NATIONAL HEALTH SERVICE (CHARGES)

HC Deb 27 April 1971 vol 816 cc262-313

4.35 p.m.

Mrs. Shirley Williams (Hitchin)

I beg to move, That an humble Address be presented to Her Majesty, praying that the National Health Service (Charges) Regulations 1971 (S.I., 1971, No. 340), dated 3rd March, 1971, a copy of which was laid before this House on 10th March, be annulled. In moving this Prayer against the Regulations which introduce increased charges for the National Health Service, I begin by saying that it has long been the view of the Labour Party, as the then Minister of Health, Mr. Kenneth Robinson, put it in the debate on the reintroduction of prescription charges on 30th May, 1968, that …ideally the National Health Service should be free to everyone at the time of need. As we know, there are only three years in which that was the case, from 1948 to 1951, though between 1965 and 1968 prescription charges were abolished. In 1968 they were reintroduced at the rate of 2s. 6d. per item, in a situation in which broad cuts were being made in all fields of Government expenditure, and in which taxation was increased.

Mr. Speaker

Order. May I interrupt the hon. Lady. Is it convenient that this Prayer and the one dealing with the National Health Service (Scotland) should be taken together?

Mrs. Williams

Yes.

The Secretary of State for Social Services (Sir Keith Joseph)

indicated assent.

Mrs. Williams

We on this side of the House must ask ourselves the question why we are praying against these Regulations. The first reason and the strongest reason is because we are extremely suspicious of the Government's intentions towards the National Health Service. The National Health Service is the outstanding social service that this country has yet created. We fear that it may suffer at the hands of the Government what one might call the death of a thousand cuts. Therefore, we wish with all our strength to resist this first round of cuts.

The second reason why we resist these Regulations is that the Government have clearly an order of priorities in which charges on the social services are being made for their own sake. The Secretary of State recently sent a letter to the Secretary of the Association of Optical Practitioners in which he said: We feel that where the user can afford it he should bear more of the cost of social services and the taxpayer less. The right hon. Gentleman will know that this is in direct contradiction to our view of the situation. We also feel that the Government are using the money raised from these charges primarily to relieve standard rate taxpayers and, even more markedly, those who are better of. If I may reverse one of the Government's slogans, there are times when it appears that the Government have given up dealing with prices at a stroke in the interests of dealing with strokes at a price.

Thirdly, in trying to justify these social charges, and the very great extension and increase in them, the Government are arguing that extending the system of means testing will avoid these charges falling upon those who are unable to pay. On this third ground, I must put before the Government the paradox which faces them. Either the means testing fails—and there is a great deal of reason to believe that many low income earners, whom I shall refer to shortly, many chronically sick, and many entitled to the season ticket, do not have the advantages of the exemptions, as hon. and right hon. Gentlemen know, or, alternatively, on the other horn of dilemma, that if people take advantage of these exemptions and the great extension of them through family income supplement, attendance allowances, school meals, welfare milk and so on, the net effect of this will be a rate of taxation amounting to more than 100 per cent. on increases in earnings over a very considerable band. The Government have not so far found any way out of the dilemma. It is a dilemma which is inescapable.

Fourthly, the Government have introduced a new and excessively dangerous principle. This is the principle of proportional charging. It is already applying to dental treatment and spectacles, and the Government intend, at present at least, to extend it to prescriptions as well, which is a direct obverse of the central ideal of the National Health Service, which is that the Service shall be free at time of need. The proportional charges mean quite directly that the greater one's need the more that one has to pay, and it interferes directly, too, with the freedom of the dentist, doctor or optician to treat his patient as he thinks best. As one senior member of the British Medical Association put it to me the other day, the doctor will now have to think not only of the patient's condition, but of his pocket book.

