HC Deb 14 February 1966 vol 724 cc959-81

5.30 p.m.

Dr. Wyndham Davies

I beg to move, Amendment No. 13, in page 6, line 44, to leave out from "circumstances" to the end of line 44 and to insert: that all practice, ancillary and building expenses are borne from Exchequer funds". I regard this as a vital part of the Bill, in that we are likely to have some spirited opposition to these provisions from the medical profession, and the Minister may find that some of his propositions in this Measure will founder on that opposition. The Minister said that he regards the Bill as an important part of the reform of the National Health Service. I want to draw attention to the almost complete lack of interest on the Labour and Liberal benches. It may be pointed out that there are only two Conservative back benchers present—but we have heard so much from the Labour Party over the years to the effect that it is the great creator and reformer of the National Health Service that we would have expected a better attendance today.

Mr. K. Robinson

Surely this is due simply to the excellent drafting of the Bill. None of my hon. Friends feels that it is necessary to try to improve it.

Dr. Wyndham Davies

It is my intention to indicate how badly the Bill has been drafted. That is one purpose of the Amendment.

The Amendment seeks to do something for the ordinary members of the public who have suffered under an inferior Health Service for so long. One of the things that I, as a young doctor and medical student, was attracted to in the Health Service—and this is true of the many idealists that we have in the medical profession—was the concept of the health centre. By that I mean a practice the costs of which, together with those of the ancillary and building expenses, are borne on Exchequer funds. Here we go back to the original concept beloved by the former right hon. Member for Ebbw Vale, Mr. Aneurin Bevan. I am sorry that his successor is not here at the moment.

Even 46 years ago the Dawson Committee, in 1920, put forward the idea of health centres as something around which a Health Service should be created. In 1944, a White Paper was brought out on the subject and this formed the basis for the provisions of the 1946 National Health Service Act. Later, the whole conception was cautiously accepted by the Porritt Committee. No serious evidence has been put forward to discredit the idea, although there have been difficulties in finding sites for planning and negotiating in relation to health centres. We must regard health centres as a generally accepted idea in local curative and preventive medicine.

One of the big problems facing the Minister at the moment arises from the fact that in certain parts of the country great difficulty is experienced in manning the service. The Minister knows that this situation exists in the valleys of South-West Wales, including the Rhondda Valley, and in the North, and this Bill would seem to provide an ideal opportunity for giving Exchequer aid to create health centres and to put forward his own ideas. Although I am a Conservative I believe that a salaried service for this type of medical practice could be of great value.

In France, out of 28,000 general practitioners and 16,000 specialists, there are 2,400 salaried doctors. That seems to be about the right proportion. However, we must bear in mind that because of our Anglo-Saxon nature there may be some resistance to any idea of a salary. This resistance probably exists mainly among the older members of the profession, although many young doctors would also indignantly reject such a scheme.

The New Zealand Government instituted a salaried scheme, but had to withdraw it and replace it by a fee-for-service scheme, or a refund scheme, according to choice. The result has been a very attractive socialised medical practice, with lists varying between 1,000 and 1,200 patients, which has provided an incentive for many English doctors to emigate to New Zealand. Australia's 1938 Insurance Act failed completely in providing an extensive salaried service, although 17 per cent. of doctors in special areas are still salaried. There is also a shortage of doctors in Sweden, so that salaried district medical officers have to be employed in the under-rewarding districts. But we can show that, generally, the great majority of doctors do not wish to be salaried. They have no desire to be directly rewarded in that manner. Only by Exchequer provision of the services and facilities that I have referred to can we attract any of our young doctors into an area that desperately needs medical services. This may be occurring in my City of Birmingham before long, in certain areas where doctors are withdrawing from the Service.

The late Aneurin Bevan thought it was desirable to have flexibility in remuneration in the Health Service. The Clause was originally drafted to assure the British Medical Association that a totally salaried service would not be enforced at any time, but if the Minister insists on going ahead with the Clause without providing any specific assurances that it will be enforced only where the Exchequer is paying the whole bill and providing facilities for the doctor, he will eventually run into trouble.

Mr. K. Robinson

There is no question of its being enforced. The hon. Member was not present in the Second Reading debate, but if he will read the report of my speech he will see that all the assurances for which he has asked were specifically given.

Dr. Wyndham Davies

I can assure the right hon. Gentleman that I read the report of his speech several times and dissected it, but I found it singularly lacking in detail. He was very general about many issues. I regret that I was not able to be present during the Second Reading debate, but that does not mean that I do not know what he said.

