HC Deb 10 February 1966 vol 724 cc759-72
Mr. W. R. van Straubenzee (Wokingham)

I beg to move, That an humble Address be presented to Her Majesty, praying that the National Insurance (Medical Certification) Amendment Regulations 1966 (S.I., 1966, No. 26), dated 14th January 1966, a copy of which was laid before this House on 19th January, be annulled. I think that it might be of assistance to the House, if with your approval, Mr. Speaker, and that of the House, we are permitted to discuss the following Regulations on the Order Paper: That an humble Address be presented to Her Majesty, praying that the National Insurance (Industrial Injuries) (Medical Certification) Amendment Regulations 1966 (S.I., 1966, No. 27), dated 14th January 1966, a copy of which was laid before this House on 19th January, be annulled.

Mr. Speaker

I have no objection, if the House has no objection.

Mr. van Straubenzee

It might be helpful if I attempted to explain in shorthand how these Regulations affect the present position. I will try to do this as quickly as I can. At present, a final doctor's certificate can only be for a period of three days. Under the Regulations we are now discussing it is possible for a certificate to be granted up to seven days. That is the first of the two effects of the Regulations. There are two possible applications of this extension from three to seven days. The first is where an illness is unlikely to last longer than seven days and the second is at the end of a long illness where the patient is likely to recover within the next seven days.

The second effect of the Regulations is that whereas at present doctors have to issue weekly certificates for the first 28 days—that is, they have to issue a certificate once every seven days—they will in future, when the illness is likely to last more than seven days, be able to issue one forward certificate up to 28 days. It is important to make it clear that a final certificate is still required but that only one standard form will be necessary in future.

I hope that the Parliamentary Secretary will feel that in those few short sentences I have truncated these somewhat complicated Regulations. I must apologise to the galaxy on the Government Front Bench for keeping them up at this comparatively late hour, but this is the product of our regulations.

It may assist the House in discussing the Regulations if I set the background and allow the House to judge the scale. I understand that at any one time there may be between 800,000 and 1,200,000 people in Britain unable to go to work because of illness. What we are talking about at present rates of benefit—that is, over the whole range—is a cost to the National Insurance Fund of approximately £180 million a year. That is the justification for taking a few minutes to look at this further extension of the Regulations. In any one year, about 40 million medical certificates will be issued. I confess that until I had looked at the matter I had not appreciated the wide range over which certificates can be issued. But of those 40 million the great majority are for sickness benefit.

It must be said that there are very powerful arguments in favour of these Regulations. The first is simplification. For example, the application of the seven-day rule, which is the first of the two changes proposed in these Regulations, means that in the great majority of cases there will be only one certificate instead of two. In the application of the 28-day rule which is the second of the changes made in the Regulations, two certificates will be issued instead of four. I have seen it estimated authoritatively that if the House approves these Regulations the reduction in the number of certificates which have to be written by the medical profession will be as many of 4½ million. That is the scale of what we are talking about—very big money and a very large number of certificates.

The second powerful argument in favour of approving the Regulations is that it is claimed that in future visits both by and to doctors will be dictated solely by medical requirements and not by the calendar requirements of the certificate period. It does not need me to gild the lily by saying that a time of great pressure on doctors this is a very important consideration.

I felt it right at the outset to refer to these very powerful arguments in favour, which I have no doubt the Parliament Secretary will underline. If I now concentrate on the arguments against, it is partially because of the nature of our procedures and partially because I have no doubt that the arguments in favour will be competently handled by the Parliamentary Secretary himself.

The arguments against are overwhelmingly concentrated on the 28-day rule and not on the seven-day rule. The extension of the rules to the seven-day certificate procedure has met with general approval. It is largely on the 28-day extension that anxieties have been expressed.

The first anxiety was voiced by the National Insurance Advisory Committee, not when it was discussing the Regulations now under review, but when it was discussing the previous change, made last year. It is rather under a year ago that the Committee issued its interesting Report, and its anxieties about the Regulations then under consideration were, first, that in its judgment then it was impracticable to devise worth-while lists of conditions which would not be too conflicting, on the one hand, and too vague and ambiguous, on the other. The Regulations upon which the Committee has now reported largely meet that particular objection, because they are a simplification, but the other two remain.