The basic charge on prescriptions is to increase from 12½p per item to 20p. No doubt the right hon. Gentleman will point out that 40 per cent. or more of the population are exempt if they claim exemption from the charges. I want briefly to deal with the grounds for exemption. The first is exemption on the ground of age. This works reasonably well, because it has no implication of means-testing and poverty about it. However, I want to ask the right hon. Gentleman whether, in the light of the increases that he is making he will not reconsider the limit on children which comes into effect at the age of 15, and not now extend it to all boys and girls in full-time education below the age of 18. We believe that those who are not earning should not be charged. Secondly, on the ground of exemption for age, I ask him to look again at the position of women between the ages of 60 and 65 who, on the National Insurance legislation, are entitled to retire on full pension at 60 but who do not get the benefit of exemption from prescription and other charges at present.

Next, there is exemption on income grounds. I understand that the Government intend to exempt those drawing family income supplement as well as those drawing supplementary benefit. Again there is a serious weakness, and it lies in the band of those at or those just above the supplementary benefit level. Those in this band are entitled, on the Government's Regulations, to exemption, but the most recent figures show that in 1970 only 1.7 per cent. of prescription charges were refunded to this income group, whereas 8 per cent. of the population were entitled to refunds. Therefore, not one in four people in this band get the entitlement which they should get at present. It is hardly surprising that four-fifths fail to get these refunds because, as a recent study by the Bristol branch of the Child Poverty Action Group showed, nearly two-thirds of dentists' receptionists did not know that people could get exemption if they were on low incomes. If dentists' receptionists do not know it, I wonder how many of the general public do not.

How sincere are the Government's proposals in raising the income limits? I am not sure whether my right hon. and hon. Friends realise it, but the increase in income limits for prescription charges is precisely 2½p, and that increase comes into effect this month.

Then there is exemption on the ground of chronic sickness. The right hon. Gentleman will know that we feel strongly that the definitions are very much too narrow. They exclude chronic bronchitis, asthma, heart disease, including those who have had artificial valves fitted and who need constant treatment. They exclude schizophrenia and almost all other psychiatric conditions. It is not surprising that the Psychiatric Rehabilitation Association has said: …chronic schizophrenia is one of the most difficult illnesses to manage and patients can, through patient medical and community care, be helped back to employment, but usually to low paid employment. Their reluctance to take medication is a known feature of their illness so that a lowering of the value of their small income will emphasise this effect with disastrous results. Another letter from the Schizophrenia Association of Great Britain says that people …who have had severe breakdowns will require medication for the rest of their lives in our present state of knowledge. We believe that schizophrenia is every bit as chronic a disease as epilepsy, sufferers from which are exempt from paying for prescriptions. Many people require expensive and semi-permanent drug therapy. I should like the Government to explore the possibility of having constant drug therapy, a medical term understood by doctors, as a basis for exemption. At present, the division between chronic sickness which is exempt and that which is not is indefensible. The right hon. Gentleman will say that we have the season ticket. But he knows that, in the half year to the end of 1970, only 59,000 people took out the so-called season ticket, whereas it is estimated that there are at least a million people on constant drug therapy suffering from psychiatric illness alone.

These higher charges will hit the many lowly paid people who are just above the exemption line, and many who do not know how to claim exemption. They may lead to delays in getting prescriptions, and many people will get only one or at the most two items on the prescription list. They may lead to reliance on multi-purpose drugs, the so-called blunderbuss treatments, by which I mean the drug which tries to involve two or three treatments in one and which doctors say is medically unsatisfactory. It leaves the doctor with less room to adapt his therapy to the patient.

All these arguments are infinitely strengthened if the Government are foolish enough to press ahead with their proportional charges idea for prescriptions. I suspect that the idea was fathered in the Treasury, and was left as an undesirable foundling on the doorstep of the Department of Health and Social Security. I hope that the outspoken opposition of the British Medical Association and its General Medical Services Council and of the Pharmaceutical Society will persuade the Government to withdraw what can only be described as a mad and bizarre scheme. It will lead to very much higher administrative costs, massive extra work for pharmacists and dispensing doctors and temptations to evasion. In addition, the professional view is that it will be medically disastrous.