In every discussion of general practice the argument concerning the isolation of the general practitioner continually comes up. This isolation was emphasised 46 years ago by Lord Dawson. His report pointed out that the general practitioner needs to remain in contact with intellectual and technical advances in medicine, and this principle is even more important today. To encourage the general practitioner to improve his knowledge and conditions of practice a good Health Service has a duty to persuade him to improve his premises and to attend post-graduate courses. If general practitioners are financially unable to implement this policy—as is often the case at the moment—this should be regarded as a fault of administration and not a fault of the general practitioner himself.

Today, there has been some confusion of thought between two social concepts—the health centre and group practice. The National Health Service Act, 1946, gave local authorities and the Secretary of State for Scotland the duty of providing health centres, and required their acceptance of the principle of the White Paper of 1944. The group practice is a simpler concept, based on the theory that doctors can organise their hours of work and ancillary help better when grouped together

Groups can be formed quite independently of the Health Service. Health centres offer doctors the same advantages, but they present difficulties in planning. Where are they to be sited, for example? Should they be near a hospital and should one wait until such a site presents itself? Should they be staffed with new doctors, or should the local general practitioners somehow be persuaded to use them? What if the general practitioners are content with their present premises? What sort of priority does a health centre have in the allocation of local funds to the welfare services in general?

An important basic answer is that the local authority services should be combined with group practice in health centres. The Report of the Medical Planning Commission of the British Medical Association, in 1942, which preceded the White Paper, recommended that antenatal and post-natal services, infant welfare and school medical services should be based on the health centres. There were fears about the working of a combination of these services with practices based on an uneasy coupling of ignorance and theory.

In 1962, the Porritt Report reflected a picture of the growth of health centres as veering between failure and suspicion. Few have been built and one recalls that the Minister specifically mentioned that some activity is now going on in the creation of new health centres. However, it is quite inadequate, so we are in a situation between failure of Government policy in creating health centres and suspicion of what the centres might mean by the general practitioners in the area.

Even where they have been created, there has been little fusing of the branches of medical care as laid down in the original 1946 Act, although they have been housed in the same building. The Porritt Report of 1962 said that a great deal more experience was necessary, whereas it endorsed Government support of group practice with enthusiasm.

Mr. Gower

My hon. Friend will probably recognise better than I the geographical problems in many parts of the country in setting up centres of this kind.

Dr. Wyndham Davies

I agree.

Regular contact between doctors is undoubtedly valuable, but a question mark hangs over the fusion of general practitioners and the local authority services in the same building. I hope that the Minister will give some indication of the plans that he has in mind for this.

The way to the Gillie Report picture of general practitioners taking over some of the preventive work of the medical officer of health is not clearly envisaged, nor can a process be rushed along. This idea has to be combined with the theory that group practices, by being able to afford and locate such equipment as X-rays and small operating theatres under staff nurses can cream off an increasing number of patients from the hospitals. Integration of preventive health services with family doctors, which was envisaged by Gillie and Porritt as well as by many humbler members of the medical profession, should be allowed to proceed at its own pace in the framework of area health administration, redesigned to unite the present tripartite division of the service.

The idea of health centres is one which I can wholeheartedly support. I am sorry to see that the hon. Member for Wandsworth, Central (Dr. David Kerr) is not present, as he directly challenged my views and said that he would like to hear what they were on health centres and salaried service. This encouraged me to give them at some length. I hope that something constructive has emerged from my speech and that the Minister will give us a glimpse into the workings of his mind and say what he intends to do with the salaried doctors for whom he is now asking permission from this Committee to to include provision in the Bill.

5.45 p.m.

Finally, I should like to quote from an open letter to general practitioners from the President of the Medical Practitioners' Union. In an issue of the Medical Practitioners' Newsletter, dated 25th January, 1966, he wrote: The issue"— he refers to the reform of the National Health Service— remains simple. Is the Government prepared to provide the money needed for an increasingly complex, comprehensive service for the nation? The future of general practice as we know it depends on the answer to this question.

Mr. Kenneth Lewis (Rutland and Stamford)

I am not sure whether I can support the Amendment technically, but I can at least support its spirit. Whether I can support it technically depends on whether I accept that the Bill does nothing to provide a disincentive to group practice. We have the Minister's assurance that it does not and I think that that is true: the Bill does nothing to provide a disincentive to group practice.

