§ 10.13 p.m.
§ Mr. Bernard Braine (Essex, South-East)
I beg to move,That an humble Address be presented to Her Majesty, praying that the National Health Service (General Medical and Pharmaceutical Services) Regulations, 1966 (S.I., 1966, No. 1210), dated 22nd September, 1966, a copy of which was laid before this House on 30th September, be annulled.It is one of the shortcomings of our procedure that, if the Opposition want to discuss a Statutory Instrument or to persuade the Minister to explain its purpose, they are obliged to pray for its annulment although they may be perfectly ready to accept, and perhaps even welcome, most of its provisions. That is the position in which we find ourselves tonight in considering these important Regulations, perhaps the most important Regulations laid before the House for some time. I should like to make it plain at the outset that we have no wish to delay the implementation of these Regulations. We shall not divide the House. Our purpose is merely to seek an explanation from the Minister as to their precise meaning and implications.
It is right that we should seek such an explanation since we must all be aware of the mounting difficulties facing the National Health Service. The Minister knows that the number of doctors in relation to population is falling. He has admitted that there is cause for anxiety but he pins his hopes to the new contract which is the subject of these Regulations.
The test of the Regulations, therefore, is the extent to which they will encourage a real improvement in general practice, will reduce the present excessive work load and so put new heart into an overworked and very worried profession.
The Regulations themselves do not tell us a great deal. Regulation No. 22, for example, simply tells us that the rates and conditions of payments to general practitioners are to be set out in a statement which the Minister may determine after consultations with representatives of the profession. If we want details of those rates and conditions, we look in vain to the Regulations. We must consult 798 the reports of the joint discussions between G.P. representatives and the Minister; we must study the various E.C.N.s, which are the directives which the Minister sends to executive councils; we must read the statement referred to in Regulation 22(1) which has been published separately as a red book. When we do that, it is clear that these Regulations are not quite as straightforward as they might appear.
For one thing, they represent a very substantial departure from the relationship which has hitherto existed between the doctor and the State. Up till now, the general practitioner has undertaken to provide a continuous service for each patient on his list to an unlimited extent. For that, he was been remunerated in a way which has never been a very happy arrangement and, as his work load has increased, it has become more and more unsatisfactory.
Now there are to be new arrangements. As from 1st October, general practitioners have agreed to a pricing of the individual elements of their work. They will receive fees related to work during normal hours, weekends, night work, and to items of service for work after midnight. They will receive direct payments from the State for the use of their premises and for the staff whom they employ. They have also agreed that it is better for doctors to work together in groups and that those who work by themselves will earn less money than if they join a group.
Undoubtedly, all this will bring considerable benefits. The basis of remuneration, though not fully related to the work load as it should be, is more sensible. Its distribution to individual doctors is fairer. In the long run, a better service should be provided for the patient. But it also spells considerable change, and I think that it should be realised that it will lead not merely to a new relationship between the doctor and the State but between the doctor and the patient.
As the Minister knows, these arrangements do not altogether reflect what the profession wanted and thought necessary to reduce excessive work load, and to ensure freedom to practise good medicine. May I be permitted to say, in passing, that they wanted the reintroduction of prescription charges, with 799 safeguards for the old and the chronic sick; they wanted the right to opt for payment by means of items of service, a system which works admirably in New Zealand; they wanted full recognition of the contribution made by a doctor's wife to the efficient running of a practice. All those were rejected by the Minister.
It would be wrong, therefore, if the impression should be given that these Regulations embody the full and unqualified agreement of the medical profession. They do not. Because of that and because on both side of the House we must all want the National Health Service to function smoothly and with the maximum good will, it is imperative in our view that the Minister should explain the Regulations and remove any misunderstanding about them. It is imperative too because he is already advising executive councils how to administer the new arrangements, despite the fact that Parliament has not yet approved the Regulations. He is doing so by means of his executive council notes. We are entitled, therefore, to ask for an explanation not only of the Regulations but of their detailed application as set out in the E.C.N.s.
What, for example, is the explanation of paragraph 3 of E.C.N. 569 which gives wide powers to executive councils, after consultation with the local medical committees, to refuse reimbursement of rent and rates in respect of any enlargement or improvement in the practice accommodation? Why should it be left to executive councils to decide whether improvements to practice premises improve the service to the patient or not? Is not this a serious interference with a doctor's judgment?
If he is to be overruled, what right of appeal has he? I ask this question, and I shall ask others, because the Minister will surely be aware that many doctors believe, rightly or wrongly, that the right hon. Gentleman would prefer to see them working in health centres, and that he would welcome the introduction of a completely salaried service, developments which they believe would destroy what is left of their professional independence. I do not know whether that is the right hon. Gentleman's own view, though it is the view of some of his hon. Friends.
800 Of course, we are all agreed that the Minister has a duty to organise the National Health Service as efficiently as possible, and in this he has our full support, but I hope, also, he will acknowledge that he has a practical interest in building up the confidence of the profession and in helping to preserve its clinical independence and integrity. We should like to know, therefore, what is the thinking behind the instructions in paragraph 3 of E.C.N. 569.
We should also like an explanation of the arrangements for abatement and reimbursement for the rent and rates of a doctor's premises. That there should be some abatement of payments for this purpose in cases where a doctor uses premises for treating private patients and National Health Service patients, either in the same premises, or in separate premises, is wholly reasonable. I do not question that at all, but at what level should the abatement take place? What principle should govern the calculation?
Under the new contract the full basic practice allowance is paid to a doctor who has a minimum of 1,000 National Health Service patients and is devoting a substantial proportion of his time to them. He is still eligible for a proportion of the allowance if he has fewer than 1,000 National Health Service patients. The test is whether he is providing an adequate service to his National Health Service patients, and that is the only test that can be applied. The fewer he treats below 1,000, the greater the abatement, and that is right and proper.