I want to express one word of sympathy for anyone who is at any time Secretary of State for Health. We are all aware of the escalation in drug prices, an escalation which follows in part from the sophistication factor as more and better drugs are developed, especially drugs like L-dopa for Parkinson's Disease, which are extremely expensive. The time cannot be long before a discussion is held between the Government and the medical profession about prescribing practices, which seems a very much better alternative than the imposition of higher charges.

I want to say a word about dental charges, where proportional charging bites already. I will not repeat many of the arguments which have been advanced so powerfully by my hon. Friend the Member for Wolverhampton, North-East (Mrs. Renée Short). The present position is that the dental service has greatly increased its productivity, mainly by encouraging more people to accept treatment. A course of treatment in the dental service in 1949 cost an average of £6 and now costs £4. One of the reasons for this remarkable reversal of the normal course of pricing is that there has been a remarkable increase in the scale of treatment. However, I am afraid that it will not do for the right hon. Gentleman to argue that, by increasing charges, he is in effect encouraging regular treatment the most recent survey of adult dental health showed in 1970 that 64 per cent. of regular attenders need some kind of treatment, and the right hon. Gentleman knows that his scheme makes it very much cheaper to pull out teeth than to save them. I have a letter from a doctor in Liverpool, who says: Worst of all, an alarming number of occasional patients have said quite firmly that, despite previous conservation of their own teeth, after April or whenever it is to be, they will only come to the dentist when forced by pain to have a tooth extracted. From another part of the country, Surrey, a dentist writes: In my practice (a high income area) I expect to lose 25 to 50 per cent. of my patients in the first year. There are many other letters which I could read. It is evident that the right hon. Gentleman has not persuaded the dentists that his new proposals will not have an effect on the scale of treatment.

There is one serious point which has not been brought up. It is that, if the number of treatments declines, as we believe that it is bound to do, dentists will go to the Dental Estimates Board, in order to protect their incomes, asking for higher rates, which will eat into the savings that the Government propose to make.

I hope, too, that the Government will look closely at the proposal to lower the age of exemption from 21 to 18. The Government know that these are the years when patterns of regular attendance are built up or broken; they are years when teeth are vulnerable. It is not surprising that in New Zealand and Sweden, two countries with extensive health services, consideration is being given to raising the age of exemption and not, as alas we are doing here, to lowering it from 21 to 18.

The proportional charges the Government are introducing for spectacles are established in such a way that we fear that the 40 per cent. of optical practice which at present takes place in the hybrid area—that is, which combines National Health Service lens with private frames—may well be driven out of the Health Service altogether. Is this what the right hon. Gentleman intends to do? We on this side fear that this is exactly what he intends. At present, the full cost of dispensing which is met by the patient means that for a very considerable range of lenses it will be cheaper for the optician and the patient to reach a deal outside the Health Service than to go through it. This could well mean the large-scale destruction of this service as a part of the National Health Service. If the right hon. Gentleman intends to save it, one thing that he can do immediately is to make lenses exempt for children who wish to have private frames.

We on this side believe that these Regulations demonstrate once again the most obvious hallmark of the Government—their belief in inequality modified only by a system of means-tested benefits. We believe that a grave responsibility will rest upon the Government if they destroy the most impressive social advance made in this or any other country since the war, namely, the National Health Service. The great poet John Milton said— Let not England forget her precedence of teaching nations how to live. There are few examples better in that respect in the last 20 years than the National Health Service, which we on this side intend to do all that we can to protect.

4.52 p.m.

The Secretary of State for Social Services (Sir Keith Joseph)

It is a pleasure to debate with the hon. Lady the Member for Hitchin (Mrs. Shirley Williams) because, however selective she is in her choice of arguments, she always manages to slip at least one sentence in which shows that she recognises the problems that Governments of any sort face.

