his heart of hearts he now regrets that he took that precipitate action.

Mr. K. Robinson indicated dissent.

Mr. Braine

The right hon. Gentleman shakes his head, but there are two reasons why he should regret it. First, on 1st April, 1965, he told the House that he estimated that the additional annual cost to the Health Service would be about £25 million in England and Wales, and he added that there would be an offsetting saving of £2,500,000 in respect of refunds to the National Assistance Board. He now knows that he was wrong. I was sorry to interrupt his speech, but I asked him to give the actual increase in the number of prescriptions and found it exceedingly odd that he did not have the figure under his hand.

Mr. K. Robinson

It was not that I did not have the figure. I said that I did not want to detain the House to find the precise figure. In fact, it is about 40 million prescriptions per year. I said that it was considerably less than one per head of the population per year.

Mr. Braine

Then the figure is even higher than I have calculated. I understand that in the first seven months after abolition of the charge 23 million more prescriptions were dispensed than in the corresponding period of 1964. If the same rate of increase had continued for 10 months, and my arithmetic is correct, then the increase would have been 30 million more prescriptions. The figure now given by the right hon. Gentleman shows that the rate at which prescriptions are now being issued is accelerating very rapidly. I expressed surprise that the right hon. Gentleman did not have the figure to his hand, because on page 20 of the Supplementary Estimates we are told that the increase in the Estimate is mainly because of the increased number of prescriptions.

Dr. David Kerr

If the hon. Gentleman consults the record of the pattern of the number of prescriptions which followed the various charges imposed by the previous Administration, he will find that they never followed the upsweep or down-sweep which he is describing. The pattern always was that there was a reduction in the number following the imposition of the charge, followed by the return to where it had been before.

Mr. Braine

There has been an unprecedented increase in the number of prescriptions this time, and I am going to go into this in some detail. It seems likely that in a full year the total cost of abolition will work out at about double the right hon. Gentleman's estimate, if we take into account not only the increased demand but the loss of revenue. It is astonishing that the right hon. Gentleman was so misled, for all experience shows that it is quite impossible to be precise about the cost of a completely free Health Service.

I am one of those who believe that the National Health Service has made a great contribution to our national life over the years and I want to see it made more effective. Unfortunately, those who founded the Service assumed that the provision of comprehensive care would, over the years, result in a reduction in the total volume of sickness. They were quite wrong. Since 1951 the cost of medical care has nearly trebled.

For this there are two good reasons. The first, as mentioned by the right hon. Gentleman, is the change in the population structure and the fact that there are now more people, more babies are being born, and people are living longer. The second, and most highly significant in this context, is that the patterns of illness and treatment have changed almost beyond recognition. One of the most potent factors, of course, has been the introduction of the new drugs, the sulphonamides, then penicillin and later the broad spectrum antibiotics which have so dramatically reduced mortality among the young and shortened periods of illness. Then again, the average stay in hospital today has been cut by two weeks since the inception of the National Health Service. Indeed, to get these matters into perspective it is fair to say that the cost of one day in hospital is greater than the average cost of four weeks' supplies of medicine. With the aid of drugs, too, we have made a dramatic break-through in the treatment of mental illness.

Yet, because people are living longer it is extremely doubtful whether the total volume of sickness in the community has been reduced, if only because there is bound to be more chronic illness and physical incapacity. I mention these matters because with this sort of background it should have been evident to the right hon. Gentleman that the drug bill would go up, and by more than he estimated when he came before the House to announce the abolition of these charges.

It is very interesting to note that since 1951 the proportion of National Health Service expenditure taken by the pharmaceutical services up to the abolition of charges has remained pretty consistent at about 10 per cent. to 11 per cent. With the awareness that people now have that modern drugs are effective, and with the knowledge, too, that human beings will not pay for things which they can get for nothing, it was bound to be the case that the drug bill would go up even more steeply when the charges were removed. It has gone up by far more than the right hon. Gentleman expected and told the House, and it will go up still further.

The second reason why I think that the right hon. Gentleman should regret his precipitate decision to abolish the charges is that it must now be very clear to him that it has made matters far worse for the already overburdened general practitioner. On 1st February, 1965, the right hon. Gentleman said, when asked about the effect on the G.P.s: I do not consider that this will cause a considerably added burden on doctors. I have said that their fears, in my view, are very much exaggerated. He went on to say of prescriptions: …I do not believe that there will be any substantial increase…".—[OFFICIAL REPORT, 1st February, 1966; Vol. 705, c. 718 and 719.] What happened? Every general practitioner to whom I have spoken considers that the decision added considerably to his burden. People are now justifying to their doctors need for tranquillisers, headache and stomach pills and the like. Some doctors put the demand for additional prescriptions up by 15 per cent. to 20 per cent.

There was an interesting article in the Daily Mail on 22nd October last which brought out the fact that the Ministry of Health does not disclose the detailed analysis of prescriptions which it receives monthly from the National Health Service Joint Pricing Committee. Under its present statistical system today's situation will not be published until 1967. The Daily Mail says: …market research surveys tend to confirm that more people are going to their doctors with trivial ailments now that the charge has been abolished and that doctors are being less discriminating with prescriptions. Inter-continental medical statistics, a market research firm widely used by the pharmaceutical industry, report an increase in prescriptions for dressings—bandages, cotton wool, plasters—which often cost less than 2s. They also report a 14 per cent. increase in the number of people calling on doctors with vague symptoms (headache, pain in the stomach) rather than a specific complaint". Later the report says: The proportion of prescriptions for tonics, antacids, and other simple medicines has also increased, according to a survey carried out by sales representatives of Aspro-Nicholas. One knows this to be the case and one should have known in advance that this is what would happen. That is precisely why the doctors changed their minds about the removal of prescription charges. It was the sudden realisation of what this would mean to their already considerable work load. Certainly drugs are costing more. I was most interested in the figures given by the right hon. Gentleman, but he cannot get away from the fact that vastly more prescriptions are being dispensed—

Dr. David Kerr

The only thing which the hon. Gentleman has left unexplained is why the doctors came to this realisation six months before the prescription charges were taken off, and not years before. What happened six months before to make them realise this?