One would have thought, therefore, that the same principle would be applied in determining the reimbursement of rent and rates in respect of premises of a mixed National Health Service and private practice, but it is not. When we consult paragraphs 14(1) and (2) of E.C.N.569, we find an unnecessarily complicated formula which seems expressly designed to penalise a doctor with private patients, though this brings no advantage to his National Health Service patients.
Under this arrangement a doctor will have payments for the rent and rates paid in respect of premises which he uses for seeing both National Health Service and private patients abated, but if he sees them in separate premises, then payment in respect of premises used solely for 801 seeing his National Health Service patients are still abated.
I must tell the House that the profession has taken this formula as a direct attack on the right of a doctor to have a private practice, and they have told the Minister so. Why should a doctor's income from private practice at other premises be taken into account—and this is the important thing—where he is carrying out his National Health Service work to the satisfaction of the executive council and the Minister?
I understand that the right hon. Gentlemen's defence has been that it is difficult to distinguish between a doctor's income from separate premises. I can understand that. If so, it is very difficult to understand why the right hon. Gentleman should have devised this very rigid formula.
Arising from that, I have two questions to ask the Minister. First, what is his attitude to private practice? Is the British Medical Journal of 22nd October correct in its assertion that the abatement formula isa fundamental change in the original agreementwhich the Minister reached with the profession? This is a serious charge. What action is the Minister taking about it?
My second question is this: is it not regrettable that Parliament should be asked to approve Regulations which, as in this case, do not spell out the principles involved in detailed arrangements which can only be found in documents separate from the Regulations and which hon. Members cannot see and which the Vote Office cannot supply?
§ The Minister of Health (Mr. Kenneth Robinson)
I assure the hon. Member that a copy of the statement and of all the other relevant documents is available in the Library.
§ Mr. Braine
I am delighted to hear that, although it is small comfort to hon. Members who come into the Chamber now and wish to consult the documents. I am not, however, complaining specifically about this. It may have been the practice for a long time. All I say is that while it is inherent in our procedures that this difficulty should arise it is a great pity that there is no clue in the Regulations that the Minister, wittingly or unwittingly, 802 is making an onslaught on private practice. But for this Prayer, Parliament would have approved these arrangements in complete ignorance of the bitter resentment which is welling up in the medical profession at the way in which agreements freely reached with them have been interpreted. I therefore hope that the Minister will give the House a firm assurance that he will look at this again and will work out an abatement formula which is both fair and seen to be fair by all concerned.
§ Dr. David Kerr (Wandsworth, Central)
The hon. Member has said that bitterness is welling up in the medical profession. I am bound to say that my experience is at variance with this. Could he give me chapter and verse for this assertion?
§ Mr. Braine
Yes. I quoted from the British Medical Journal of 22nd October in which it was made plain that the profession's representatives greatly resented this interpretation.
I should like to turn now to the question of ancillary help. Clearly, as long as we are faced with a shortage of doctors, the only way in which their work load can be substantially reduced is by the provision of skilled help. On this we are all agreed. I am glad to acknowledge that the Minister has actively encouraged inquiries into ways of doing this. I have particularly in mind the experiment in three different sized practices being carried out by the North-East Faculty of the College of Practitioners, a project which began last year with the assistance of Ministry money. I see, for example, in World Medicine of 18th October,Already the G.Ps. involved are confident that efficiently-organised nurses can take on many of the tasks that are usually and wearily performed by over-houred G.Ps.We on our side of the House warmly welcome the scheme introduced in these Regulations for the direct reimbursement of the major part of the expense of employing paid ancillary help. Here again, in order to discover precisely what is involved we have to turn to the Minister's directions. We cannot see this in the Regulations. When we do this we find two quite extraordinary stipulations.
Paragraph 2 of E.C.N. 567 says that ancillary staff must be paid direct by the doctor. This would seem to eliminate staff supplied by an agency. Is this 803 correct? Has it been the subject of representations by the profession and, if so, what is the answer which the right hon. Gentleman has given?
The second stipulation is far more serious. The same paragraph says that the scheme excludes doctors' wives and other relatives. Nowhere can I find any explanation of this nonsensical exclusion. While it may be reasonable to exclude relatives as such, is it reasonable, does it make sense, at a time of acute shortage of skilled health workers to exclude relatives who are experienced State Registered Nurses or trained dispensers? It is significant that in the experimental project to which I referred a moment ago it was agreed from the start, because of the shortage of hospital nurses, to recruit only unemployed State Registered Nurses. That was a very sensible decision, because it would not have helped, for purposes of an experiment of this kind, to lure nurses away from the hospitals into general practice.
But one of the doctors engaged in this experiment found that although he could get unemployed nurses, the best-qualified person available was his own wife. She was specifically excluded, and she would be excluded under these new arrangements.
This is an absurd situation and I cite an actual case to show how absurd it is. The wife of Dr. X is a State Registered Nurse. He has a rural practice and she knows the area like the back of her hand. However, because of the restrictions on the employment of wives, she works full-time in another practice 15 miles away, which means that she must travel 30 miles each day. Dr. X hires two people in her place, at a considerably higher cost to the taxpayer than if he employed her. Everyone is disadvantaged. Dr. X is more fortunate than most because, being a rural doctor, he is able to obtain suitable help; although his wife would be admirably suited to assist him if he were allowed to employ her.