The other two objections which it then pinpointed were that it was not possible for a diagnosis and a prognosis to be sufficiently firm in the early days of an illness to justify a 28-day certificate. Its second anxiety as previously expressed was that, psychologically, to be the recipient at the very outset of an illness of a 28-day certificate might have a very adverse effect. I repeat that those are not my arguments, but those of the right hon. Lady's Advisory Committee.

Let me give an example of the sort of thing that I mean. The illness which we all call jaundice, but which is now generally known as hepatitis, is a very lowering disease; it makes one want to murder one's wife, or whoever is closest to one. It is a disease where the morale of the patient is very low. Many years ago I myself suffered from it as a boy. If, at the outset of that disease, a doctor were to prescribe a 28-day certificate, it could have a debilitating effect upon the morale of the patient, and that was the anxiety which was expressed so well in the report of the Advisory Committee.

I am very much obliged for the presence of the Parliamentary Secretary. Is he satisfied that the arguments in the second report of the Minister's Advisory Committee, which largely base themselves on the pressures on doctors, outweigh the arguments in the first report which were largely based on the clinical and psychological effects of a 28-day certificate? If he reflects on paragraph 22 of the Committee's report on the present Regulations, I am sure that he will agree that, to put it mildly, it is giving its approval reluctantly.

The Committee still believe that the clinical and psychological objections remain, and I should like to be sure that the hon. Gentleman is satisfied that the claims of the pressures on the doctors are such that they outweigh the clinical and psychological objections which were so powerfully argued by his right hon. Friend's Advisory Committee less than a year ago.

So strongly did the Committee feel, that it sought three assurances. First, it sought an assurance that the medical services available to the patient would not be affected by these new Regulations. Secondly, it sought an assurance that in future visits to patients would be dictated solely by medical considerations. Thirdly, it sought an assurance that the only effective reduction in medical visits by doctors as a result of these Regulations would be visits by doctors purely and simply for certification purposes.

Those were the assurances sought by the Committee, and my second question to the Minister is, is he satisfied with the assurances which the Committee received as a result of this Report which is now before us? Is he satisfied that, in all the circumstances, the assurances are as good as they ought to be in view of the Report?

The second objection to these Regulations came from the T.U.C. who, perfectly properly and responsibly, highlighted the position of employees who are members of occupational sick pay schemes. The T.U.C. argued that these men and women would be required to produce weekly certificates, and that a situation could arise where employers might require certificates more frequently than will be mandatory under the Regulations if they come into force.

The T.U.C. argued that if certificates were required more frequently an employee might find himself in the difficult position either of having a doctor refusing to give a certificate more frequently, or of him making a charge for that certificate, and, not unreasonably, the T.U.C. asked that this real objection should be considered most carefully. The answer given by the right hon. Lady's Committee is contained in paragraph 23 of the Committee's Report, but it is a lukewarm assurance. The Committee says: On this we have had some reassurance. That is not a strong reply or reassurance to genuine anxieties.

As I understand the Report, employers, through their corporate body, have undertaken that all their members will be encouraged to fall into line, that they will all be encouraged not to ask for certificates more frequently than will be required under these Regulations, and that they will not ask for separate additional certificates. I must, however, draw the Parliamentary Secretary's attention to the closing words of paragraph 23, where it says: We would have found it most difficult to approve the draft regulations if we had not been prepared to believe that employers generally would respond sympathetically to the suggestions which have been made to them by the Government. Are the Parliamentary Secretary and his right hon. Friend satisfied that the undertakings given by the employers will be honoured, and that the fears of the T.U.C. are groundless?

I must refer to an objection which interests the general public, namely, the extension to 28 days of the period for which a certificate can be granted. It is suggested that this will encourage scrimshanking or evasion. There are respectable precedents for making this accusation. Lord Robens, who has a name to conjure with, and who is respected on both sides of the House, recently made a vigorous attack on absenteeism in the coal mines. He told the country that last year it cost, in production, the equivalent of £64 million, which itself was equivalent to shutting down for three quarters of a year the whole of the West Midlands Division of the Coal Board, which is its most productive division.

The anxieties expressed in some quarters that there may be an element of evasion if this scheme is brought into effect cannot lightly be thrown aside, in the light of Lord Robens' statement, but hon. Members on both sides of the House must be very careful before making wild assertions of widespread evasion. That is why, on the last three occasions when we have discussed this question—all in the space of a week—both Front Benches have been at pains to make it clear that if there has been evasion or a stretching of the rules it is on a comparatively small scale, and affects a comparatively small number of people. Unless there is much firmer evidence than exists at present I do not regard it as responsible to make theatrical assertions from this Box that our people, generally speaking, are grossly abusing the system.