Mr. Braine

The hon. Gentleman is a member of the noble profession and he can aswer his own questions. I would be steering very wide of the mark if I started attacking, criticising or even defending the medical profession in this context. All I would say is that I do not think that even the harshest critics of the Government would argue that 15 months of Socialism have made the nation so sick that it needs this vast quantity of additional medicine.

I am well aware that this debate is confined but it is proper for one to say that it raises, in the most acute form, the whole question of priorities in the National Health Service. I have never disputed the right hon. Gentleman's sincerity or his knowledge and dedication to the Health Service. But in his sincere desire to abolish charges because of the promises that his party made, can he lay his hand on his heart and tell this House that this ranks as one of the first priorities? He knows that the Health Service is short of money, doctors and staff. He is now facing the greatest crisis ever in general practice.

Let us take a very brief look at the general picture. Over 90 per cent. of all known illness is treated by the family doctor. There are not enough of them to practise good medicine and every family doctor knows that this is so. I know what the Minister is trying to do in this connection, but he will be the first to acknowledge that the family doctor is overworked and underpaid. He must be greatly disturbed that in relation to the population the number of family doctors is now beginning to fall.

Mr. Deputy Speaker

Order. The hon. Gentleman is now getting well away from the particular Civil Estimate which we are now considering.

Mr. Braine

That is quite true, Mr. Deputy Speaker, and I will bear your warning in mind.

If one had the opportunity of deciding whether to spend money on removing prescription charges or on something else, I have not the slightest doubt what the answer should be, given the present state of the Health Service. For example, preventive medicine is a very poor second to curative medicine. A great deal of illness which could be dealt with by drugs if patients were treated by a doctor is not being treated at all. One in five diabetics die of the disease without ever having gone to a doctor. Many women are unaware that they have cervical cancer until it is too late. Anaemia in vast numbers of women is not being treated at all, and the majority of sufferers from psychotic depression never get near a doctor who might be able to help them.

I hasten to add that nobody can be blamed for this. I am not trying to throw brickbats at the Minister. The frontiers of medicine, as the right hon. Gentleman knows better than most in the House, are always being pushed back. Because of this, the priorities are always changing, and this is a powerful reason in itself why prescription charges should not have been removed so precipitately.

My right hon. Friend the Member for Reigate (Sir J. Vaughan-Morgan) exposed the weakness of the Minister's position. The Government have their priorities wrong in this matter. As the drug bill mounts—and I predict that it will mount ever more steeply—the mistake which the right hon. Gentleman and his colleagues made will loom ever larger.

6.12 p.m.

Mr. R. T. Paget (Northampton)

If I were faced with a choice of whether we should have the best Health Service or the most free Health Service, my choice would go to the best Health Service. Of course, we should like to have both, but if it be a question of choosing between free drugs or the best drugs, it is important that we should have the best drugs. We have drugs which are both free and the best.

But when it comes to apparatus it is not so. We are being denied, on financial grounds, in a direction in which I am interested, what is recognised to be the best apparatus. I am particularly concerned with what is referred to generally as the invalid tricycle, which can be supplied under Section 3(1,b) of the National Health Service Act—that is, medical, nursing and other services required at or for the purposes of hospitals". That was a bold interpretation of that Section, but when Nye Bevan saw a need he was bold in seeing that it was satisfied. Certainly invalid tricycles have done an astonishing amount of good in terms of human self-respect and human happiness.

The paralytic was almost a vegetable—confined to his house, a burden on his family, incapable of earning, incapable of independence. The tricycle gave him the capacity to earn. It gave him freedom. Almost in a word, it enabled him to live. But one thing from which it did not save him was loneliness. By being condemned to a vehicle which would take only one person, he was condemned to loneliness and the fear of loneliness.

I have had a great many very pathetic letters on this matter. One said, "I can get to work on my tricycle". Another said, "There is no other way in which I can be helped. I can never go out with my wife. I am condemned to loneliness." A person suffering from disseminated sclerosis wrote, "You must realise the fear of being alone, never knowing the next muscle which is going to go and condemned to not having somebody with you".

Mr. Deputy Speaker

The hon. and learned Gentleman has gone extremely wide of the Supplementary Estimate which we are considering, which concerns increased hospital pay awards.

Mr. Paget

I was dealing with Supplementary Estimate 14— …provision of hospital services under the National Health Service"— and this is a hospital service.

Mr. Deputy Speaker

If the hon. and learned Gentleman looks at the expenditure involved, he will see that it relates solely to increased rates of pay and the dates of the awards to which the increases relate.

Mr. Paget

I would much rather see a charge made in this respect than economies effected which mean that the best apparatus is not being used. It is well recognised that in many cases—not every case; in a number of cases the tricycle is ideal—a two-seater car of various sorts is the right apparatus, and—

Mr. Deputy Speaker

The hon. and learned Gentleman is returning to his original position, which was out of order.

Mr. Paget

I have made my point. I have done my best to urge my right hon. Friend the Minister to provide this apparatus. To my astonishment, he has refused the authority which would enable it to be provided on what seems to me to be the curiously despicable ground that if he had the power this House—

Mr. Deputy Speaker

Order. The hon. and learned Gentleman must not strain my indulgence any further.