I want to explain the set of problems, going far outside the Health Service, though I shall not take more than a moment to refer to them, that we found on returning to office. We found, as we realised before the Election that we would find, an excessive marginal rate of taxation afflicting the people. We found a hideous number of gaps in social provisions, all of which stretched back through previous Governments of both parties but which had remained hideous gaps during the previous six years of Labour Government. I refer to such gaps as the lack of any proper treatment for the chronic sick and the lack of any proper consideration in services for the disabled. We found family poverty. We found very badly neglected sectors in the National Health Service.

Faced with this series of needs, we deliberately set about fashioning a new system of priorities. We knew what we would find. We told the country that we identified these and other defects which we would try to cure, above all by a better series of priorities.

In the first speech that I made from this Box in the office I hold, I told the House that the Government, as I believe any Government, including the last Government, would be looking at the scope for raising charges where they would not hurt the citizen, so as to contribute towards putting right some of these defects.

At that time I spelled out the clear principle that in seeking scope for increased charges we should be guided above all by one overriding rule—that we should design no charge that would deter the patient from necessary treatment. I have added since that if the records show—time will need to be given before we can fairly judge—that any charge we apply has a deterrent effect on patients, we will look again at the charge.

Mr. Alec Jones (Rhondda, West)

It will be too late then.

Mr. John Mendelson (Penistone)

They will be dead then.

Sir K. Joseph

We cannot guarantee that the charge of, in this case, 20p for a prescription, for instance, will not deter the occasional improvident householder any more than right hon. and hon. Members opposite could guarantee that their prescription charge of 12½p would not deter the occasional improvident householder. We are determined to ensure that the charges do not deter large numbers of people from necessary treatment.

The search for scope for raising charges without deterrence meant that we had to look also at the system of exemptions that we found when we came to office. I shall come to this aspect.

I must tell the House, as the hon. Lady reminded us, that the process of looking at charges is not yet over. We have already announced that we intend to put before the House proposals to lower the exemption limit for dental treatment from 21 to 18. There will need to be legislation. The House knows, because my right hon. Friend the Chancellor of the Exchequer announced it last October, that we were to bring forward proposals to discuss with the professions for relating prescriptions to cost. Such proposals have been put to the professions and I am studying the comments of the doctors and the chemists.

I repeat the assurance that in looking at charges the determination to avoid deterrence of the patient remains the rule in the forefront of my mind.

Mrs. Shirley Williams

If it is the view of the professions, as it certainly is about proportional prescription charges, that there will be an effect on patients, on what will the Secretary of State base his judgment that there will be no effect on patients as regards putting them off treatment?

Sir K. Joseph

I shall obviously want to study the comments of the professions very carefully. There will then need to be a dialogue in which each side examines the other's point of view. In other words, my answer to the hon. Lady is that there will be a rational consideration of what is said, just as I hope that there will be a rational consideration by the professions of what I say.

I must take issue with the hon. Lady when she was so severe about the concept of a proportionate charge. She spoke in comprehensive terms of her dislike of such a formula. I remind the House that we have had a proportionate charge for some time in a part of the National Health Service that is not totally trivial. After all, the Labour Government themselves applied what was virtually a 50 per cent. rule to the cost of dentures. As far as I know, there has been no withdrawal by the present Opposition from the approximately 50 per cent. cost of dentures which was applied by the last Government. The charge for full dentures in 1968 was £5. In 1969 it was increased to £6 5s.—a 25 per cent. increase. What we are proposing will mean a cost of £7, which will be an increase not of 25 per cent. but 12½ per cent. I ask the hon. Lady to bear in mind the proportionate charge for dentures when she next speaks about the proportionate formula.

