§ Motion made, and Question proposed,
§ That this House do now adjourn.—[Mr. Bishop.]
§ 10.37 p.m.
§ Mr. Leo Abse (Pontypool)
The new decision to enable doctors in the National Health Service to make charges to a patient for prescribing or fitting contraceptive appliances is particularly unfortunate in the light of the absurdly ambiguous position of the family planning services of this country. Rarely has there been more public concern expressed about the increase in illegitimacy, never has there been more public debate about reforming the abortion laws, and never has there been in existence so weighty an opinion that so many children are suffering terrible deprivation, a rate which falls upon them because they are born to parents who already have more children than is possible for them to support.
It is also understood today that we pay a grim price in our divorce rates for the ignorance and fear of childbirth which precipitates so much marital disharmony. Yet although the need for the rapid availability of advice on planned parenthood is widely understood, the State's attitude to family planning is prissy and evasive. It lays down certain permissive rules within which local authorities can operate, and even those rules are severely limited so that the service which the local authorities may provide is one in which advice must be strictly limited to cases where there are medical reasons against a further pregnancy.
Snidely, the State then tries to wash its its hands of what I regard as one of its major duties, namely, to take all possible action to strengthen family stability and happiness. It merely hints in tortuous circulars to local authorities that they may strain the law to contribute to voluntary organisations, provided only that they are formed for the purpose of the prevention of illness.
Yet, in spite of the clamour for the need for abortion law reform, of the shock of the recent well-publicised report on poverty among children and of the well-known fact that divorces are 432 prompted so frequently by fear of childbirth, the State has totally dodged the need for contraceptive advice to those who wisely desire to achieve the aim of planned parenthood, even though no specific danger to health is involved. This devious avoidance of acknowledging that the State should be using all its efforts to provide contraceptive advice on social grounds, as recommended by the Royal Commission, is, unfortunately, continued in the decision which we are discussing tonight.
It is particularly unfortunate that I should have occasion to criticise a decision of a Minister who, in the past, has undoubtedly shown himself to be singularly sensitive to the need to have family planning on social grounds. But it is really no use the Minister saying, as he said in the exchanges at Question Time when we were discussing this issue, that this is a misunderstanding in that the doctor in the National Health Service has always been able to issue a private prescription for a contraceptive. Of course he has. We are well aware of that, but he has not until now been able to charge for it. And no amount of sophistry can cloak the fact that, having fulfilled our election pledge to abolish prescription charges, we now give a new right to doctors to charge for a prescription when a doctor believes that one should be given for compelling social reasons.
It is no less unfortunate that the Minister has agreed to do this even without any negotiation as to what charge may be made. He has conceded the right without agreeing the charge. It is true that, out of the exchanges that took place, the Minister indicated, as I understood it, that it may be a charge as low as 2s. 6d. Is that the figure which is in mind and, if it is—and I trust that it is no more—could not the Minister have told the doctors, at a time when on average they are getting more by way of an increase in pay than a seaman's total wage packet, that it ill becomes them to demand their miserable half-crowns for giving prescriptions to those who are in need of them for compelling social reasons? Could it not, in these negotiations, have been emphasised that this payment would act as a deterrent to the woman most in need—to the families about whom society is most 433 concerned because of their poor standards of child care; that each additional child would become an additional burden and so depress still further the family standards?
I will put a few questions to the Minister. What means, if any, will there be to determine whether a prescription is given free on medical grounds, or for payment on social grounds? Is the genuine anxiety of a wife fearing another unwanted pregnancy a medical or social reason? Does not the new provision put a premium on the doctor finding that it would be a social reason?
If the Minister seeks to reprimand me now, as he sought to reprimand one of my hon. Friends when the suggestion was put to him at Question Time, and say that there is no question of a doctor distorting his decision for the sake of half-a-crown, why is there the demand for the half-crown at all? If we did riot suspect an avaricious motive, we should not be pursuing the inquiry. If, in fact, doctors are fighting for this pittance, are we not justified in wondering whether they should be the sole arbiters in deciding whether a prescription is given for social rather than for medical reasons?
Why has this demand been made without insistence upon safeguards? The Minister knows perhaps better than anybody that the majority of teaching hospitals—it is an unfortunate fact—make little or no provision for training medical students in contraceptive techniques. We give extra payments to general practitioners who have certain special skills. If the Minister had to negotiate, would it not have been wise to insist that those who will now have the right to make these charges shall have the skills which could, perhaps, in some circumstances justify a charge being made?