The first check on the system is the integrity of the doctor. The House must understand the considerable difficulties under which doctors labour in this respect. Let us consider the case of a closely-knit community—a mining community or a community in the deep country. If a doctor there gets a reputation for being very hard in the matter of giving certificates it may be difficult for him to conduct his practice.

There is no secrecy in certificates. A certificate is a public, open document. If a patient arrives to see his doctor on Monday morning, plainly unable to go to work, from a medical point of view, and if it is clear to the doctor that his patient's weekend has not been spent in mental and physical refreshment—as we hon. Members are accustomed to spend our weekends—he cannot say so with blistering frankness on the certificate. I am told by my medical friends that it is not known for diagnoses in hospital to be written down followed by the letters G.O.K., which, I understand, stand for "God only knows".

The medical practitioner is not given that let-out. His is a public certificate. It is only reasonable and honourable for the medical practitioner sometimes to play safe. He may feel that the condition which he is investigating is the early condition of something much more serious. In that connection, we should not overlook the increasing peril which doctors face now in view of the very welcome spread of the legal aid system.

The second check is the reference to the Minister's regional medical officers. I know that there is the initial stage of the legal officers, but I am concentrating on reference to the medical officers. In 1963, 544,000 were referred to the regional medical officers and that is no light figure. It is tailored to the facilities of the Ministry for conducting these reviews. It is not a significant figure, in the same way as the selections for the 11-plus will reflect the places available at local grammar schools.

When one breaks down those figures for 1963, one finds that, of the numbers referred, just over 50 per cent. were found to be incapable of work, 10 per cent. were capable of work, 20 per cent. had recovered before the examination and 20 per cent. never attended the examination at all.

Mr. Speaker

I hesitate to interrupt the hon. Gentleman, but I hope that he will link his remarks with the changes proposed in the Regulations.

Mr. van Straubenzee

I apologise if I have inadvertently strayed, Mr. Speaker. I was about to argue that the change in the 28-day regulation from seven to 28 may cause an extension in the number of references to regional medical officers. But, of course, I see that that may be only lightly touched upon.

I think it only fair, since I have made that case, to say that, in the Report of the Advisory Committee, the reply is given that the reference procedures which may be extended under the 28-day rule are only, in the main, applied where the illness could have been expected to be short, but in fact was of much longer duration and that therefore it is normal for about 40 per cent. of the references to have recovered before the regional medical officer investigates their case.

Therefore, I conclude, with one most important proviso, that the abuse, if there is abuse, is very strictly limited. I think that it is right to say so. The proviso is mentioned in the Advisory Committee's Report. If these Regulations are brought into force, I understand that it is calculated that they can easily be in force by June, 1966. It therefore follows that the figures from June, 1966, to June, 1967, can be available, according to the Report, by August, 1968. It will, therefore, be possible to review the figures by the end of 1968. The proviso is that there should be, in accordance with the Advisory Committee's recommendations, a review of the figures by the end of 1968. This is the advice tendered to the Minister by her Advisory Committee.

The question I should like to ask the Joint Parliamentary Secretary, finally, is whether he and his right hon. Friend accept the recommendations of the National Insurance Advisory Committee that the Regulations that we are now discussing should be reviewed in any case not later than the end of 1968. It seems to me that that is a minimum requirement if we are to give this extension both to the medical profession and to the Ministry.

I apologise for having taken a little longer than I intended, but these are complicated matters, and I have put the matter in as fair a perspective as I have been able. I am certain that it is necessary, though tonight we certainly cannot explore it in any sort of detail, to remember that if there be any abuse, it is not a disease in itself but a symptom, and that what is being done under successive Governments by group practices, by secretarial assistance, by special provisions in the review body and the rest for relieving the pressures on doctors will mean that they will be better able to operate the certification procedures which we are now discussing.

I hope that what I have said will help us not only to examine this very important matter in some detail but, in the context of the National Insurance and National Health Service as a whole, to keep it in proper perspective.

Mr. Speaker

I would call attention to the fact that we cannot discuss the whole question of National Insurance and the registration and certification of illnesses, apart from the way in which they are altered in the Instrument which is before the House.

10.33 p.m.