6.19 p.m.

Mr. Paul Dean (Somerset, North)

The hon. and learned Member for Northampton (Mr. Paget), with his great knowledge of the ways of the House, has succeeded in making his point. For fear of incurring your displeasure, Mr. Deputy Speaker, I had better not comment on his remarks. I hope that the hon. and learned Gentleman will forgive me if I do not do so.

The theme which has run through the speeches of hon. Members opposite, and indeed through the speech of the Minister, is that the abolition of prescription charges was a correct allocation of priorities. The Minister quite rightly pointed to the fact that the National Health Service has not been starved of resources as a result. But surely the point—and it is the main point that I wish to make—is that if we are to meet the ever-growing demands which new medical methods are creating, we must get in resources to a greater extent than we have been able to do in the past. That, surely, is the central dilemma.

These two Supplementary Estimates illustrate the point extremely well. The drug bill will continue to grow as we get more effective and more expensive drugs. Certainly it will lead to great long-term benefits in the relief of suffering and in improving the health of the country. But more resources will be required. Equally, in the case of the pay of hospital staff, they are perfectly naturally and rightly going to want increased pay along with other sections of the community, and the real problem is that under present arrangements the overwhelming proportion of these resources comes out of taxation.

Every Government has met the dilemma that the resources are insufficient to meet the demand, and in my view the present Administration have increased the dilemma by abolishing prescription charges and, therefore, the money which came in in that way. After all, the right hon. Gentleman's own party met the dilemma in a very striking form when they had to put a ceiling of £400 million on Exchequer resources to the National Health Service in 1951 and introduce the charges.

The central dilemma came out very clearly in the National Plan. Speaking of prescriptions, the National Plan pointed out that it was not possible to plan and to foresee expenditure on this branch of the National Health Service, and it went on in page 184: …expenditure on the pharmaceutical services depends on prescribing by general practitioners, which is influenced by changes in the range of drugs available and in other ways. Partly as a result of that, we are now considering an extra £11 million on that account. Equally, total expenditure on pay depends upon the rates of pay, which are subject to change. Here again, we are dealing with an extra £29 million for the pay of hospital staff on that account.

The National Plan brings out the dilemma in this way on page 185: Although the share of the national resources that can be devoted to health and welfare is the main limit on the development of these services, the number of qualified staff available also inhibits the expansion of some branches of the health services. We all know that we shall not get the qualified staff that we require unless their pay reflects the movement in pay in other sections of the community.

In these two Supplementary Estimates, we are dealing with two factors which must, to some extent, be unpredictable in their costs and therefore raise the central dilemma of inadequate resources. The drug bill inevitably depends on the amount of sickness, the number of prescriptions, the cost of prescriptions and the composition of prescriptions, and therefore also on new drugs, more expensive drugs and more effective drugs coming along. Equally, hospital pay depends upon both the number of staff and the scales of pay.

On those two counts alone, the original Estimates have been underestimated in England and Wales to the extent of something like £40 million. If the Government are to succeed in keeping the increase in public expenditure to 4¼ per cent. a year, Supplementary Estimates of that order can easily throw the calculations out very badly. So I hope that the hon. Lady who is to reply to the debate will be able to tell us what the Government are doing to try to make estimates in these matters more predictable and, much more important, what the Government are doing to try to ensure better value for the money which is spent in these two connections. We heard nothing on those points from the right hon. Gentleman in his opening speech, and I hope that the hon. Lady will be able to say something about them.

I should like to illustrate the dilemma to which I have drawn attention in particular by reference to the Estimate dealing with hospital pay, which is the larger of the two. The total net revenue expenditure on the hospital service in 1964–65, which is the last year for which firm figures are available, was £570 million; in other words, something like half the total expenditure on health and welfare services. But, as my right hon. Friend the Member for Reigate (Sir J. Vaughan-Morgan) pointed out, of that figure of £570 million, rather more than 70 per cent. falls into the category of pay for the staff.

The position in the mental health field is even more striking, as I observe from a report which has come out today entitled "Progress in Mental Health" from the Office of Health Economics. It points out that in mental health, of the figure of 190,000 or so mentally ill patients in mental hospitals and general hospitals, the cost to the National Health Service is £114 million, about 90 per cent. of which is on nursing and domestic expenses. So we are dealing with what the economists would call a service which is essentially labour intensive.

That emphasises the vital need for labour-saving devices so that the valuable time of trained staff is not wasted. My right hon. Friend the Member for Reigate has already referred to the importance of efficiency studies, O. & M., work study, ancillary services and the like. They can do something to ensure that the time and therefore the pay of those highly-qualified staff are used to better effect, so that they can deploy their skills in a more effective way than they are able to do at the moment. This is very closely linked with pay, and it clearly raises the whole question of better facilities, including buildings.

How much of the time and therefore of the pay which at present is going into the hospital service is swallowed up by inadequate facilities and inadequate buildings? No one can say. In my view, the lesson is clear. One cannot divorce Estimates from more effective buildings within the hospital service, and I do not believe that we shall get them until we find ways of bringing in additional resources over and above those provided by the taxpayer and the ratepayer. I believe that we can get these additional resources by encouraging voluntary effort, by encouraging pride in local hospitals, through the League of Hospital Friends and so on, and by encouraging those who wish to do so to take out voluntary health insurance.

6.30 p.m.

Mr. J. Bruce-Gardyne (South Angus)

My hon. Friend the Member for Somerset, North (Mr. Dean) said that we were dis- cussing two particular Votes. I hope he will forgive me if I correct him and say that we are discussing three. I want to devote my remarks to the third of these, Vote 18, which deals with Scotland, and I am happy to do so because I think it will help to justify the summing-up of the debate by the hon. Lady the Under-Secretary of State for Scotland.