If my right hon. Friend thinks that this is comparatively unimportant, let me remind him that lawyers know better. Even if the general public does not know, lawyers know of claims frequently arising in cases in which doctors, no doubt good in other spheres of work, are clumsy or ill trained and are sued for consequences such as tearing of the cervix. That is common enough. My hon. Friend the Member for Falmouth and Camborne (Dr. John Dunwoody), who, 434 I think, may be about to interrupt me, will appreciate that I do not make that observation without it being well founded upon my clinical experience. There is some medical opinion that it is wrong to fit even an intra-uterine device, the coil, except in the operating theatre. This may or may not be correct, but what I do say is that, when we know that, unfortunately, doctors as a group have so little knowledge of contraceptive techniques, this could have been the moment, if negotiations were being toughly conducted, for the Minister to insist that those who sought this charge should at least be properly and effectively trained in the work which they were claiming they wanted to do for a certain price.
As I understand it, the Minister's excuse for this decision, given at Question Time, is that it would encourage people to go to the family doctor. I do not understand that argument. The idea that they can get contraceptive advice and a prescription by making a payment does not strike me as being a very effective method of encouraging people to come into the family planning service. However much my right hon. Friend may affirm that he thinks that this will help family planning, it is abundantly clear from what is said in the Third Report of Joint Discussions on the Family Doctor Service that the Minister has his apprehensions.
It is said in that Report thatThe Government would want to be sure that the power to charge in no way discouraged family planning …Why should they have these hesitations and doubts in the Report and yet express such certitude in the House at Question Time? These are precisely the doubts which are generally felt. Again, it is stated in the Report that the Government want to be sure thatwhen a doctor decided to prescribe oral contraceptives or to fit a contraceptive appliancehe did not actto the disadvantage of a patient who required this service on medical grounds …Is this why the Minister has decided to have a period of experiment? Why should there be such an experimental period if he and his Department did not have grave doubts on the matter?
435 I do not doubt that the family life of the nation will be much strengthened when general facilities for family planning devices and treatment are made available within the National Health Service from properly trained doctors. I regret that a step has been taken which, whatever sophistry may be advanced by way of reasons, will, in my view and in the view of many others, be one step further backward away from the goal of having a family planning advice service completely embedded within the National Health Service.
§ 10.50 p.m.
§ The Minister of Health (Mr. Kenneth Robinson)
I am well aware of the interest my hon. Friend the Member for Pontypool (Mr. Abse) has always taken in the family planning services. I certainly would not dissent from his opening remarks on the importance of the subject, although I reject utterly the strictures he levelled at the State's attitude, in so far as they were implicitly directed against me as the current "voice", so to speak, of the State in matters of health and welfare.
I appreciate my hon. Friend's concern, which I share, that no action should be taken which might discourage the development of these services. I am glad that he has raised the matter, not only because it gives me the opportunity to clear up any misunderstanding there may be arising over the proposed changes in the family doctor's terms of service as they concern family planning, but also because this is an occasion on which I may properly express my own views of the importance of these services.
I hope that I do not need to persuade my hon. Friend or the House that I am most anxious to promote family planning, that I have already taken important steps to that end and that I would not countenance any action which might have the effect of impeding this advance.
My hon. Friend referred by implication to the issue in February of a circular from the Ministry to local authorities giving guidance on the future development of the family planning services. That circular ended a period of over 30 years which had passed without a single word of advice from the centre about the local authorities' role in encouraging family planning. Perhaps I can remind 436 the House of the clear terms in which the services have been commended to the local authorities. I described them as… an essential aspect of family welfare.the circular went on:Planned parenthood strengthens family life; lack of planning, often due to ignorance of effective methods of contraception, may lead to marital disharmony, ill-health and social breakdown, and in some cases even to criminal abortion and death.The circular asked local authorities to review their present arrangements in the light of this statement of principles and of practical suggestions made to them. I hope my hon. Friend will agree that I have not been slow to promote family planning. It was a disappointment to me to discover the statutory limitations on local authorities' powers which confine their activities to those who require family planning services on medical grounds, but I cannot claim responsibility for the Statute that brought this about.
I want to ask my hon. Friend to regard the small charge, that it is proposed that family doctors shall be able to make to their patients in certain carefully prescribed circumstances, in the context of this new positive approach to the family planning service generally. I will now attempt to deal in some detail with the special position of the family doctor in relation to family planning.
On a previous occasion, my hon. Friend referred to the Royal Commission on Population and its recommendation that the giving of advice on contraception to married persons who wanted it should be accepted as a duty of the National Health Service, the responsibility for giving advice resting, in the Commission's view, on the family doctor. The Commission also suggested that there should be no restriction to giving advice only in cases where pregnancy should be avoided on medical grounds.
I should like to make it quite clear that there is no question of charges for family planning advice, which may include examination, given by family doctors to their National Health Service patients. The Government and the profession's representatives agree that where a doctor gives such advice, it is in all cases medical attendance and treatment properly forming part of the services he provides under the National Health Service. There is no charge for it at present 437 and no charge is proposed for it under the new contract for the family doctor service.