Most of us who support the Bill do so because it provides further opportunities in the Health Service for greater scope and variety. Perhaps one point which has concerned some of us in the last few years is that the Service has, in many ways, got into a groove. The variety which ought to be there does not exist. This is one of the reasons that we criticise the policies of the right hon. Gentleman and his hon. Friends in their outlook on private medicine. We think that there is scope within the service for the development of private medicine apart from the free service provided by the stamp. I hope that the Conservative Party will, in the future, extend the scope of private medicine. However, I must not get out of order, so I will not pursue the matter on this Amendment.

The advantage of group practice is that it enables the doctor to give his patients a service—it is service to the patient which matters most—without his becoming overtired. It has been interesting, in the last few years, to see the way in which the young doctor has come to like group practice The older doctor who has always been used to the old type of family practice clings to it. The result is that there is now the opportunity to build up, alongside one another, group practices run by younger doctors with the practices of old family doctors.

At present, when it is so difficult to get staff and, indeed, to get doctors, there is something to be said for group practice. The staff who can serve two or three doctors are probably the same staff who can serve one. Certainly, the staff who serve three doctors are no more than would be required for two. This is most needed in the Health Service as a whole, because not only are doctors finding it difficult to get the kind of staff they need, but so are the health centres and the hospitals.

It must help from a staffing point of view and it certainly helps to give the doctor more leisure, because it means that he can have a weekend off without having to be on the end of the telephone or without feeling that he is duty bound to stay at home because there might be a call which would take him out to a patient. It helps in operating an appointments system, which is not so easy to do in a family practice. Where there is more than one doctor, one can be out while the other is in the surgery meeting people by appointment.

We encouraged the development of group practices and I hope that the right hon. Gentleman intends to encourage it. Together with the development of health centres it can add to the variety of services, which is of benefit to the patient—and it is the patient who matters. He will thus have a choice of the kind of doctor he wants to meet his own health needs, and that is a factor which should concern us when we are passing the Bill.

I support the spirit of the Amendment, and I hope to hear the Minister say that he is in favour of the spirit of it, if not of the technicality of it.

Mr. Gower

I echo the sentiments expressed by my hon. Friend the Member for Rutland and Stamford (Mr. Kenneth Lewis), but I am not satisfied that the exact wording of the Amendment would put into practice exactly what my hon. Friend the Member for Birmingham, Perry Barr (Dr. Wyndham Davies) seeks, although he is moving in the right direction.

The Minister has asserted on a number of occasions that he has no desire to impose a salaried service. On the other hand, I recollect a few of his words on Second Reading which could give rise to some possible misunderstanding. He reminded the House that half the doctors in the Health Service are already on salary and he gave the example of doctors in the hospital service, from consultants downwards. He did not think that the fact that they were salaried meant that their relationship with patients was in any way less satisfactory than the relationship with patients of doctors paid on a capitation basis. Hon. Members will find that in column 1426 of HANSARD of 3rd February.

One need not dissent from those comments, but they seem to be attempting to justify an extension of the principle of a salaried service. Saying that the fact that some people were on a salary did not affect their personal relationships seemed to suggest that it would be a good idea to extend this system. As I understand it, that is not the object of the Clause; it is based not on the idea of extending a salaried service but on the idea of introducing a more flexible arrangement which would include a salaried element. I hope that the Parliamentary Secretary or the Minister will make it clear that those remarks on Second Reading were not intended to suggest that there should be a wide extension of the salaried principle.

The Parliamentary Secretary to the Ministry of Health (Mr. Charles Loughlin)

I do not know whether the hon. Member intends to develop this point, but perhaps we ought to clear it up now. Those remarks were made in connection with the question whether a salaried service necessarily interfered with the patient-doctor relationship, and they can be read only in that context. There is no question of any other meaning. It was simply a question whether the fact that a doctor was salaried impaired in any way his relationship with the patient. My right hon. Friend said it did not.

Mr. Gower

I accept that, but I am not sure that it is a valid comparison. The fact that a consultant has a satisfactory relationship with a patient in the hospital service does not demonstrate that a similar salaried service for general practitioners would not be injurious. A consultant is in a very different position. But I accept what the hon. Member said.

Both my hon. Friends have emphasised the great advantages of group practice. It was my experience in the recent malaise in the profession, when speaking to doctors in and around my constituency, that those who were most uneasy and unhappy, and perhaps most stretched, and who found their work getting beyond them were single-handed doctors, in practice on their own and without the extra help available to those who work in group practice. Those who were more optimistic were the younger doctors and those who were associated in groups, group partnerships or larger practices. Those doctors had an economy of administration, often with the employment of only one secretary, and, as my hon. Friend the Member for Perry Barr pointed out, they were not constantly on call. All these were advantages.