The Joint Parliamentary Secretary to the Ministry of Pensions and National Insurance (Mr. Norman Pentland)

Mr. Speaker, I have taken particular notice of your remarks because the hon. Member for Wokingham (Mr. van Straubenzee) covered a very wide area which, to my mind, was not specifically related to the Regulations which we are discussing tonight.

Perhaps I can begin, as the hon. Gentleman did, by reminding the House of the purpose of the two sets of amending Regulations. It is to lighten the burden of non-medical work which doctors are expected to carry—that is, to reduce the 40 million certificates a year which they were issuing for National Insurance purposes. I might add that a reduction in the number of certificates is not so important as a reduction in the number of visits which had to be made to and by doctors weekly under the old rules simply for the purpose of issuing certificates at weekly intervals. That is one matter to which the hon. Gentleman referred—the pressures there are on the doctors.

The hon. Gentleman correctly interpreted the change that the Regulations make, and here I come to the hon. Gentleman's other point. The doctors will, of course, be able to issue the certificates that are necessary when they have to see patients for medical reasons. This has a bearing on the hon. Gentleman's probing about the pressure on doctors, and his question as to whether or not a doctor would now be able to concentrate more upon the medical requirements. It is not an arbitrary interval of a week, as under the old rules. In case it is thought that this certification in advance is something new for doctors, I might remind the House that once an illness had lasted a month, doctors were always able to issue certificates for up to four weeks in advance and, from March 1965, for up to 13 weeks in advance.

Two national committees, the National Insurance Advisory Committee and the Industrial Injuries Advisory Council, have approved the purpose of the Regulations. There are separate Regulations for each side—the sickness benefit and industrial injury benefit sides—but as the test is "incapacity for work "on both sides and as it is no part of the doctor's responsibility to decide whether a claim is for sickness or injury benefit, the rules must be the same. Both advisory committees include among their members representatives of employers and employed persons, and the N.I.A.C. took oral evidence from the representatives of the employers, the C.B.I., and of employed persons, the T.U.C.

The hon. Gentleman questioned me about the concern of the T.U.C. in regard to the certificates. They were concerned about the possibility of employers requiring employees to submit and pay for weekly private certificates, although the doctor had issued a National Insurance certificate for longer than a week under the new rules. As the hon. Gentleman said, in its Report the N.I.A.C. referred to assurances that it had been given by the employers' representatives to the effect that they would do what they could to encourage employers not to ask for certificates at more frequent intervals than were required for sickness benefit purposes. The Committee also referred to the fact that my right hon. Friend the Minister of Health had sent letters to employers generally asking them, for occupational sick-pay purposes, to follow the practice already followed by many of accepting the sight of a certificate or a copy of one issued for National Insurance purposes and not to ask for a separate certificate.

It is also true, as the N.I.A.C. stated in its Report, that certain people had misgivings about absenteeism but, as it also said, the Ministry knows little or nothing about absences from work of less than four days. The word "absenteeism" has been bandied about quite a lot recently, both outside and inside the House. It was referred to during the Second Reading of the National Insurance Bill on Monday by hon. Gentlemen opposite and I also referred to it in my speech replying to the debate.

What do people mean when they use the word "absenteeism"? To some it means the odd day or so's absence from work. I wish that they would tell us what they mean about absenteeism in connection with National Insurance certificates. In fact, the odd day or so's absence from work has little or nothing to do with these certificates. But it has a lot to do with employers and we would be very interested to know the extent of it and what employers are going to do about it. The National Coal Board publishes its figures but, strangely enough, other employers are rather reluctant to publish theirs.

It is not perhaps realised that we are not normally interested in absences of less than four days and we do not normally hear about them. National Insurance benefits are not normally payable for less than four days' absence and therefore patients do not normally ask for certificates and doctors do not normally issue them. Instead, patients ask for private certificates which it seems they need for their employers' purposes. I have already dealt with that aspect of the private certificate.

Even supposing such days were covered by National Insurance medical certificates they would not normally attract benefit. Still less would they attract the proposed new earnings-related supplement for which there has to be a preliminary waiting period of a fortnight. To argue that the prospect of earnings-related sickness benefit will lead to increased absenteeism—and the hon. Gentleman implied as much—only makes sense if right hon. and hon. Gentlemen opposite are thinking in terms of absences of longer than a fortnight which will qualify for the earnings-related supplement.