No doubt the Minister reads the medical Press. Did he see an article headed "Ancillary services essential to my practice" in the November issue of General Practitioner? It stated:It is all very well for the Government to talk about easing the doctor's burden, but when physiotherapists, radiographers and dispensers are leaving the hospital service for 804 better pay with the drug firms what hope have we G.P.'s of obtaining the help we need? In the event of payment to wives being disallowed, my wife will have to travel 16 miles to work for a colleague, and his wife will come to work for me. This obviously is a ridiculous arrangement.The Minister is fond of saying that he believes in the rationalisation of the medical services and I believe that he is genuine about that. He also talks a lot about bringing more ancillary help to bear, but how does the right hon. Gentleman reconcile those aims with these absurd restrictions on the use of skilled help?
When one considers the crisis facing general practice, is it not all the more important that a doctor should be able to employ his wife? What often determines whether or not a doctor emigrates is the attitude of his wife towards conditions in the Health Service. The right hon. Gentleman may reply that the new practice allowance includes an element for responsibility devolving on a doctor's wife, but he knows that the profession does not accept this. He knows that it is no answer because it makes no distinction between the wife who answers the telephone and makes cups of tea and the wife who is a skilled and trained nurse and who, as the College of Practitioners' experiment has shown, can play a major rôle in reducing the work load on a doctor.
He should know too that in law, a wife has no duty to work for her husband and, if she chooses to do so, she is entitled to fair remuneration. The present arrangements are unfair and exceedingly shortsighted, and I challenge the Minister to justify them. Better still, I urge him to have the good sense to look at the matter again.
I have studied the new arrangements to see what help they give to general practitioners in regard to diagnostic aids and other essential equipment. Obviously the better a general practice is equipped the better service the doctor can give to his patients and the more he can do to reduce the load on our already overburdened hospitals. Most doctors consider it essential to have an electrocardiograph machine. To some doctors this equipment is as basic as a stethoscope was 50 years ago.
The trouble is that too many doctors lack essential diagnostic aids and have 805 to send their patients to hospital for examination or have to arrange for a consultant to make a domiciliary visit, in both cases throwing a considerable financial burden on the Health Service. If under these new arrangements help is not given to doctors to obtain this equipment, what is the right hon. Gentleman's reasoning behind the omission?
In all of this, the aim must be to provide a better service to the patient. That means cutting down waiting time in doctors' surgeries, and eliminating unnecessary calls. Bound up with this is the necessity for a simple and effective appointments system. We warmly welcome the encouragement the Minister is giving to doctors to establish an appointments system and to patients to understand how and when to make appointments. But if he really means business, paragraph 7 of his E.C.N. 570 seems far too permissive. I will read an extract:The Minister has asked Councils to give all reasonable assistance to doctors who wish to introduce an appointments system, the extent of the assistance to be discussed with the local medical committee and to include the printing and distribution of circulars and the postal charges involved.That is excellent. It goes on to say:It will be appreciated that because the work would have to be fitted in with the Council's other duties it may not be possible to give immediate assistance to all doctors who wish to take advantage of this arrangement.That is not a very happy way of starting off the new arrangements.
Who, incidentally, will bear the cost of printing and postage—the doctors of the executive council? We welcome the Minister's "Help the Doctor" campaign. We assume that the object is to help the patient to help the doctor to help the patient. I am sure that with good will and intelligence on both sides a great deal can be done to improve general practice, and perhaps the Minister will say something about this. But will his campaign also tell the general public about the fundamental changes which these Regulations are bringing about, particularly the fundamental changes set out in Schedule 1 of the Regulations limiting the freedom of the patient to call the doctor of his choice?
Finally, I should like to ask a question about the date when the new contract comes into force. As I understand it, 806 the effective date of some, but not all, of these arrangements is 1st October. But here arises a substantial point of principle. Here we touch upon the heart of the crisis which is facing the medical profession. The House will be aware of the unhappy story of how the Review Body's recommendations were handled, how on 4th May the Prime Minister modified those recommendations by phasing them over two years, how he met the B.M.A. and agreed that it should discuss with the Minister precisely how the phasing should be carried out. The Minister was helpful. In fact, agreement about the phasing was reached quite quickly. Then came the pay freeze and postponement of the first phase of the award.
We recall that the Review Body was unanimous, that its recommendations were the minimum necessary to produce a decent Health Service. Yet, as a result of what many doctors regard as a breach of faith, they will get in their first year not one-half but one-quarter of what the Review Body considered necessary for the whole future of medical care through general practice.
It is against this frustrating, unhappy background that general practitioners will be considering the new arrangements authorised by these Regulations. What will they find? When they study the statement in the red book prepared by the Ministry of Health, under Regulation 22, they will see on page 1 a schedule with two columns relating to fees and allowances. Column 1 states:From 1stOctober, 1966 or later date where indicated".Then in column 2 we see:From a date to be announced.What will be their reaction? One doctor friend of mine has reacted very quickly. He said, "What little faith we had in the Government has now been completely shattered."
This is what Parliament tonight is being asked to approve. The Minister will be aware of the deep dismay, and even anger, that the pay dispute has engendered. Cannot he see that continued vagueness and uncertainty of this kind is hardly likely to encourage the notion that these new arrangements, many of the features of which we welcome, will make for better relations between the Government and 807 a great and noble profession? All of us in this House, on both sides, and certainly the Minister, passionately desire these better relations in order to make the National Health Service as effective an instrument as we can.
Nearly 90 years ago Disraeli observed thatThe health of the people is really the foundation upon which all their happiness and all their powers as a State depend.It still is. We shall be interested to know what the Minister's views are as to the final date when these new arrangements will be fully implemented. If he has difficulty over this, let him have the courage to tell us. We shall understand, but we shall expect him in return to convey our strong disapproval to the Prime Minister.
§ 10.41 p.m.