The hon. Lady spoke as though in bringing forward these Regulations the Government were motivated by only one thing, to do damage. But she knows that no Government would lightly bring forward increases without a carefully thought out and deliberately constructive purpose. We are seeking intensively for more resources for the National Health Service. We are seeking intensively for methods of reducing the marginal rate of taxation. We are seeking intensively for ways to reduce family poverty. We are seeking intensively for ways to fill the whole spectrum of gaps that we found in social provision.

These increased charges play their part in making it possible to increase hospital and local authority services in real terms by more than they have been increased for several years. They are part of the total plan which makes it possible for the House to have approved the Family Income Supplements (Computation) Regulations, which will make a substantial attack on family poverty at its worst. They play their part in making it possible for us to have proposed to the House in the Budget to offer the country comprehensive tax cuts.

Mr. John Mendelson

These charges have nothing to do with taxation.

Sir K. Joseph

I have carefully refrained from praying in aid the large package of benefits for the chronic sick which come not from taxation but from the National Insurance Fund, and I am grateful to the hon. Member for Penistone (Mr. John Mendelson) for giving me the chance to refer to that.

Without some freedom to move on charges, the Labour Party condemned itself more than it need have done to a straitjacket from the point of view of the National Health Service. Hon. Gentlemen opposite increased charges, and they reinstated charges after withdrawing them. I shall give the House an example of what their dogmatic refusal to look at reality meant for some of the people suffering worst from the shortages. My predecessor sincerely wanted to do something for the mentally handicapped. After the revelation of the conditions in one hospital he wanted, above all, to find more resources for this neglected group. Nobody could impugn the right hon. Gentleman's sincerity, but what did he find? He found an extra £1½ million, but he could not tell the House for how many years that would continue.

As a result of the total changes that we have brought about, my right hon. Friend the Chancellor of the Exchequer was able to announce last October an extra £110 million for England, Scotland and Wales for the National Health Service over the next four years specifically for the three most neglected cinderella sectors of the service, the elderly, the mentally ill and the physically and mentally handicapped, in hospital and in the community.

We know that that is not enough, but it is many times more than the previous Government were able to add, and that figure comes on top of the fairly regular annual increase, in real terms, for the resources of the National Health Service. The result is that for this year, 1971–72, there will be an increase in real terms for hospital and local authority services of 6.1 per cent., compared with 3.8 per cent. last year, and 4.3 per cent. for 1968–69, a fairly typical Labour year.

The National Health Service is getting—I hesitate to use the word when we know that the need is so much greater, but it is true—a record increase of resources in real terms this year and next year because, among other things, of the increased charges which form the basis of the proposal before the House this afternoon.

Mr. Will Griffiths (Manchester, Exchange)

The right hon. Gentleman has been using statistics of expenditure in real terms. Will he say something about the history of expenditure on the National Health Service expressed as a percentage of the G.N.P.? Let us look at the record there.

Sir K. Joseph

The hon. Gentleman does not have—

Mr. Will Griffiths

Answer the question.

Sir K. Joseph

I shall answer it. The hon. Gentleman does not have to behave as though I am saying that the National Health Service has enough resources. I am not for a moment saying that. In terms of G.N.P., our figure is lower than that of many similar countries. I am not sure that proportions of G.N.P. are an objectively reliable method of measuring the delivery of health care, but that is another matter. I ask hon. Gentlemen opposite to bear in mind that we are trying to operate a new system of priorities to help the wealth creators, the leaders of industry, managers of industry, families at all levels of income, those suffering from family poverty—which we are doing by means of the family income supplement—the mentally handicapped, the elderly, the mentally ill and the chronic sick. We have given evidence that we are making a start on these objectives.

As the hon. Lady fairly said, the strategy on which we are embarked depends crucially upon effective exemptions, and I hope that even hon. Gentlemen, opposite will give us the credit for trying to increase the take-up of the exemptions available against National Health Service charges. We have embarked on a campaign which, I believe, is the largest ever in money terms and certainly is in effort, to bring to the notice of the men and women concerned their rights for exemption.