To this extent my hon. Friend's suggestion that these ancillary services should be available under the conditions envisaged in the Clause appears to have a good deal of substance. I am not quite satisfied about the form of the Amendment, but I am sure that the Minister will agree that there is substance in some of the points which have been made.

6.0 p.m.

Mr. Loughlin

I do not know whether I should be wholly in order if I followed the hon. Member for Barry (Mr. Gower) in his closing argument, because there is an essential difference between group practices and health centres and the Amendment relates to health centres and not to group practices.

First, may I repeat what I said earlier about my right hon. Friend's remarks on the question of the number of doctors employed in the Service on a salaried basis. Those remarks bore relation only to the doctor-patient relationship.

We have had three contributions in this limited debate. The hon. Member for Rutland and Stamford (Mr. Kenneth Lewis) supported the hon. Member for Birmingham, Perry Barr (Dr. Wyndham Davies) on the issue of health centres. I am delighted to see the enthusiasm with which both hon. Members paid tribute to "Nye" Bevan's original concept.

Dr. Wyndham Davies

The hon. Member does not seem to have listened to my speech. I explained that this conception was 46 years old, from the Dawson Committee in 1920, being put forward again in 1938 by the British Medical Association and brought out by the wartime Coalition Government in 1944 in their White Paper and merely continued by certain Socialists thereafter.

Mr. Loughlin

I suggest that we might find ourselves in some difficulty if we begin arguing about the origins of the Health Service. I was referring to "Nye" Bevan merely by way of taking up the hon. Gentleman's reference to him. I had not intended to devote a great deal of time to this matter; only to remind the hon. Gentleman that "Nye" Bevan would have been pleased to find the hon. Gentleman referring to him in such glowing terms.

We want to see an extension of health centres—as far and as quickly as possible. However, it would not seem that this will follow from adopting the Amendment. I think that the hon. Member for Barry twigged that something had gone wrong. Something has gone wrong, because the Amendment, if accepted, might interfere with the extension of health centres because such centres are, to a large extent, paid for by local authorities. Amendment No. 13 states' that all practice, ancillary and building expenses are borne from Exchequer funds". Whatever glowing tributes the hon. Member for Perry Barr might pay to health centres, the Amendment would not assist an extension of these centres.

My right hon. Friend the Minister of Health went out of his way, on Second Reading, to make the position clear when dealing with the canard that we were trying to impose a salaried service on the private practitioner. I do not know whether hon. Gentlemen opposite have read and digested my right hon. Friend's remarks, but it is worth reminding the House of what my right hon. Friend said. Speaking about the circumstances in which family doctors should be paid, he referred to the National Health Service Act, 1946, which was amended in 1949, and said: The amendment was introduced to fulfil an undertaking given by the Government of the day shortly before the Health Service came into being in 1948 to meet the fears of the medical profession that a full-time salaried State medical service might be imposed upon them. Those fears were as groundless then as they are now.

Dr. Wyndham Davies

rose—

Mr. Loughlin

The hon. Gentleman must not be so impetuous.

My right hon. Friend added: I recognise that there are still misgivings in the minds of many general practitioners on the subject of payment by salary, and the Government would certainly not wish to force it on doctors against their will."—[OFFICIAL REPORT, 3rd February, 1966; Vol. 723, c. 1381–2.] If a more categorical assurance could have been given to any section of the community, I would like to know what my right hon. Friend might have said.

Dr. Wyndham Davies

I read the right hon. Gentleman's remarks and I hope that that is what the Minister really means and that he will bind his successor to those words. We have already drawn attention to the specific assurances given by the Minister in July, 1964, to the effect that he was all in favour of grants for general practice premises. We have seen him reverse his ideas of 1964 in 1965. Will the right hon. Gentleman reverse his ideas of 1966 in 1967?

Mr. Loughlin

I appreciate that the hon. Member has not been in the House for very long. One of the most dangerous things for any hon. Member to do is to impute an ulterior motive to any other hon. or right hon. Gentleman. I trust that the hon. Gentleman will not do that. If he is saying that he has read my right hon. Friend's speech, but is not convinced that my right hon. Friend means what he says—which is what the hon. Gentleman said; he will be able to read his words in the OFFICIAL REPORT tomorrow—then he is doubting the integrity of my right hon. Friend. I wish the hon. Gentleman would get out of the habit of doing that. Suffice to say that no other hon. Member of the Committee doubts my right hon. Friend's words, because the Minister, in dealing with this issue of the salaried service, has made his position clear, and is absolutely honest in his intentions.