I note from this Vote that the pharmaceutical services in Scotland are likely to cost about £14¼ million during the current financial year, or about 23 per cent. more than in 1964–65. This is the gross cost, but the net cost to the taxpayer, after allowing for prescription charges in the previous financial year, is an increase of about 50 per cent.

Unlike my hon. Friend the Member for Essex, South-East (Mr. Braine), I have never regarded prescription charges as distasteful. On the contrary, I felt that the abolition of them was perhaps a classic example of what the Continentals have come to call the English sickness. A move of this kind, taken at a time when the Government had largely forfeited the confidence of their foreign creditors, was nearly the last straw which broke the backs of our foreign creditors. I say specifically "English sickness" because I believe that a Government in which Scotland was more firmly represented could never have indulged in such frolic.

What concerns me particularly is the effect of that decision on the general practitioner service, and in particular the general practitioner service in Scotland. In his opening speech, the right hon. Gentleman referred to the gross neglect of general practice by the previous Government. I am sure that he does not know, so I should like to tell him the result of 13 years of "neglect" of the general practitioner service. The total number of doctors in general practice in Scotland was higher at the end of 1963 than ever before, or since. During 1964 it rested on a plateau, and when these charges were removed the number began to decline rapidly.

In the first half of last year in Scotland there was a net decline of 29, that is, after allowing for the arrival of doctors from the medical schools in Scotland. In the second half there was a net decline of 33, and last week the B.M.A. in Scotland warned that if the drain on the general practitioner service in Scotland continued at the present rate it might be difficult to sustain a general medical service there at its present standard. This is the situation facing us, and I suggest that we have arrived at this situation largely because of the Government's decision to abolish prescription charges.

In a statement issued last weekend—and I am sure that the hon. Lady has noted this carefully—the B.M.A. calculated that over the past 18 months about 150,000 people in Scotland had been deprived of their family medical service. This is a serious situation, and I cannot see how it can be a coincidence that this decline occurred when prescription charges were withdrawn.

I wonder whether it is the Government's theory that one can pay for the cost of free prescriptions, at any rate in Scotland, by watching the decline in the number of general practitioners and economising on the rest of the general practitioner service so that in Scotland we shall soon have the situation that it is possible to get free drugs but it is not possible to find somebody to prescribe them.

Mr. Woodburn


Mr. Bruce-Gardyne

I do not believe that a service which is provided free is treated with respect by those who use it. Perhaps I might tell the right hon. Gentleman of an incident concerning a doctor in my constituency. He was summoned urgently by one of his patients. When he arrived, his patient asked him to dress her dog's back—it had hurt itself on a barbed wire fence. When the doctor pointed out that that was not his job, she explained that it would cost money to call a vet. Instances such as that are not unusual.

We have heard a great deal from hon. Gentlemen opposite to the effect that if there is over-subscribing it is the doctors who are to blame. But, as the hon. Member for Wandsworth, Central (Dr. David Kerr) pointed out, doctors have to consider the impact on their capitation fees of resisting the demand for free prescriptions.

Mr. Will Griffiths

Is the hon. Gentleman saying that the character of Scottish doctors is so inferior that rather than have the courage to tell their patients what they should or should not have they leave the Health Service and emigrate? If he is, it is a serious reflection on the medical profession.

Mr. Bruce-Gardyne

I am saying no such thing. What I am saying is that the abolition of prescription charges, coming on top of the other difficulties with which family doctors have to contend, has perhaps been the last straw. I do not believe that it is pure coincidence that the drain of doctors from Scotland, which is reaching serious proportions, started when prescription charges were abolished. Doctors there find that their services are being abused, and as a result they feel little inclination to carry on, and I believe that we shall be faced with a serious situation in the family health service in Scotland unless the present trend is reversed.

6.38 p.m.

Sir Keith Joseph (Leeds, North-East)

Considering the rules of order laid down by the Chair, we have had a satisfyingly wide debate, and we are grateful to you, Mr. Deputy Speaker, and to your colleagues for it.

At the beginning of the debate, the Minister defended himself on three grounds against the charge made from these benches of wrong priorities. First, he said that over a number of years his party made the most solemn of pledges. Secondly—and this was an honourable acknowledgment by him—he said that he did not realise how much it would cost. Thirdly, he said that anyway he has not felt financial cramp by the cost which has emerged. I should like to deal with these and other points which have arisen in the course of the debate.

I propose to deal first with the right hon. Gentleman's mistake. He openly acknowledges that it was a mistake, and all I can say, as my hon. Friend the Member for Essex, South-East (Mr. Braine) pointed out, is that there were a number of reasons available, even to people outside the Ministry, why he should have been somewhat sceptical of a forecast of the order which he made. But he was not the only Minister to make a mistake at about this time. At that time, in the autumn of 1964, the Chancellor of the Exchequer seriously misjudged the pressures on the economy. Historians of the future may say that it was odd that the first time this country had an economist as Prime Minister the economic situation was seriously misjudged during the first months in power.

So we have two mistakes, interacting upon each other. First, there was the Chancellor's mistake about the pressures on the economy—and the right hon. Gentleman honourably acknowledged this in c. 221 of yesterday's OFFICIAL REPORT—and, secondly, the mistaken assessment by the Minister of Health of how much the abolition of these charges would cost. We are left to wonder what would have happened had both Ministers not made these mistakes. If the Chancellor had got the pressure on the economy right and the Minister of Health had got the cost of the proposed abolition of the prescription charges right, it is probable that the Cabinet would have come to a quite different decision and that we should not be having this debate today.