I ask the House to note the campaign, which is about to get into full stream, based upon the booklet "Family Benefits, your right to claim them". In addition 30 million copies of a simple explanatory leaflet have also been published. We have advertisements in the Press. We have 140 television showings of a 30-second film. We have an operation going on in all the social security regions of the country, by which people from my Department's social security offices are explaining to social workers, to voluntary workers, and to statutory workers all the facts which they need to help them guide the citizen. I have sent letters to 200,000 people in local authority and social services, in church voluntary bodies, and in many other groups, asking them to help identify and guide the exemption claims of the public.

I know the House will be glad to hear that the results obtained during the first week before the campaign had got fully under way indicate that, partly by a combination of public awareness of the increased charges, and partly by way of the campaign, applications for free welfare food, free milk, exemptions from prescription, dental and optical charges, and school meals, are multiplying many-fold.

Mr. Christopher Mayhew (Woolwich, East)

The right hon. Gentleman did not say that there had been an increase in the category to which my hon. Friend referred, that is to say, the psychiatrically ill, who rely on drugs. Has he any evidence that the applications from that category are improving?

Sir K. Joseph

I am coming now, systematically, to the various groups in which charges are going up, and I will deal with that matter in its proper place.

I would like to turn now to the three main groups of charges covered in these regulations. First, the prescriptions. The I House may know that about 23 million people are exempt or have the right to exemption—that is 42 per cent. of the people in Great Britain. Because they cover a large number of people with more than average needs for medicine, no less than 50 per cent. of prescriptions are free of charge.

But the House may not be aware what the non-exempt individuals have on average—I am departing from the average in a moment—to face. A person who is not exempt—and that excludes all children, all people over 65, all people in certain chronic sick groups, all nursing and expectant mothers, all war disabled for their war disability are exempt, as are the supplementary benefit households and the family income supplement households and the needy—faces on average five prescribed items a year, perhaps in five prescriptions, perhaps in fewer.

For the average person, five items at the extra cost imposed by these regulations of 7½p, adds up to just under 40p a year. For the average person, there is no need to worry; the worry is for the people who are not average.

Mr. John Mendelson

I know that the right hon. Gentleman likes to have information, and he is asking for it. I have an example of people who do not conform to that meaningless average. A miner's wife told me that her husband regularly needed two prescriptions every 10 days. He is not of retiring age, but he has not been able to work. Why does the right hon. Gentleman waste the time of the House with these meaningless average figures, when he says that he will get to the real situation later?

Sir K. Joseph

I do not think that they are meaningless averages. I will come to that case in a moment. I am very interested to hear what the hon. Gentleman says.

So we come to the people who are not average and who are not exempt, because that is what the debate is about—

Mr. John Mendelson

Hear, hear.

Sir K. Joseph

The hon. Gentleman was discourteous to say that I am wasting the time of the House in explaining the background. The hon. Lady said—I thought that it was slightly glib for someone of her debating quality—that she was dissatisfied with the chronic categories for exemption. I suppose we all are, but she knows quite well that her right hon. Friends negotiated very hard with the B.M.A. to try to persuade doctors that it would be possible for them to allow the Government to pay the prescriptions free for more chronic sick categories, including, perhaps—I do not know the details of the past Government—the category to which the right hon. Member for Woolwich, East (Mr. Mayhew) referred.

The trouble, as explained to us by the B.M.A., is that they did not want doctors to have to decide whether the use of a drug which can serve both a chronic illness and a non-chronic illness should be free for a particular patient or not. I have sufficient respect for the negotiating ability of my predecessor not to promise the House that I shall be more successful with the B.M.A., but I shall, at a suitable time, if it seems to make sense, reopen the subject with them. But I cannot hold out much comfort that I shall be successful. We recognise their problems and I shall see whether they recognise ours sufficiently to be able to move at all.