The hon. Member for Perry Barr began by saying that the Bill was badly drafted. That was a most unfortunate remark for him to make, because when I was in opposition I indulged in pieces of private enterprise parliamentary draftsmanship and, like the hon. Gentleman, often came unstuck. There is nothing wrong in that. We must learn by our mistakes. Often a badly drafted Amendment is a peg on which to hang an important discussion.

The hon. Gentleman has come unstuck on this occasion, because the Amendment would, because of the way it is worded, have different results from those envisaged in his speech. It would, first, remove the need to make any regulations at all, and, secondly, it would remove the special protection offered to doctors by ensuring that the payment of salary could not be enforced on them. I appreciate that that was not the hon. Gentleman's intention, although that would be the effect of the Amendment.

On the very question on which the hon. Member for Perry Barr spent so much of his speech—the suspicion among general practitioners towards payment by salary—the Amendment would make the position even more difficult than it is now because the Clause already gives absolute protection in relation to doctors giving their consent. While I appreciate that the hon. Gentleman hoped that the Amendment would achieve the objects outlined in his remarks, it would do precisely the opposite. I therefore ask him to withdraw the Amendment.

Amendment negatived.

Dr. Wyndham Davies

I beg to move Amendment No. 14, in page 7, line 3, to leave out from "with" to the end of line 5 and to insert: representatives of the British Medical Association, the Medical Practitioners Union, and the General Practitioners Association, or such bodies as suitably represent the wishes of all the practitioners concerned". I am very concerned that those whom the Minister, or a future Minister, may have to consult shall be proper representatives of the medical practitioners concerned. It might well be that when the representatives of the British Medical Association have finished their negotiations with the Minister and have reported back to their own members in their most democratic procedure—it is, I think, one of the most democratic procedures of any organisation—the members may not choose to re-elect them in the subsequent year, and many of those members may resign and join a body that may be far more active in looking after their interests.

For example, a few years ago when problems of general practice arose in the National Health Service, a large body of general practitioners joined together to form what was called the General Practitioners' Association. This Association has worked very hard. It has received money and effort from many general practitioners. It has engaged the highest form of legal opinion, and has carried out valuable general practice surveys which I hope the Minister and his Parliamentary Secretary have read most carefully. I am sure that many people in the Ministry have done so.

Further, the General Practitioners' Association went to a very respected Member of this House—the hon. Member for Stoke-on-Trent, Central (Sir B. Stross)—and presented a Petition signed, I believe, by 7,000 or 8,000 general practitioners, bemoaning the state of the National Health Service way back in 1962, with particular reference to general practice. I should like to see such a body consulted by the Minister.

The Medical Practitioners' Union was set up in the late 'twenties or early 'thirties by keen full-time workers in the health service of that time. Many of them were members of the Socialist Medical Association. The Medical Practitioners' Union is the only medical organisation that has direct representation in the Trades Union Congress. For years it has worked hard to put forward the views of many of our doctors. Last year it rid itself of an attempted take-over by Communist elements, and since then, with the appointment of new officers, it has served the profession well.

I understand that a week or two ago, for example, representatives went to a meeting of white-collar workers' unions with the intention of putting the case for various reforms in general practice. The meeting was supposed to last for three hours, but I believe that the First Secretary of State spoke for one hour and 50 minutes of the three hours and thereby prevented any useful statement on the problems of general practice being made.

My plea to the Minister is, therefore, that he should not choose just whoever he likes to consult, but should take into account the wishes of general practitioners through whichever body they choose to represent them, whether it be a newly-created body, or such existing organisations as the General Practitioners' Association, the Medical Practitioners' Union, or the body that has been so well known for so many years and which still represents the great mass of practitioners—the British Medical Association.

6.15 p.m.

Mr. Gower

I wonder whether my hon. Friend might not consider that the present wording of the Bill achieves most of the objects he has outlined. It states that …the Minister…shall consult with such organisations as appear to him to be representative of the medical profession. How the Minister could then fail to consult the British Medical Association and the other bodies, I cannot imagine. I think it undesirable to tie the Minister or his successors down in this way; and that the words in the Bill are reasonably satisfactory.

Mr. Loughlin

In due course I shall ask the hon. Member to withdraw his Amendment. I cannot see that it is necessary to list in the Bill a whole host of organisations and then add a reference to such bodies as are suitable, because that would mean that the Minister could, if he wished, consult the bodies referred to by name, or ignore them and consult someone else. Again, the Amendment is one of those bits of private enterprise work to which I have already referred, which does not get the hon. Member very far.