Anyway, the right hon. Gentleman does not feel cramped by the priority he has chosen. He justifies this by telling us the amount of money that he has made available for three different medical subjects, all of them important. First, he says, "Look what the Government have done for medical education." That is very necessary and very important, but not yet very expensive. It is not of the same order of magnitude as the sums of money involved in this Subhead of the Supplementary Estimates.

Then he says, "Look—even today I am able to announce"—he got only as far as announcing it before he was stopped. He then went on to say that the Government had accepted the recommendation of Lord Cohen of Birkenhead's Committee on Health Education. We welcome that. But he did not tell us the cost of this acceptance, and we know from the intervention of my right hon. Friend the Member for Reigate (Sir J. Vaughan-Morgan) that although the acceptance of the recommendations of that Committee involves a substantial sum—£500,000—again it is not of the same order of magnitude as the figures that we are discussing today.

Thirdly, he says, "Look how generous the Government have been on hospital building. We are providing an extra £5 million." But if they had not provided that extra £5 million the current programme of building would have had to be cut back because of the rise in costs due to Socialist Government policy.

Hon. Members on this side of the House say that the Minister has not yet shown that he is not cramped by the decision that he has made. We say quite soberly that the test is still to come. It will come when he publishes his review of the Hospital Plan and when the Government face the recommendations of the Kindersley Committee on the award to doctors. I hope that the Minister has noted the sober warning uttered by my hon. Friend the Member for South Angus (Mr. Bruce-Gardyne) about the beginning of a drain of general practitioners from Scotland. Those are my main comments on the Minister's defensive position.

I now turn to the substance of the matter. Hon. Members on this side of the House grant all the technical points made by the Minister. We grant that the trend in prescription charges is numerically and financially up because of a more health-conscious population, a larger population, and a population containing more young people and more old people, and also because the therapeutic quality and therefore the cost of drugs has risen. We grant all these points, and go on to say that what is at issue today is not the whole of whatever may be the final cost of his decision—£40 million or £50 million—but simply a question whether the interests of our public health could have been better served by another use of part of this money.

My hon. Friend the Member for Somerset, North (Mr. Dean) put very clearly a number of points involved in this judgment. It is not a question of all or none; it might be a question of some charges to some people who could well afford them to enable the Government to spend more money on hospital building—people who could not, short of eccentricity, be said to be deterred by these charges. In a very interesting speech the hon. Member for Manchester, Exchange (Mr. Will Griffiths) sought to make an analysis of the philosophical differences between the parties. He said that the Conservative Party was always full of compassion for those in genuine need, but that once we went above those people we thought there ought to be a charge. Surely he must realise—and his hon. and learned Friend the Member for Northampton (Mr. Paget) pointed the moral—that we have a choice between everything free on the one hand and providing more things for those in need on the other.

There is a genuine dilemma in which those who argue for everything free find themselves, because they are ineluctably forced to prevent money being spent on very urgent needs—needs more urgent than those of the better-off people who could afford to pay something for drugs.

Dr. Sammerskill

May we take it that Conservative policy on this question is that some charges should be paid by some people?

Sir K. Joseph

The hon. Lady has been sitting most patiently throughout the debate and has now made that point twice. I shall not shirk it. I shall refer to it shortly. The hon. Member for Manchester, Exchange coined a phrase. He said, "When the Tories were in Government they took the florins and did not provide the hearing aids." This struck me as a rather memorable phrase, so I consulted our admirable Library, and our admirable Library referred me to the expert on hearing aids—and who should it turn out to be but the right hon. Gentleman the Minister of Health!

I was referred to an article by him in the New Statesman and Nation on 3rd April, 1964. The right hon. Gentleman did not fail to criticise the then Government if he thought that they were failing to do something for the health of the country, but in this article on hearing aids, which runs over three columns, he makes no criticism of the Government at all. I cannot imagine that if it were true he would not have said that the Government of the day were scandalously lax in providing hearing aids.

In fact, hearing aids have been provided free for all those who needed and wanted them. The right hon. Gentleman's article was concerned with the fact that despite this about 280 commercial companies were cashing in on the market. So the hon. Member's point rather falls flat. Although in the last few years we took a florin, we have, in all the time that they were available, provided hearing aids free.

Mr. Woodburn

The right hon. Gentleman thinks that the well-to-do should pay by way of prescription charges, but that is only a different method of paying. Would not they also pay through taxation?

Sir K. Joseph

They are paying in taxation already, because the National Health Service is largely supported by taxation.

Mr. Will Griffiths

The right hon. Gentleman has referred to me, but when I intervened it was when the right hon. Member for Bridlington (Mr. Wood) was speaking. It was he who posed the question about the alternative between charges and, in his own words, hearing aids. What I understood him to mean concerned the development of hearing aids other than the Medresco. I thought that he was referring to bone conduction hearing aids—a superior type—and putting a perfectly fair proposition. My reply to that was that the superior aid had not been produced by the former Government although they continued to take the florins from our pockets.

Sir K. Joseph

The hon. Gentleman must allow me to exploit the coincidence of discovering the hearing aid expert to be the right hon. Gentleman the Minister of Health.

I now turn to the question put by the hon. Member for Halifax (Dr. Summer-skill) about the Opposition's attitude to this subject. We acknowledge that the system of charges which was operated by us had the difficulty of all such things, that some people did not get exemption because they were just outside the exempt groups. We have thought very seriously about this problem. If we find, on our return to office, that the National Health Service is severely starved of resources, either for hospital building or for staff—in terms of numbers or pay—or of resources for apparatus, we shall see, among other things, whether we can evolve practicable methods of exempting all those who could be hurt or deterred by a reimposed charge.