The hon. Lady then referred to two distinct categories—children still in full-time education over the age of 15 and women between 60 and 65. I am advised that these groups, although they both attract a large amount of emotional support, do not statistically have any higher demand for medicines than the normality of people between 15 and 65. If I could be convinced that they had a much higher demand, I should have to think again about this question. I will keep those two categories under review.

But I should like to remind the House of the protection which is available for those who are not exempt but for whom even the extra 7½p per item might be a deterrent, particularly if, for instance, a household had an infection and several adult members had to have several prescribed items for several weeks running. For anyone near the supplementary benefit income level, the supplementary benefit remission is available. I admit that the exemption limit has been raised only a trifle, but the prescription charge is not in itself a very heavy charge. I am told that the arrangement for taking into account the income of an earner disregards the first £2 of the earnings, disregards rent—including mortgage and owner-occupier outgoings equivalent to rent—and disregards the working expenses and any regular burdens on the household connected with the hire-purchase, diet or heating requirements of any member of the household.

We shall have to see whether, as the take-up campaign develops, we get any evidence that people whose income is low enough perhaps to deter them from having proper treatment are not getting proper treatment. We shall then have to see whether the formula is right. But the campaign will be pressed vigorously, and if it does not produce good enough results the first time, we shall have to mount another. Also—

Mr. John Mendelson

Money for everything except for prescriptions.

Sir K. Joseph

Hon. Members do not appreciate that we have allowed for a very successful take-up campaign in computing the net saving to public funds of the rise in charges. We have allowed for the cost of the take-up campaign and for the cost of succeeding in the campaign. All supplementary benefit households are exempt from prescription charges automatically, and there is an exemption form in their order book. The family income supplement order book, when it comes into payment in August, will also increase the specific exemption from prescription charges.

I come to the point raised by the hon. Member for Penistone, who made the same point last July. I then gave him advice which I thought was perfectly solid—that he should tell his constituents about the "season ticket". He was very scornful about that, but it provides as many prescriptions as the doctor may prescribe for any citizen for the cost of 1p a day or 7p a week. If the hon. Gentleman has not advised that household—I think that he quoted the same one in July—

Mr. John Mendelson

No.

Sir K. Joseph

—then he should not quote the same type of household. He should recommend them to buy a prepayment certificate. For £2 for six months or £3.50 for 12 months, which works out at 7p or 8p a week, the person concerned can rest secure that, no matter how many treatments he or she may need, that is the total cost that will have to be met. Because the season ticket had only 50,000 or 60,000 buyers last year, we have embarked on an advertising campaign.

Mr. Mendelson

Again!

Sir K. Joseph

This was provided for in our expenditure. I am glad to tell the House that we are already up to 100,000 buyers. Today, for the first time, advertisements started appearing in the national Press drawing specific attention to the prepayment certificate.

Mr. Stanley Orme (Salford, West)

How much did it cost?

Sir K. Joseph

I think about £14,000.

Mr. Mendelson

When the previous Administration introduced prescription charges, the first estimate given was that there would be a saving of about £25 million per annum. Will the right hon. Gentleman tell the House, on the basis of the figures, how much was saved after all the exemptions had been catered for and all the administrative expenses had been applied? Was it anywhere near £25 million, or what will the figure be?

Sir K. Joseph

I cannot without notice. I can only look at the last Government's published announcements. If the hon. Gentleman cares to put down a Question I will look into the past and see how they managed. However, I can tell the House now that the N.H.S. savings from the charges are about £33 million, of which there will be net savings of £29 million. I think that £4 million will go in increased supplementary benefit payments for dental and optical services. That includes the cost of the take-up campaign.

Dr. Shirley Summerskill (Halifax)

Are the figures which the right hon. Gentleman has given based on the charges which have been increased plus the cost proportion scheme, or are they solely the increases which are now in operation?

Sir K. Joseph

The latter—the 1st April, 1971, charges. I am obviously not taking into account what might be the result of further changes in the form of the charge.