I shall not argue which organisation the general practitioners should belong to or attempt to say whether it should be the General Practitioners' Union, or any other. That is their business wholly and solely. But if hon. Members look at the present trade union structure in industry and commerce, they will appreciate the many difficulties that would face any Government that attempted to legislate on the basis of the possibility of a union's leadership losing the confidence of the members, and those members either not joining another union—which is always possible—or joining a different body altogether. The simple situation is that all Ministers have hitherto recognised as representative of G.P.s the two General Medical Services Committees, one for England and one for Scotland, because they are not only Committees of the B.M.A. but also the central organisations of the local medical committees recognised under Section 32 of the 1946 Act and Section 33 of the 1947 Act.

Bearing in mind what I said about the wording of the Amendment, hon. Members will see that this leaves it entirely in the hands of the Minister whether he should consult or not. Bearing in mind the place held by the General Medical Services Committees, one can assume that if we continue the practice which has been followed by successive Administrations we should have consultations with organisations representative of the general practitioners as at present. We have to ensure that the Bill will give an opportunity for fully consulting representatives of the general practitioners. The Bill as it stands does that. It certainly would not guarantee it if the words submitted by the hon. Member were adopted. I plead with him to withdraw the Amendment.

Mr. Laurence Pavitt (Willesden, West)

Without wishing to support the case put by the hon. Member for Birmingham, Perry Barr (Dr. Wyndham Davies) I wonder if in further consideration of the Bill the Parliamentary Secretary might look again at the rôle which the General Medical Services Committees play.

There is an anomaly that as the Committees were constituted under the Act they are part and parcel of the British Medical Association. We have the anomalous position when a Minister is engaged in discussions with the profession that there is the annual conference of local medical committees representative of the general medical services, and then—perhaps a few days later—the annual conference of the British. Medical Association of which each G.M.S.C. is a part. This constitutes a difficult position for a Minister seeking to negotiate, because it may be that the annual conference of the local medical committees can consist of some who are not members of the British Medical Association. The time has arrived when this anomaly should be cleared up.

I recognise that this is not a job for the Minister but for the profession. When negotiations are going on he might perhaps use his influence with the profession to look at the possibility of there being only one annual conference representing the profession, which would have at its head the General Medical Services Committee of the British Medical Association, or the British Medical Guild—which is the only association permitted by law to negotiate for doctors—or the Medical Practitioners' Union. It would be in the general interest of medical practitioners if it did not happen, as last year, that one organisation came to a decision and then another organisation—in which there were some doctors, as it were wearing other hats—came to an entirely different conclusion.

I do not support this Amendment, because I do not think it would have the effect desired.

Amendment negatived.

Mr. Wood

I beg to move Amendment No. 16, in page 7, line 8, at the end to add: (4) No regulations shall be made under this section unless a draft of the regulations has been laid before Parliament, and has been approved by resolution of each House of Parliament. The Minister on Second Reading, as reported in the OFFICIAL REPORT at col. 1426, described the safeguards which would exist in this experiment for the payment of salaries. He said: We shall consult the medical profession. Which is what we have been discussing. We shall make it clear that this payment will only be made with the consent of the doctors concerned. The appropriate order will be subject to annulment Prayers can be tabled against it if any hon. Member thinks that consultation with the doctors has been ignored."—[OFFICIAL REPORT, 3rd February, 1966; Vol. 723, c. 1426–7.] I was surprised, because the language the Minister has used in Clause 10(2) is very different from the language used in Clause 3(2). It may be that there is a very good reason for this difference which at the moment has escaped me. I take it from the right hon. Gentleman's clear statement that the appropriate Order will be subject to annulment, that the only difference between us on the basis of the Bill as it stands is as between the affirmative and the negative procedure.

I have no wish to cause difficulties, particularly on St. Valentine's Day, but the wisdom of choosing the affirmative or the negative procedure seems to depend largely on whether the hon. Member for Wandsworth, Central (Dr. David Kerr) or I was right in our reading of the Bill. After I made the suggestion that the affirmative procedure might be adopted, the hon. Member said in his speech: I resist that suggestion, in the hope, however optimistic it may be, that as time passes and pressures grow the number of occasions on which the Minister will want to make orders for the determination of salary payments will increase,…"—[OFFICIAL REPORT, 3rd February, 1966; Vol. 723, c. 1389.] I certainly did not visualise that the Minister would have to ask the House for approval whenever a doctor or group of doctors consented to be paid by salary. I cannot believe that that is the intention. I assume that the intention would be to prescribe certain circumstances and then, perhaps a year or two later, the right hon. Gentleman, or whoever by that time may have replaced him, would prescribe new circumstances to take account of any changes which had taken place in the intervening period.