§ Dr. Shirley Summerskill (Halifax)
I appreciate that this is a late hour to speak on this Prayer, but I should like to make a few comments on the contribution of the hon. Member for Essex, South-East (Mr. Braine). He opened his remarks in a mild and benign fashion, saying that he was merely seeking information. But then he worked himself up into an attack on the Government's management of the Health Service, on the conditions under which doctors are working, and said that these excellent proposals have been put forward against "an unhappy and frustrating background"—all of which he attributed to the present Government and the present Minister.
I hope that my hon. Friends were not at all impressed, but were completely unimpressed by quotations he made from the medical Press, because those newspapers and journals, if we can call them such, are, as we know, financed by private drug firms and their sole purpose when distributed to family doctors is to try to sell drugs of various kinds. Most of them consist of advertisements with the occasional snappy article around the advertisement.
§ Dr. Summerskill
No. I was not including the British Medical Journal, but 808 what the hon. Member called, in a grandiose way, the medical Press.
§ Mr. Braine
I am sure that the hon. Lady does not mean to be unfair, but the only other journals which I quoted were World Medicine and a newspaper called G.P. and I quoted an observation by someone writing about doctors' wives which merely supplemented an illustration I had already given to the House. These strictures, therefore, bear no relation whatever to anything I said.
§ Dr. Summerskill
I would certainly respect, with modifications, anything which the hon. Member may have read from the British Medical Journal, but I would not accept as gospel the journalese in journals produced by private drug firms.
In opening his remarks, the hon. Member implied that the Minister in this document had failed at various points. He blamed the Minister for not doing everything that the doctors want—as examples, removing prescription charges and not giving adequate remuneration to their wives. On the other hand, he blamed the Minister for interfering with their independence and apparently for not leaving them alone enough. Thirdly, he implied that the Government were inflicting on doctors something they do not want, such as health centres and a salaried service.
The hon. Member gives far too much attention to private practice. I believe that only 1 per cent. of doctors in the whole country live entirely on private practice, while 99 per cent. earn their living and their families' living from State practice. In the same way, too much emphasis is given to public schools and not to State schools. The House should give far more attention to conditions in State practice than it does to conditions in private practice.
I commend the Regulations to the House. I do not think that they have been brought out against a background of frustration and unhappiness, as the hon. Member implied. I commend their contents to the House.
§ 10.45 p.m.
§ Mr. Graham Page (Crosby)
My hon. Friend the Member for Essex, South-East (Mr. Braine) made a powerful case of 809 criticism against the merits of the Regulations. He complained that they referred to documents not contained within themselves. I was amazed when the Minister endeavoured to justify this omission by saying that the documents were in the Library.
This raises an extremely serious constitutional point. The 1946 Act contemplated that executive councils would settle pay, remuneration, fees, with the profession. Section 33(1) provides that executive councils shallmake … arrangements with medical practitioners for the provision … of personal medical services …The words aremake arrangements with medical practitioners"—not to legislate or to dictate to them, but to make those arrangements in accordance with such regulations as the Minister might make. Subsection (2) provides that the Minister shall make regulations to ensure that thosearrangements will be such that all persons … will receive adequate personal care …Nowhere in that Section is any mention made of the Minister prescribing fees by regulation.
It is obvious from that Section that it was not contemplated that the Minister would dictate the remuneration of the profession, not even by Regulation. Parliament gave the Minister power to make Regulations under the 1946 Act for certain purposes. It certainly did not give him power to fix the remuneration of medical practitioners by a statement outside the Regulations and merely laid in the Library for the information of Members. This House has always set its face very much against the delegation of delegated powers. Parliament delegated to the Minister the power to do certain things by Regulation in connection with the medical profession. It did not permit him to delegate those powers to anybody else or to delegate them in some other form than a Regulation. Here he is endeavouring to make law by a statement outside regulations.
Regulation 22 shows the real significance of this. It states:For each financial year ending on 31st March the Council shall make payments to practitioners providing general medical ser 810 vices in their area in accordance with such rates and subject to such conditions as the Minister, in a Statement, may determine …I repeat the wordssubject to such conditions".Here the Minister is endeavouring to legislate for the medical profession by a statement not included in any legislation. It might never have been known to us if he had not laid it in the Library. I suppose that the House should now adjourn to go and read it in the Library in order to know what we are talking about. When the right hon. Gentleman informed us that it was in the Library, I was of a mind to ask for the House to adjourn for the purpose of reading it so that we might know what we are debating. But undoubtedly the right hon. Gentleman is trying to legislate in a form not authorised by the House and in a form which is not in accordance with constitutional practice, let alone the Act of 1946. He should describe to the House very carefully what powers he claims to have to do this.
§ 10.50 p.m.
§ Dr. David Owen (Plymouth, Sutton)
It is with great pleasure that I rise to welcome the Regulations. I can understand the Opposition Front Bench feeling the need to indulge in a certain amount of nit picking, but it should be stated clearly that general practitioners and the vast majority of doctors who work in the National Health Service welcome these Regulations and the Charter to which they are addressed.
I do not think at this stage that any of us would bring much benefit to the situation by going back over the very difficult circumstances of the last two to three years. In fact, the situation has existed far longer than that. My right hon. Friend the Minister of Health has borne a very heavy burden over the last two years. He has had to negotiate against 18,000 signatures held by the B.M.A. and I believe that he has shown great patience, great tact and great skill. I believe that that is a tribute that most hon. Members opposite would also apply to him.
I want to mention the question of the increase in pay doctors have been given. There is a feeling in the country, and we must face it honestly, that it is too much, that it is against the Government's prices and incomes policy. There is also 811 a certain amount of resentment. We should try to emphasise that there is in this pay rise a very substantial element of productivity bargaining. For the first time, the Government are not giving an increase straight across the board to all G.Ps.