Coming now to the provision of the means of contraception as opposed to advice on family planning; where a family doctor decides that oral contraception should be prescribed on medical grounds because there are medical reasons against pregnancy, he may at present issue a free Health Service prescription. I can assure the House that no change whatever in this is proposed. The Government have no intention of singling out a particular drug—an oral contraceptive—needed on medical grounds and levying a charge for it while all other drugs which are medically necessary are provided free of charge. Such an action would he quite unjustified and wholly out of keeping with our decision to abolish prescription charges.
There are, however, occasions when a patient wishes to have oral contraceptives and her doctor judges that pregnancy would not be detrimental to her health. I would only say to my hon. Friend that this is a judgment which must be left to the family doctor concerned. Oral contraceptives are, therefore, in such cases needed only on what might be termed social grounds. On such occasions, the doctor may issue a private prescription, but at present he may make no charge for this service. This is a position which it is difficult and, indeed, impossible to defend logically.
The Government have now said that they are prepared as part of the new contract to agree that in future the doctor may make a small charge in these circumstances provided that he has satisfied himself initially that the oral contraceptives are not needed on medical grounds and that this continues to be the case. On that basis, the Government would amend the terms of service to permit a charge for this service, and similarly for the prescribing or fitting of a contraceptive appliance in social cases.
My hon. Friend took me to task because, he said, there had been no negotiation about the charge. No Minister of Health is in a position to negotiate a charge with the medical profession for services which come outside the doctor's obligation under the Health Service, any more than I can attempt to prescribe a 438 charge for an insurance certificate needed for private purposes by a man's employer.
I ask my hon. Friend to bear in mind that the doctor is providing a service in these circumstances which, though it may be, and I think is, socially desirable, is nevertheless not medically necessary. I know that the House appreciates just how hard pressed family doctors have been in coping with the strictly medical demands of their patients. I venture to suggest that where the doctor provides his patient with a service which cannot be said to fall within this description, it is not unreasonable that he should receive a small award for this extra work over and above his Health Service remuneration.
The profession will be making recommendations on the amount of the fee to be charged for prescribing oral contraceptives, just as it has always done in the case of fees for other work outside the National Health Service contract. I think that I can safely say that the fee will be only a small fraction of the amount which the patient will be paying in any event for the pills themselves over the period of several months which I would normally expect the prescription to cover.
Perhaps it would be appropriate for me at this point again to attempt to remove the misunderstanding which became evident when the question of a charge for the writing of prescriptions for contraceptives in social cases was discussed at Question Time on 9th May. On that occasion my hon. Friend and the hon. Member for Somerset, North (Mr. Dean) both appeared to think that there was some discrepancy between the Government's pledge to remove the prescription charges and other Health Service charges and their acquiesence in this limited charge by general practitioners.
As I then pointed out, there is no discrepancy. The Government have already redeemed their pledge to remove the National Health Service prescription charges. The prescribing of contraceptives where no question of danger to health through pregnancy arises is not part of the family doctor's medical care under the National Health Service and for that reason, such prescriptions have always been private and not provided under the Service. There is no new principle involved in allowing National Health Service doctors to charge patients
439 for transactions which do not form part of the medical care which they provide for them. It has always been open to doctors to charge a fee for certificates desired for various private purposes. It is not unreasonable to regard the writing of prescriptions or the fitting of appliances not needed on medical grounds as broadly comparable with this existing arrangement.
I trust that what I have said has convinced my hon. Friend that I would in no way wish to discourage family planning. I hope that such incentive as there may be in this small reward will encourage more busy doctors to find time to acquaint themselves with family planning techniques and that patients may on the same account, hesitate less to take up their doctor's time for what is strictly speaking a non-medical purpose. If patients are prepared to pay the chemist a comparatively large amount for the pills, they will hardly grudge the doctor a small fee for prescribing them, especially as a single prescription is normally likely to cover several months' supply.
440 The Government have no reason to suppose that doctors will abuse the power to charge, but in any event the proposed new arrangements are to be regarded as an experiment, subject to review in the light of experience. This does not mean that I expect that they will be abused. The fact that this is experimental and subject to review is, shall we say, an additional incentive, if one were needed, for the doctors to fix the charge at a suitably low level and for their professional organisations to recommend a sufficiently low charge.
I can assure the House that I will keep a very careful eye on the arrangement and will certainly not hesitate to act should it prove contrary to my expectations to be less than satisfactory. I should be willing to consider any evidence which hon. Members might receive that would indicate that the proposal was acting in any way against the interests of family planning.
§ Question put and agreed to.
§ Adjourned accordingly at three minutes past Eleven o'clock.