If this interpretation is correct I should have thought it reasonable to suggest that there will not be many occasions on which the right hon. Gentleman will be bringing Regulations before the House to afford Parliament an opportunity to give its formal approval. On the other hand, if the hon. Member for Wandsworth, Central is correct and the right hon. Gentleman intends to issue a flood of Regulations—perhaps in this medical connection "cascade" would be the proper word—we might have to think about the matter again. I should like to hear the right hon. Gentleman's explanation of whether my interpretation about what kind of Regulations these would be or the interpretation of his hon. Friend is correct, because it appears that on this will depend ultimately the procedure we ought to adopt for discussion and examination of Regulations in this House.

6.30 p.m.

Mr. K. Robinson

The right hon. Gentleman's interpretation in the last part of his remarks was perfectly correct. It is a fact that we do not envisage a whole series of Regulations, but in the first instance one Regulation prescribing a set of circumstances in which we would consider it appropriate that there should be the option of payment by salary; and until the circumstances materially change and we want a new set of circumstances, presumably that Regulation would stand.

Perhaps I can explain to the right hon. Gentleman why there is a difference in the wording compared with Clause 3(2). Under the Bill as it stands, Regulations on salary would be subject to the negative procedure pretty well automatically, because I am informed that, by virtue of Clause 11, the Regulations would be made under the National Health Service Acts, which provide for all Regulations under those Acts to be subject to the negative procedure, with the exception of those made under two Sections dealing with superannuation and transfer and compensation of officers. Therefore, Regulations would not be, in the wording of the Amendment, "made under this section". They would in fact be Regulations under the main Act.

The difficulties in the way of the affirmative procedure are several. First, I do not think that there is any need to provide an additional safeguard. There is adequate protection, since the Regulations could not be implemented unless the doctor concerned agreed to be paid by salary.

As to Parliament and the public in general, any issue of principle as to the wider use of payment by salary with consent will have been settled by the passage of the Bill itself. The Regulations will merely specify the administrative details. In those circumstances, we believe that the negative procedure ought to be enough.

The Regulations will be similar in general character to a number for which the negative procedure is already provided in the 1946 and 1947 Acts, and in particular the Regulations under Section 33 of the 1946 Act and Section 34 of the 1947 Scottish Act regarding arrangements for general medical services. Further, the Regulations are likely to be made in conjunction with other Regulations made under these two Sections. If different parts of such joint Regulations were subject to different procedures, we should run into very considerable complications. In any event, consolidation of all Regulations relating to family doctors is carried out periodically so that the doctor can have easy access to the terms of his contract laid down by Statute.

Because of the procedural differences between the negative and affirmative procedures, any attempt to present a consolidated version to Parliament, involving as it does laying in draft also the Regulations that need not be so laid, and distinguishing them by italics, would be extremely complex and would not, on past experience, be attempted. As a result, the Regulations governing the family doctor would be divided inevitably into two distinct parts.

I hope that the right hon. Gentleman will agree that there will be every opportunity for Parliamentary scrutiny of these Regulations if the House of Commons so desires; and since provision is made in the Bill itself, both for full consultation with the profession before Regulations are drawn up and also for the prior consent of any individual doctor who is to receive payment by salary, I hope that the right hon. Gentleman will feel that he is not obliged to press the Amendment.

Mr. Wood

It is evident from what the Minister has said that if my hon. Friends and I pressed the Amendment it might cause the whole machine to break down. As there is nothing that we should like to do less than interfere with the smooth running of the machine, I must ask my hon. Friends to be satisfied with the assurance that we have had from the right hon. Gentleman that these Regulations made under the Acts he mentioned will come before Parliament to be prayed against, if necessary; but before that stage is reached we shall have had the automatic assurance, not only that the profession will have been consulted, but also that the individual practitioner or practitioners will have agreed to be paid by this method. If we have any doubt about those built-in assurances, we shall be able to pray that the Regulations be annulled.

In view of what the Minister has said, I myself would be satisfied with that assurance. Therefore, I beg to ask leave to withdraw the Amendment.

Amendment, by leave, withdrawn.

Question proposed, That the Clause stand part of the Bill.

Dr. Miller

Will my right hon. Friend indicate whether the Clause envisages the possibility of encouraging more doctors to opt for salaried service? I do not believe that doctors should be forced into a salaried service if they do not want it. However, I believe that they should be encouraged to do so, and it should be obvious to them that salaried service is available if they wish to join it.