The G.P. who benefits from these Regulations will be the good G.P., the practitioner who is prepared to use ancillary help, to take on preventive work, cervical smears and immunisation and to invest money in his surgery. This is a positive advance. The person who just has a very large list, operates a lock-up surgery and gives poor service to his patients will not get as much money and that is right and in accord with the prices and incomes policy.
Another thing we must emphasise is that my right hon. Friend was facing a manpower shortage. Doctors were leaving the Health Service, particularly the G.P. service, and others were not coming in to fill the gaps. Again, this was an exception allowed under the prices and incomes policy statement. So I would say to those critics of the Government for giving this very substantial pay rise that there is both an element of productivity and agreement with the prices and incomes policy.
Having said that, I ask the medical profession—I do so as one who has worked and still works within it and whose father is a G.P.—to co-operate with the Minister of Health to make the National Health Service, and the G.P. service, a real national service. I hope that we shall have less talk about stimulating private practice, for, let us be honest about it, private practice is sought after by one section because it is able to buy the privilege of extra time—and this is the essence of what a private practitioner gives. He gives time—and the people who pay for that time are of necessity those people who are only getting service from the N.H.S., and we are already short of doctors. To spend a lot of time increasing the private sector can only impair the public sector.
I hope that the medical profession will accept the spirit of this Charter and the spirit of the Regulations and that we will now hear less about pay and much more about service and the quality of service. I hope that this is only the first 812 step. There is a very long road ahead in changing the N.H.S. and particularly the G.P. service.
At the height of the crisis, some of my friends and I wrote a Fabian pamphlet "General Practice" and tried to draw the Minister's attention to the path ahead. We simply have to move to a system by which we can have true cooperation between the hospitals and the local authorities. We have to move to a system by which surgeries are community surgeries, sited in relation to the hospitals and the community services provided by local authorities. We have to look upon the general practitioner as the leader of a domiciliary health team.
I believe that the great many advances which these Regulations can bring about will aid this development, but they are only a start. A great burden of responsibility now rests with the medical profession. General practice has been likened to a cottage industry and in many instances that is still the situation. More general practitioners have to group and, we hope, will group voluntarily. We must go for more health centres at which a wide range of preventive health services is offered to the public.
I should like to pay tribute for this charter to an organisation which often gets little publicity, my own union, the Medical Practitioners' Union, which my hon. Friend the Member for Willesden, West (Mr. Pavitt) served so long and so successfully and which largely laid down the basis for the charter on which the Minister has been negotiating. That union has always tried to present the deficiencies in the National Health Service rationally and sensibly and in the spirit and the belief that it could make a major contribution to the health, prosperity and happiness of the nation.
I strongly believe that the Service can emerge from the difficult times which it has gone through and is going through. It will need inspiration from the medical profession. It is no good the profession always looking to the politician to sort out its problems. There is a tremendous tendency in the profession to criticise politicians and everyone else but itself. Much of the trouble in the Service today can be laid firmly at the door of the profession and its leaders and it is time that that was acknowledged. A career 813 structure in general practice and a career structure in the hospital service could and should have been tackled by the profession itself.
I end by saying that I welcome the Regulations. I think that they are widely welcomed by general practitioners throughout the country and I hope that they will mean the opening of a new chapter in the relationship between general practitioners and the National Health Service.
§ 10.58 p.m.
§ Mr. Laurence Pavitt (Willesden, West)
My hon. Friend the Member for Plymouth, Sutton (Dr. David Owen) has made some interesting comments. I agree with him that these Regulations provide an opportunity for co-operation from general practitioners in organising themselves far more effectively and move away from being a cottage industry into a system of working which will give more efficient use of their time. The Regulations provide the right kind of incentive for that process.
Production of the Regulations has been a major task. There are 42 pages of this document and a wide variety of Regulations. The size of the task was given its greatest commendation by the fact that the hon. Member for Essex, South-East (Mr. Braine), a previous Parliamentary Secretary to the Ministry of Health, who knows the National Health Service himself, put searching questions which boiled down to very little. The fact that there was so little of real substance to question shows what a tremendous task my right hon. Friend has succeeded in doing.
I go back further than the recent two years of difficulties, back to the tremendous upheaval in 1956 which led to the establishment of the Pilkington Committee and the three years which it took to produce its report which led to the establishment of the Kindersley Committee—ten years of turmoil. I welcome the change from the old system of general practice by which the more service doctors gave, the less reward they got. The whole of the pool arrangements which doctors have resented for the last ten years disappear in these Regulations.
Sometimes the country and people at large do not realise the quiet, day-today work which went on from the beginning of 1965 until the Regulations came 814 before us tonight. Day in and day out there was constant negotiation, giving here and taking there, leading to what is, in effect, a complete recasting of our family doctor service. I join my hon. Friends on this side, and, I feel sure, part of the commendation given by the hon. Member for Essex, South-East, in paying tribute to this rather unspectacular, very quiet, solid job of work which has been done and which opens up so many new fields.
Points have been made about the doctors not being fully satisfied. When 100 per cent. of the doctors are fully satisfied and quite happy with everything that goes on, the receptionist will probably be St. Peter and we shall be queueing up in our robes outside for our E.C.10s. When I organised doctors, now many years ago, my experience was that if I had twelve doctors, I would get twelve separate opinions.
The hon. Member for Essex, South-East made a plea for private practice. There is nothing in the Regulations which puts down private practice. What I can never understand is that when people claim freedom so that they shall have private enterprise in their business of dispensing medicine and curing the sick, at the same time they seem to want a subsidy from the National Health Service to enable them to do it. The Regulations are quite right in not permitting that kind of thing.