When I say "all those", I am thinking of groups such as the elderly, the children, low wage earners, the chronic sick and disabled and pregnant and nursing mothers. Even if all these groups were exempted—and any other groups which were justified—there would still be some substantial numbers of the population left. Moderate charges on them would still be available to increase the volume of hospital building or the pay and numbers of staff and apparatus. That is the point which we are making, that it is not a question of all or none—

Mr. Pavitt

Has the right hon. Gentleman taken into account the policing system, the checking system, which would be needed in order to administer such a scheme?

Sir K. Joseph

Yes. The hon. Member knows as well as I—the Minister has not interfered with this—that the taxpayer has at the moment to find £1 million for the policing of the dental charges, yet the Government have not so far attacked them. Policing is certainly a factor to consider, but there would still be a substantial net benefit to the Health Service, far larger than the £5 million for hospitals, the half million pounds for health education and the few hundred thousand pounds for other education, to which the Minister referred—

Mr. K. Robinson

The right hon. Gentleman might have a look at the other estimate, that of staff and pay for the hospitals. That is not negligible.

Sir K. Joseph

No, indeed. It is not negligible, but the test, as I said to the right hon. Gentleman, will come when the award is made. That is when he may well long for more of the resources which he has conceded.

My right hon. Friend the Member for Reigate and my hon. Friends the Members for Maidstone (Mr. John Wells) and Essex, South-East pointed out very clearly the number of priority needs which the Health Service still has, which the Minister must want desperately to satisfy. My hon. Friend the Member for Essex, South-East pointed out how rapidly the frontier of medical skill is advancing and how inevitably this must lead to greater demands for greater resources. The hon. and learned Member for Northampton, before he was stopped, clearly showed how important, for the happiness of people, are extra resources in apparatus in the case of his argument for tricycles.

I thought that the Minister was a little disingenuous in arguing from an absolutely massive figure that the National Plan will be all that beneficial to the National Health Service. Of course, the fact is that the National Health Service took a stable proportion of a rapidly rising gross national product during the 13 years of Tory Government. Despite all the protestations and promises of the present Government, the share of the gross national product which it is plain from the National Plan that the National Health Service will be taking between now and 1970 is slightly lower than it is at the moment.

The right hon. Gentleman will acknowledge that the National Plan is based on a 25 per cent. increase in the gross national product by 1970. In chapter 20, we find that the increase in resources for the National Health Service is 23 per cent., marginally a smaller proportion of the gross national product than under the previous Government or, indeed, even than now. I hope that the Joint Under-Secretary of State will tell us why health expenditure will fall behind national expenditure between now and 1970.

We say to the Minister that this indiscriminate abolition of charges for all, whether they need help or not, must reduce hospital building and/or the numbers or pay of doctors and nurses and medical staff, or involve further increases in taxes or contributions. The hon. Member for Willesden, West (Mr. Pavitt), whose interest in this subject we all acknowledge, said that so much in the Health Service needs to be done. We agree. That is the burden of what we are saying today. It was true when we were in power, it is true now, and, because of the expanding needs of the country, it will be true in five years' time.

There will be less hospital building, fewer doctors, fewer medical staff possibly, resulting from the Government's decision to remove all charges wholesale whether the people from whom they were removed needed help or not, unless the Government are telling us that they will raise taxes or contributions even further just to make good this indiscriminate concession. That is the point which we are making against the Minister's policy and that is the point which we hope that the hon. Lady will answer satisfactorily.

6.56 p.m.

The Under-Secretary of State for Scotland (Mrs. Judith Hart)

I shall begin by dealing with one or two of the detailed points made, and then come to what the right hon. Gentleman the Member for Leeds, North-East (Sir K. Joseph) rightly said was the most important aspect of the debate—the fundamental conflict of principle with which we are concerned.

I would say to the hon. Member for South Angus (Mr. Bruce-Gardyne) that he made a singular and extraordinary speech about the loss of doctors in Scotland. His figures were not wholly correct, in that the figure which he was quoting of the loss of doctors quoted by the B.M.A. last weekend in Scotland referred not to any period since the abolition of prescription charges, but to the 18 months to the end of last December. Therefore, it bore no strict relation whatever to the ending of the charges.

Indeed, when the period is broken down into quarters, a steady decline is revealed right from July, 1963, onwards, culminating, I agree, in the highest number in the quarter ending October, 1965, but related, I suggest—he must know that this is true—not to the abolition of the prescription charges but to the general discussion of general practitioners' discontents during last summer.

On the supply of medical manpower, I would say that, had there been more extensive plans for the provision of more medical schools, instead of the result of the plans of his own hon. Friends, the output would have been something like 200 doctors more during this period. In justice, he must accept that, in the last year, my right hon. Friends the Minister of Health and the Secretary of State for Scotland, in the discussions which they have had with the general practitioners, have done more to set general practice on a proper footing in this one year than was done in the whole of the previous decade.

Because of the National Health Service Bill which we discussed last week, because of the new arrangements which are being made in discussions with the general practitioners and because of the new links with the hospital service, we in Scotland are creating the satisfaction in the job which is the main concern here. It is not, I suggest, worthy of the hon. Member to relate his statistics in this respect to this one isolated point. He can do better than that.