I am thinking particularly of areas which have been mentioned already, where local authorities are embarking upon fairly large schemes of health centre development. Would it be possible under the Clause to indicate clearly to the doctors in such areas that there is the possibility, if they wish, to enter into some form of agreement with their executive council which will administer a salaried service for them? I believe that many more doctors than previously would now willingly accept a salaried service. It is incumbent upon the Minister to make it clear to doctors that this possibility exists. Is the Clause as it stands strong enough and specific enough to permit this to be done?

Mr. Pavitt

I want to raise a further point arising from the part of the Clause which reaffirms the original Act, which refers to the medical services being paid wholly or mainly by salary. As I understand it, the Clause makes it possible for a general practitioner to opt wholly for a salary under the provisions of the Bill. Would this permit a very large portion of the remuneration of a general practitioner working in a health centre to be paid on a salary basis, beyond the basic practice allowance?

I have in mind a situation where an endeavour is being made to persuade local general practitioners to come together in a health centre provided by the local health authority. These doctors know that, as they stand in their present circumstances and with their present branch surgeries, they attract a certain number of patients to their lists. If eight general practitioners are consolidated in one centre, they do not know how many patients they are likely to lose in the process and what their resultant capitation payment will be.

A local health authority seeking to promote a health centre might be prepared to say to a general practitioner, "Providing that you are prepared to join this scheme, we will guarantee that the amount of your remuneration will be no less than that which you at present earn". Under the Clause it would not mean someone being wholly paid by salary, but he would be mainly so paid, because, with the basic practice allowance, plus some kind of subvention from the local health authority, his main remuneration would be in the nature of a salary. Would my right hon. Friend explain exactly how this will work out in practice? Is this the kind of thing that the Ministry envisages in the development of more health centres and group practices?

Mr. K. Robinson

May I answer, first of all, the last point made by my hon. Friend the Member for Willesden, West (Mr. Pavitt). The kind of circumstance which he described, of a group of doctors coming together to operate in a health centre, is the kind of circumstance in which it would be, one hopes, possible and appropriate to pay those doctors by salary if they so wished. But, of course, this would not be paid by the local health authority; it would be paid by the Executive Council because, as my hon. Friend knows, the local health authority is not empowered to provide general medical services but is empowered merely to provide premises where those services can take place.

I do not think it would be a question of the local authority giving a sort of guaranteed minimum. The doctors could continue on a capitation basis, or a modified capitation basis, or opt for salary, as they wish, under the proposals in this Clause.

Dr. Wyndham Davies

Can we be entirely clear from the right hon. Gentleman that the term "health centre" is not being used just as a title merely for a group of rooms where a receptionist and a nurse may be provided, but that it is to be a health centre along the original lines of the 1946 Act with all ancillary services? We do not, and many doctors do not, want just groups of rooms called health centres and then to be asked to practise there for a salary. They want something created which will be a real health centre in every meaning of the word.

Mr. Robinson

That, of course, is what I, too, would like to see. The hon. Gentleman should not approach this subject as if it were something which has got to be done for doctors by a benevolent local health authority. This is something in which we want to see doctors themselves taking the initiative, going to the local health authority and demanding facilities of this kind if that is what they want. When I talk of health centres in this connection I am thinking about publicly-provided premises. Naturally, one wants to see those premises as comprehensive and well-equipped as possible, with full accommodation for ancillary help and the rest. I do not think that there is anything between us on this issue.

Dr. Wyndham Davies

Surely what we are after is something for the good of the patients, not for the good of the doctors?

Mr. Robinson

Exactly. But this was not implicit in the hon. Gentleman's first intervention.

My hon. Friend the Member for Glasgow, Kelvingrove (Dr. Miller) asked me whether I thought this Clause would encourage doctors to choose payment by salary. The important thing about the Clause is that it makes it possible, for the first time, for those who want to be paid by salary to be so paid. This is really the significant step forward.

For my part, I would want to give as many as possible of those doctors who wished to be paid by salary the opportunity of salaried service, but I would not want to mislead my hon. Friend into thinking that we should, at any rate in the initial stages, find it possible to offer a completely free option to every doctor. There are all sorts of complications which arise from a salaried service and a capitation, or modified capitation, system of payment co-existing side by side. I repeat that I myself would like to see as many doctors as possible who wished to be paid this way have the opportunity to be so paid.

Question put and agreed to.

Clause ordered to stand part of the Bill.

Clause 11 ordered to stand part of the Bill.