Similarly, the way in which the recasting of expenses has been done means that there will now be a clear payment for the rent and rates of premises. It is absolutely right—and this is provided for in the Regulations—that if the taxpayer is paying for a clearly discernible service, that of the premises from which the doctor practices, he should have the right to say how well those premises should be equipped, and make sure that the standards are commensurate with the payment. This is the kind of thing which common sense would demand that any Minister of Health, of any party, who tried to recast the system of general practice should consider.
I would be grateful if my right hon. Friend would expand a little on Regulation 8(1,b,iii), which permitstreatment which it is reasonable in the circumstances to delegate to a member of his staff, being a person who is competent to carry out such treatment".815 In our present shortage of doctors, if this provision is to be used effectively, it could give a great deal of benefit to the hard-pressed general practitioner. I hope that this means that the doctors, together with my right hon. Friend the Minister, will not regard this simply as a permissive power, but will be able to take practical measures to extend the degree to which routine work is lifted from the shoulders of the doctor, thereby enabling him to devote himself to clinical work for which he would not otherwise have time.
My hon. Friend the Member for Sutton finished his contribution to the debate in the same way as I should like to conclude mine. The Regulations represent a fresh start for general practitioners but they are, at the same time, the basis for moving away from curative to preventive medicine. The Regulations provide that opportunity.
I think that the whole House will join in tribute, not only to my right hon. Friend, but to the patient civil servants who must have been working behind the scenes for a long time and to the patience of the doctors who served on the negotiating committee and their understanding of the situation, particularly on the part of some of those who have taken a large amount of their own time away from their practices to go into the details and to prepare this excellent document which is now before us. It is not perfect—there is still a lot to be done—but, at least, it is the foundation upon which the kind of family doctor service that most of us want to see as the front line in the Health Service can be built.
§ 11.5 p.m.
§ The Minister of Health (Mr. Kenneth Robinson)
Although we are debating a Prayer against a particular set of Regulations I very much welcome the assurance of the hon. Gentleman the Member for Essex, South-East (Mr. Braine) that he did not wish to see these Regulations annulled. It would be very unfortunate if it were otherwise, as I will explain in a moment. The House has taken this opportunity to debate general practice on this Motion simply because it is a matter of some interest and importance, which ought, from time to time, to receive the attention of the House.
I am very glad to welcome the initiative of the hon. Member and his hon. 816 Friends and, broadly speaking, the way in which he introduced the Motion. I would also like to thank my hon. Friends the Members for Halifax (Dr. Summer-skill), Plymouth, Sutton (Dr. David Owen) and Willesden, West (Mr. Pavitt) for the constructive contributions that they have made. I am also glad to have an opportunity of saying something about the progress that we have been making in rescuing general practice from the state of neglect and depression into which it had fallen over a period of many years.
It is not really true to say, as the hon. Gentleman the Member for Essex, South-East said, that these Regulations do not embody the full agreement of the profession. They do. This is not to say that they give the profession everything for which it asked in its original charter. That is a different matter. They are the result of protracted negotiations, in which there has been give and take on both sides. The hon. Gentleman also, I thought, suggested that I had done something faintly improper in giving instructions to Executive Councils before—I thought he said—Parliament had approved these Regulations. He is an old enough Parliamentary hand to know that Parliament does not have to approve Regulations which are subject to the negative procedure.
§ Mr. Braine
The right hon. Gentleman may have misunderstood me. It was a fact that these Regulations had already been sent out before the House had had an opportunity to discuss them and but for the Prayer, it would not have been possible to discuss, in any kind of detail, the kind of instructions that the right hon. Gentleman was sending out.
§ Mr. Robinson
We both welcome the fact that an opportunity has been made, through the initiative of the hon. Gentleman and his hon. Friends to discuss this matter. It would be right for me to make my remarks within the context of the General Medical and Pharmaceutical Regulations comprised in the Motion before us, rather than to range too widely over the whole sphere of general practice.
I said that it would be unfortunate if there were any serious suggestion that the Regulations should be annulled, and this is because they form a most important step in the long and detailed programme 817 arising from my negotiations with the profession towards the rehabilitation of general practice. The new Regulations, which for convenience are in the form of a consolidation of those that have been in force since 1962, and subsequently amended, introduce a number of amendments falling under two main headings.
The first and most important concerns the arrangements for general practitioners' remuneration. Perhaps I can now deal with the point raised by the hon. Gentleman the Member for Crosby (Mr. Graham Page), which he said was of major constitutional importance. In the past, when there has been a change in the level of general practitioners' remuneration it has not always been necessary to change the Regulations, because by and large, the actual level of the various tees payable were not embodied in a Statutory Instrument. They were notified administratively from my Department and what the Regulations used to contain, and have contained for many decades past, was something called a distribution scheme.
This was originally designed to be a method of distribution of a particular sum of money, available to individual insurance committees under the old National Health Insurance arrangements The same arrangement was brought into the National Health Service and we have continued to have a distribution scheme until the present day. Had we merely been concerned with a change in the level of remuneration this scheme, and consequently the Regulations, might have remained unchanged. But as the House knows, the new system of remuneration which the Government have worked out with representatives of the profession, represents a radical departure from the previous method, known as the Pool System.
Because of this change in the method of payment, we have had to make considerable alterations in the governing regulations. What we have done, instead of amending the whole distribution scheme in detail, is to deal with general practitioners' remuneration as we already deal with remuneration of some of the other professions providing Executive Council services, by issuing a "Statement of Fees". This is a sort of handbook for each individual general practitioner setting out in detail and in as simple language as possible the size 818 of the individual fees and payments to which a doctor is entitled and the conditions for receiving them.