I will now give the accurate figure for which the hon. Member for Essex, South-East (Mr. Braine) asked. There has been some confusion between the annual figure and the figure for 10 months and between the figure for England, Wales and Scotland and that for England and Wales alone. This was confusing the House earlier. In fact, the precise figures for the 10-month period are these—in England and Wales, 33 million additional prescriptions; in Scotland, 3.3 million. This is the clear figure which the hon. Gentleman wanted—

Mr. Braine

The figure for the seven months was 23 million, which if my arithmetic is correct, would mean that, in 10 months, it would have increased to 30 million. The figure of 33 million, therefore, bears out my contention that the increase in the number of prescriptions seems to be accelerating.

Mrs. Hart

There is no evidence for this. When one begins to look at a breakdown of the number of prescriptions over different months of the year one has to take into account all kinds of other factors, such as the incidence of different diseases and illnesses. But one cannot reasonably break down the figures any further.

The right hon. Member for Reigate (Sir J. Vaughan-Morgan) spoke about the Whitley Council system. He asked what investigations my right hon. Friend was making into this. My right hon. Friend tells me that, very much to his surprise, he found when he came into office, that the staff representatives were not dissatisfied with the basic Whitley structure. There were a number of discussions with them over the last year and with the T.U.C. Some suggestions for improvements have been implemented and others are being considered. But my right hon. Friend's own proposal was made because of the frequent failure of the Whitley machinery to reach agreement and, consequently, the frequent recourse to arbitration. This was what worried him. It is worth noting that in the first 12 months of the Labour Government there was not one single reference to arbitration. This is a measure of the fact that the machinery is working a good deal more smoothly than was the case previously.

Sir J. Vaughan-Morgan rose

Mrs. Hart

I think that my reply deals with the point which the right hon. Gentleman made. I can see that many points will arise on every reply which I make, and if I give way each time it will take far too long.

I want to give a little information about the length of stay in hospital, which the right hon. Gentleman mentioned. He will be interested to know the kind of research which is being done into a question of this kind—operational research which is comparatively new in the Health Service. King Edward's Hospital Fund is carrying out research studies which include the study of communications and discovering some factors related to the length of stay. We are proud that in Scotland last year we set up a new research and intelligence division which is dealing with operational research and which is to continue the work study activities already in progress.

May I turn to the general theme of the debate? I think that I need not go in detail into points which have been covered by my right hon. Friend and by both Front Bench speakers opposite on some of the factors involved in the increasing number of prescriptions and the increasing cost of the drug bill. These include increasing community and hospital care, new drugs, the fact that mentally ill people are treated at home, the increasing number of old people and so on. The right hon. Member for Leeds, North-East covered these briefly in his summing up.

We must recognise basically that people go to the doctor when they are ill. One can establish this by reference to the analyses which are provided. Any hon. Member who doubts it should look in detail at the health statistics. If he does that he will find that there are seasonal variations in the average daily number of prescriptions issued by the chemists. I will give four examples of the highest peaks which have been reached in the last few years—February, 1956, October, 1957, February, 1959 and February, 1961. In those periods there were outstandingly high peaks in the number of prescriptions dispensed daily by chemists.

In each case the month of peak prescriptions corresponds with a peak in the number of deaths from acute respiratory illnesses, whether influenza, Asian flu or one of the other virus influenzas or acute bronchitis. In each case there is a steady relationship between what we know about the incidence of illness and what we know about the spread-over of prescriptions. There are no facts to be found to refute the claim that the frequency of prescriptions is related to the incidence of illness.

The hon. Member for Angus, South talked about the trivial reasons for which people went to the doctor. I think it was he who spoke about the priority which needed to be given to preventive medicine. Does he not understand that if people do what they are advised to do in preventive medicine—consult their general practitioners when they have early symptoms of any illness—then some of the early symptoms may not be symptoms of serious illness? Every general practitioner interested in preventive medicine, as most general practitioners are interested in it, welcomes the fact that patients come to him with early symptoms. This is a reflection of the fact that people go to their doctors when they are ill.

Mr. Bruce-Gardyne

Surely the argument is not about whether patients are being deterred from going to a doctor. We are concerned with whether they are being encouraged to collect prescriptions without any serious regard for the need for those prescriptions.

Mrs. Hart

To the extent that the hon. Member means what he says, he was answered by my hon. Friend the Member for Manchester, Exchange (Mr. Will Griffiths).

It is, of course, of the greatest importance within the Health Service that there should be the kind of operational research which allows proper cost control to be exercised. I am surprised that no hon. Member opposite has touched on that, because I should have thought that they would recognise the importance here of the work being done in this respect and of the studies being made by the Ministry of Health and in Scotland into the causes for regional variations and into the patterns of prescriptions to see whether any points are revealed which indicate any further need for cost control.

We are concerned with a matter of principle, and we are also concerned with the question of which other priorities the Government might have taken. May I indicate, briefly, the example of Scotland? In the course of the next five years—between now and 1971—we shall spend £60 million on the hospital services of Scotland compared with £34 million in the previous five years of the previous Government. This is an indication of the expansion of the hospital services which a Labour Government are prepared to undertake in Scotland. It means that we are to provide over 2,000 additional geriatric beds and over 650 new and replacement maternity beds and to continue with the programme of district and teaching hospitals. This is an indication of the fact that within the context of the National Plan there is a degree of expansion of the hospital services which far exceeds and is almost double that which was achieved by the previous Government in the last five years.

Sir K. Joseph

Is this expansion significantly different from the expansion forecast: by the Hospital Plan produced by the previous Government?

Mrs. Hart

The 2,000 geriatric beds and the 650 maternity beds are new provisions which were not in the previous Plan.

Mr. John Wells

It is interesting to have the figures for Scotland, but is not the south-east of England being robbed to the same extent that Scotland is being well looked after?

Mrs. Hart

No. I can assure the hon. Member that that is not so.