If the Opposition think that, they must also be thinking that doctors will issue certificates for longer than a fortnight, regardless of the circumstances of the particular case. They must also be ignoring our control procedures, although the hon. Gentleman did not do so. It has been implied—and the hon. Gentleman, although fair in many respects, did imply—that, because the rules for certification are being relaxed, doctors will relax their checks on absenteeism.

Are the Opposition then saying bluntly that they do not trust the doctors? Such questions are bound to be asked by people outside, because the whole trend of the Opposition's case means that, in the last analysis, they do not really trust the doctors. One can go further. Are the Opposition implying that they expect the doctors to act irresponsibly and issue indiscriminately certificates for complete weeks or months without regard to the nature of the illness or the time the patient may be expected to be incapacitated? Alternatively, are they saying that doctors will submit to pressures to issue certificates for longer periods than their judgment would indicate? Are they saying that doctors will issue certificates for longer than a fortnight just so that patients can get the earnings related supplement?

I should explain that we expect the doctors to issue a certificate saying what a person is suffering from and how long it is likely to make him incapable of work. That is all. But some people seem to think that the doctors should act as policemen. I was interested to read an article in the Economist on 29th January. I will quote an extract. It said: In any case, doctors are not employed by industrialists to keep absenteeism down. Nor are they concerned with the level of sickness benefit, which must affect workers' willingness to go sick, and which, when related to wages as is now proposed…will encourage more of them to do so. The Ministry of Pensions has its own system for checking unjustified claims for benefit. If employers find a comparatively high rate of absenteeism among their workers, they should ask themselves what is causing it, instead of relying on doctors, and extra, private, certificates, to keep it in check. A doctor is concerned with a patient and his symptoms, and it is hoped that the new rules will allow him more time to investigate these than he has at present. Even if the hon. Gentleman thinks that claimants will make the most of the new certificates, and even if he is rather sceptical about the control procedures which the Ministry has in operation at present, obviously the Economist does not.

As I have said already in the House, we have a regular system of checks on incapacity for work. The latest figures show that during 1965 we referred to regional medical officers and appropriate health departments some 628,000 sickness benefit claimants and about 190,000 injury benefit claimants for an independent medical opinion on incapacity for work, a total of 818,000 references in the year. Additionally, we made about 476,000 visits to claimants in their own homes in that year to satisfy ourselves that incapacity for work was continuing.

Of all the claimants referred during 1965, about half were considered by regional medical officers to be incapable of work. The hon. Gentleman referred to the work which was being done by the regional medical officers. I am also delighted to see the right hon. Member for Bridlington (Mr. Wood) in his place, because as he was the responsible Minister in the last Government he knows full well the work that is done in these control procedures.

This hardly suggests that the Ministry is easy in applying these control procedures. Indeed, it has been alleged on more than one occasion that we are far too quick off the mark in checking on people's incapacity for work. I heard that criticism long before I became a Member of Parliament. As I said in Monday's debate, we are fully aware of the comparatively small number of people we have identified for our own purposes as malingerers, but for obvious reasons we do not make public how we identify them for special control action. I know that the right hon. Gentleman will agree with that.

People generally may not know about them; but this, too, is understandable. I am talking now about people outside not knowing about malingerers, because malingerers are hardly likely to make public the fact that they are subject to special control action every time they make a claim for benefit; nor will they make public the fact that benefit is often withheld. They will just not disclose these facts.

I could go on about the purposes of the Regulations, but to keep strictly within the confines of order I end by saving that we recommend to the House these Regulations which my right hon. Friend laid before the House in January of this year and we hope that they will be accepted.

10.49 p.m.

Mr. Van Straubenzee

I am sure that the House is grateful for most of what the Joint Parliamentary Secretary has just said. If justification were needed for tabling these Prayers, which I am sure it is not, the remarks made by the hon. Gentleman towards the end of his speech about the control procedure are extremely valuable for everyone to know.

The hon. Gentleman must not make a speech in answer to the speech which he thought I would make but which I did not make. I think that when he reads my speech, he will find that I was not unreasonable in my approach. It was I who used the phrase that the integrity of the doctors is the first check. I am the last person to say—I did not say and, if I may say so in a friendly way, I resent somewhat the inference that I did say—anything detrimental to the doctors. I am sure that this will be found by the hon. Gentleman, who is a very fairminded person, when he reads my speech.

Nevertheless, in view of the explanations and the helpful attitude of the hon. Gentleman, I beg to ask leave to withdrawn the Motion.

Motion, by leave, withdrawn.