If hon. Members will turn to Regulation 22, they will see that, as it is now drafted, it refers to the Statement and defines what the Statement must cover.
§ Mr. Graham Page
I am grateful to the right hon. Gentleman for that explanation. I now have the Statement in my hand, having acquired it from the Library. What worries us is to know what force of law it has. Is it an agreement between the executive councils and the medical practitioner, and how would anyone enforce it? This is the difficulty when one has a Statement outside Regulations of this sort.
§ Mr. Robinson
It is an agreement between the Government and the profession, implemented by executive councils. I could have laid regulations setting out the fees, but that would have been a little complicated, and I think that there is no constitutional horror in the course which we have adopted. It is for the general convenience of all.
I should like to mention briefly how the new payments structure which the Regulations enable us to put into effect is one of the most important steps towards the reforms which are vital to general practice. The new system is designed to move away from the old idea of remunerating doctors primarily on a per capita basis, towards a system where there is a much closer conformity between the work done by the doctor and the expenses incurred on the one hand, and his income on the other.
I cannot think of any one step which has been taken to help general practice of greater significance than the introduction of schemes for the direct reimbursement of expenses incurred with premises and the employment of ancillary staff. The hon. Member for Essex, South-East mentioned both these, and I will try and deal with his questions in the course of what I have to say.
Although it may take some time before the real value of these new arrangements will become apparent to the profession as a whole, I have no doubt that, as this is realised, it will make a real difference to general practice and, therefore, to all of us in our role as patients when we are in need of treatment.
819 I will deal briefly with the question of ancillary staff, which covers nurses, dispensers, receptionists, secretaries and the like. Broadly, under the scheme, the doctor is reimbursed directly a large percentage of the salary which he pays to his ancillary helper for the time that she spends on the qualifying ancillary duties. In addition to the proportionate reimbursement of the salary paid, Selective Employment Tax is reimbursable, and the balance of expenditure incurred by doctors on staff continues to be taken into account in the fees and allowances which they receive.
The hon. Gentleman mentioned doctors' wives. There is no question about this and one has only to refer to the Review Body's Report to see that this element is taken into account in fixing doctors' remuneration. The hon. Gentleman is not the first to complain that no distinction is made between what he called the ordinary wife who answers the telephone and the wife who is herself a qualified nurse and who can make a much bigger contribution to her husband's practice.
We thought very carefully about this, but I can assure the hon. Gentleman that both sides in the negotiations came regretfully to the conclusion that it was quite impossible to draw a dividing line and make special arrangements for the type of "special wives", as they came to be called, whom he described, which would not give rise to very considerable anomalies, arguments and, indeed, to bitterness between doctor and doctor and, what is perhaps even more terrifying, between doctor's wife and doctor's wife. We came to the conclusion that the only reasonable way of dealing with the whole question of wives was to ask the Review Body to take it into account. We have its assurance that it has done so.
The second scheme provides broadly for direct reimbursement of the rent and rates which the doctor pays for surgery premises which are regularly and substantially used for National Health Service purposes, or a payment in lieu of rent together with rates where the doctor himself owns the premises. This is a little complicated, because the scheme has to allow for a wide variety of circumstances in which a doctor may practise. He may, 820 for example, practise from his residence, in which case only part of the total outgoings of the premises are due to be taken into account and an apportionment has to be made.
The hon. Gentleman asked why should the executive council have to approve that new premises should qualify for direct reimbursement? Well, my answer is that it is surely reasonable that the executive council, after consultation with the local medical committee, should need to decide that a move to new premises would not unreasonably increase rent and rates without also improving the service.
Surely this is a fully justifiable provision, because, after all, it is the Minister who has to pay the rent and rates and he has to ensure that these are not unreasonably high in relation to the service given to patients.
§ Dr. David Kerr
Would the right hon. Gentleman also explain what role the district valuer has to play in the assessment of these rent and rates repayments?
§ Mr. Robinson
The district valuer plays a key role. It is on his assessment that the reimbursement is based. An aggrieved doctor who does not like the decision of the executive council can make representations direct to the Minister.
The hon. Member for Essex, South-East also raised the question about the need for abating the payments where the doctor also engages to a significant extent in private practice. Unless an adjustment were made, of course, the Government would be subsidising private practice. Because I do not want to see the Government subsidising private practice it does not mean that I am opposed to private practice in all circumstances. It was fully accepted by the profession's representatives that there would have to be abatement in these circumstances.
It was recently represented to me, however, that one particular method of abatement relating to private practice from separate premises, which had been agreed on behalf of the profession, might be unfair to some doctors.
To meet their point I did put forward to them another formula to the one mentioned in paragraph 14(ii) of the agreed document, and this proposal of mine has been accepted in principle by the doctors.
§ Mr. Braine
Is the right hon. Gentleman saying it has been agreed to amend paragraphs 14(i) and (ii) of E.C.N. 569?
§ Mr. Robinson
I am not amending the actual Regulations, but there will be supplementary instructions to executive councils offering an alternative formula. I would be glad to explain this in detail, but it is very complicated and it would take me well beyond the end of the time we have for the Debate.
I want to make it absolutely clear that we accept fully the principle of abatement. All that was troubling us was the fact that the profession appeared to be disturbed about this. I am very glad to hear what the Minister has said.
§ Mr. Robinson
I think that they were unnecessarily disturbed. It had not seemed to us that many doctors would draw up their accounts in such a way as to make possible the alternative method I have now put forward, but I am told that some do and I am very glad to offer them the choice.