May I turn to the basic economic and political conflict of principle? Many of my hon. Friends were most interested, as I was, to hear the replies given to my hon. Friend the Member for Halifax (Dr. Summerskill) who asked the question twice—what have the Conservative Party in mind? One had assumed from various things said in the past that they supported the reintroduction of prescription charges.

The right hon. Member for Bridlington (Mr. Wood) said quite clearly that he and and his hon. Friends would keep the system of prescription charges but remove the inequities in it. The right hon. Member for Leeds, North-East went on to expand that and to define some of the categories which he thought needed help. It is not good enough for hon. Gentlemen opposite to define categories like old people, pregnant women, the chronic sick and those with low incomes unless they are prepared to go on to explain how this fits into a new pattern which presumably they are about to devise.

There are many questions which they have not attempted to answer. The logic of their argument leads one to ask a number of questions to which apparently they cannot find answers. For example, would they confine their help—or expect us to do so—if prescription charges were kept, to people on National Assistance? Would they have us take account, in those circumstances of the chronic sick? This is one of the categories which the right hon. Member for Leeds, North-East particularly mentioned in a speech he made on 29th October last to insurance brokers in Leeds, when he said: There must be more generous help for those with chronic illnesses". How would he define "chronic illness", knowing that the doctors are trying to move away from that phrase because of the medical problems involved and the psychological effect of defining someone as "chronically ill"? Hon. Gentlemen opposite must answer these questions if they want to convince us that they have a workable alternative—and I will refer to the ethics of their alternative shortly.

Would they take account of the lower wage earners? I gather from what they have said that they would, but how, in that event, would they define the people who need help? Would they subsidise everyone whose wages fall below the national average, and so subsidise the employer who does not pay high enough wages? Do they believe in a minimum wage or income? We have not been given any indication of their answers to these questions.

Let us consider those who certainly need help. Would families who are above the National Assistance level but living on low incomes, to which attention was drawn recently—if we take the figure of 11 per cent. of families with children under 16 whose gross household income is only £10 to £15 per week; there are a lot of people in this bracket—be due for help? The only answer is that, in the long term, one can meet this kind of problem only by the gradual redistribution of wealth and income. One cannot meet it simply by a sort of ad hoc donation to particular categories of people, as the previous leader of the Opposition would have favoured.

The right hon. Member for Bridlington suggested that one thing which, in his view, should be encouraged, within the context of a society which imposed prescription charges, was insurance for private medical care to reduce the costs and raise more money for the National Health Service. Some years ago the right hon. Member for Enfield, West (Mr. Iain Macleod) expressed himself as very positively in favour of putting the Health Service into the category of a means test social service.

At that time the right hon. Gentleman was in full agreement with his hon. Friend the Member for Stratford-on Avon (Mr. Maude) and his right hon. Friend the Member for Wolverhampton, South-West (Mr. Powell). I do not know whether they are all three in agreement on a means test Health Service. If so, they are saying—and the right hon. Member for Bridlington and the right hon. Member for Leeds, North-East are saying—that health should be treated as a commercial commodity; that there should be—and this has been put forward by Conservative economists in recent years—a free market in medical treatment. They are apparently prepared to apply classical economic theory to the provision of health services and to ignore all the professional standards or medical ethics. Their point of view was put at its most extreme by the American Medical Association's Research Economist, Dr. Dickinson, who said not long ago: The doctor is essentially a small business man. He is selling his services, so he is as much in business as anyone else who sells a commodity. This kind of private medical market place is the thinking of Conservative economists and is what lies behind the tenor of what we have heard from hon. Gentlemen opposite today. As Professor Titmuss put it some time ago, to apply this kind of analysis to consumer demand is to equate mink coats with Caesarian operations in childbirth.

Several Hon. Members rose

Mrs. Hart

I will not give way, because I am making the fundamental point that the logical extension of the means test Health Service, in which the right hon. Member for Enfield, West believes—of giving help to those within the Health Service who are in special categories, about which the right hon. Member for Leeds, North-East spoke, and the need to retain charges but to remove some of the inequities, about which the right hon. Member for Bridlington spoke—leads, although perhaps some of their hon. Friends have not yet understood this, to the concept of a free market place, something which has been advocated by many leading Conservative economists, notably Dr. Lees in the pamphlets which he has published in the last two or three years.

In our view the individual has the fundamental right in a good society to a free health service and we believe that there should not be a tax on illness. It is a matter for ethical judgment and—[Interruption.]—

Sir K. Joseph

Before the hon. Lady proceeds, would she answer two points? First, is she aware that her attitude is inevitably preventing the Government from spending money on urgently needed priorities and, secondly, will she say why, with this attitude, the Government are reducing in their five-year plan the share of the gross national product going to the National Health Service?

Mrs. Hart

The answer to the second question is that we are concerned—and I take it that the right hon. Gentleman is equally concerned to have a rapid expansion of the Service in terms of hospital building and everything else. This we are going to achieve, as our figures show. Within the context of the National Plan we are achieving much in the sphere of pensions and education that hon. Gentlemen opposite utterly failed to do—[Interruption.]—and while I hear an hon. Gentleman opposite saying that we are merely reducing the slice of the cake, as he knows, the share of the gross national product which goes fundamentally to the people in the form of education, the Health Service and pensions—

Mr. Speaker

Order. The hon. Lady is getting a little wide of these Estimates.

Mrs. Hart

I was provoked, Mr. Speaker. I will end by saying that we are concerned with ethical judgments, with fundamental political attitudes and relative judgments. I can only believe, from what has been said by hon. and right hon. Gentlemen opposite, that their judgments are either irrelevant or wrong.