Both these schemes for reimbursement came generally into operation on 1st October, although doctors will not, of course, receive the first payments until they submit their claims at the end of the quarter. But for the income standstill the scheme would have started on 1st April last, and I am aware that following the publication of the Review Body's Report and the announcement of the Government's acceptance in principle on 4th May, many doctors in good faith engaged extra ancillary help or, before the announcement of the standstill, committed themselves to taking improved or more expensive premises in the expectation that the additional expenditure would rank for reimbursement. I have been able to make arrangements by which such additional expenditure will attract direct payments as though the schemes had been in operation from 4th May.
The hon. Gentleman dealt broadly with the effect of the incomes standstill on the award to general practitioners. I do not want to go over too much of the history, because I have not a great deal of time, but I think the hon. Gentleman knows that the method of phasing which the Government felt was necessary was agreed with the profession. Then, subsequently, the effective date of payment 822 of the first phase had to be deferred for six months in accordance with the standstill. Those payments originally effective from 1st April of this year became effective on 1st October, and some payments which were to have been effective on 1st October will become effective on 1st April, 1967.
The date on which the second phase becomes effective—this was the point made by the hon. Gentleman—depends on Government policy during the period of severe restraint. For this reason the higher payments set out in the statement on fees are headed, "From a date to be announced". The Government's announcement on incomes policy during the period of severe restraint will be made shortly, and the date of implementation of the second phase should then become known. I am aware that the profession expects this date to be 1st April, 1967, and that it is concerned that this should be announced before the end of the year.
The new system of remuneration also provides for payment of the basic practice allowance, that is, a lump sum, which above a certain level is independent of the number of patients on a doctor's list, and this, too, in so far as it represents a departure from the old type of capitation system, seems to represent a marked advance.
The hon. Gentleman mentioned the question of equipment. The equipment that a doctor uses is, of course, very much a matter of personal choice, and in assessing remuneration, from time to time account has been taken of the need to provide for capital requirements of the practice. But the House will be aware that there are reserve powers in the National Health Service Act, 1966, for the General Practice Finance Corporation to lend money for the purchase of equipment should it become apparent in the future that doctors are experiencing difficulty under this head.
I turn now to the other main change which is embodied in these Regulations, that relating to the doctors' terms of service. As the House will be aware, the negotiations with the doctors resulted in the issue of three reports, each of which contained specific ideas for changes in the terms of service for general practitioners under the Health Service. It was finally agreed with the doctors' representatives 823 that these changes would be embodied in new terms of service which were to be entirely rewritten.
This process is now being worked on in my Department, and is very near completion; but meanwhile, since new Regulations had to be made to accommodate the change in the system of payments, I thought it right to include in them certain other changes which should help general practitioners to cope with their work over the coming winter months, and to which the doctors themselves attach particular importance.
One, perhaps on the face of it comparatively minor, point was that doctors have hitherto had no right to delegate any treatment to ancillary workers. This point was mentioned by my hon. Friend the Member for Willesden, West. This has now been changed, and where a doctor employs a practice nurse or someone with similar qualifications he may delegate to her work appropriate to her ability and training.
Another change is that it has been made quite clear that a doctor who is off duty and has made proper arrangements with another doctor to look after his list of patients is free from all obligation to provide services. This is something which everybody else enjoys, and it has been something of an anomaly in the past that general practice should be treated differently.
The hon. Gentleman made one point concerning appointment systems. It is true that I have asked executive councils to give every reasonable assistance to doctors who wish to introduce an appointments system, because I want to encourage it in every way possible. It is something which is good for doctors, and for patients. The executive councils will themselves bear the cost of printing and distributing these circulars and paying the postage. I had to say that we could not guarantee to give absolute priority in all cases because it has to be fitted in with the other work which the Executive Councils have, and they have a great deal of extra work to do as a result of these new regulations, and that must take first priority.
Finally, I come to a point which has been something of a grievance with the doctors. Exactly what a doctor's duty 824 in the National Health Service consists of is something which has never been defined, and is hardly suspectible of definnition. In a common sense way we have known that there are certain services which a doctor may render to his patients which are clearly outside the scope of the National Health Service, but it has hitherto been ruled that even though that was perfectly clear, a doctor could not charge a fee to a patient for any treatment whether it was given under his terms of service or not.
An obvious example is that of a man arrested on a charge of drunken driving who asks his doctor to attend him at the police station. The doctor should not be expected to do this without a fee. It is clearly not an obligation of his under the Health Service. In future, if a doctor does attend in those circumstances he can charge the patient, and I think that it is altogether reasonable that he should be able to do so. In the same category are three other possible charges—for vaccination required solely for the purposes of travel abroad, for the prescription of oral contraceptives for other than medical reasons, that is when the prescription is required purely at the wish of the patient herself, and for ritual circumcision performed by the doctor.
I have done my best to explain to the House the more important changes in these Regulations and how they will affect general practice. They by no means represent the whole story, because the negotiations which I have had with the doctors resulted in a good deal more than is embodied in this document, and it will take some time yet before all the changes envisaged can be put into effect. But it is a considerable pleasure to me that, after all the long and sometimes difficult negotiations of the past 18 months, I have been able to lay Regulations putting a number of agreed changes into effect.
This applies particularly to the new method of remuneration which will, I am sure, have the stimulating effect on general practice which we have all wanted to see. General practitioners from now on will be in a much better position than ever before to equip themselves with the necessary staff, to operate from more satisfactory premises and at the same time to see their remuneration bearing a proper relationship both to their financial 825 outlay and to their efforts. They will also have the satisfaction of knowing that a few, perhaps not very major grievances, in their terms of service have been remedied, and they can be sure that further changes of this kind are to come soon.
The problems with which we have been dealing are so large and so complex that one cannot hope that at any given moment there will be some spectacular break-through which will eliminate them. There is a gradual process of reform and improvement in which these Regulations represent an important step forward.
§ Question put and negatived.