I turn from prescriptions to optical charges. As the House knows, we are moving towards charging the total cost except for sight testing, which remains free. We are raising the charge for the lenses to an average, banded, real cost. The full cost of the frame is already paid except for the National Health Service frame. I have been told by the profession that it would like to find a more acceptable frame for children, who are exempt. I am glad to confirm that we hope to move into the free category a frame which is widely popular in the adult category so that children, in more cases than now, will be able to have a free frame which they will be glad to use. We shall bring this about as soon as supplies make it possible.

There is here a more substantial addition to the supplementary benefits scale for exemptions. The House will have seen from the income guide in the advertisements and answers to Questions in HANSARD this morning that we are adding a tolerance of £1.50 to the supplementary benefits scale, adjusted for working expenses and so on, and a variable for rent, to help those who find optical treatment too expensive. Children's treatment remains exempt.

I turn to the dental increases. I am particularly glad to acknowledge that although the British Dental Association disagreed with what the Government proposed, once it was persuaded that the Government intended to go ahead the Association undertook to advise its members on an approach to dental patients to explain exactly the new system which was being brought in.

I have here the folder of advice which is going out today from the B.D.A. to its members. It has made a first-class job of it. It emphasises the new principle introduced by the Government of making dental charges half the cost of treatment up to a maximum of £10 while retaining all present exemptions and keeping the examination and report on teeth absolutely free. The B.D.A. explains that this system should be a great encouragement to people to attend their dentists regularly. Instead of a standard charge for all non-exempt patients of £1.50 or the cost, whichever was the lesser, as up till 1st April, there is now a clear economic advantage to the patient to have regular and relatively small treatment because he will pay only half the cost.

The result of retaining all the present exemptions and of setting a maximum of £10 for any treatment, which may be spread over a series of visits, will perhaps interest the House. If we apply the new system of charges to the 1969 dental experience we get the following results. About half of all courses of treatment—those for children, for young people between 16 and 20, other than for dentures, and for nursing and expectant mothers—remain exempt.

Mrs. Shirley Williams

They remain free at the present time.

Sir K. Joseph

They remain free at the present time. The only change proposed, which would involve new legislation, will remove the 18 to 20 age group from that free category.

Of the remaining half who are not exempt, half—that is, a quarter of the whole—will either be free, because they involve only examination and report, or will cost less than under Labour because the total cost, except for examination and report, will be less than £3. Therefore, the charge will be half the cost and that will be less than it would have been under Labour.

To summarise the position, three-quarters of dental treatment, based on the 1969 experience, will either be exempt or free or cost less than in 1969

Of the remaining one-quarter, there are three separate twelfths. One-twelfth would have cost between £1.30 and £2.40 and one-twelfth would have cost between £2.40 and £10, but a large number of those would have been for dentures which were charged at half cost under Labour and averaged about £6 5s. in Labour's last years. Therefore, there is very little change for that one-twelfth. There will be a whole 1 per cent. who will be at the maximum charge of £10.

I apologise to the House. I have missed out one-twelfth. To begin again, the remaining quarter is one-twelfth under £2.40, one twelfth between £2.40 and £10, and one-twelfth for dentures where the charge will be very little different from what it was under Labour.

The dentists are very wise, in our view, to recommend the new principle in the trms put to them by the Government. "Recommend" is perhaps too strong a word. The B.D.A. is wise to explain to the dentists what the Government's new proposals mean, because three-quarters of their patients will continue to be exempt, to get their treatment free, or to get it at less cost than under Labour.

All the supplementary benefit families are exempt or get automatic remission of charges. All the family income supplement households will have their charges totally paid for. Those who are above supplementary benefit level, and are earning, will be entitled to a higher tolerance and to help with or total remission of charges, taking into account in the assessment their actual rent for housing expenses, their actual working expenses and any particular burdens on their household.

So I think that the charges will not do damage. There will be, as there always has been under both Conservative and Labour Governments, a small dip in the take-up immediately after the charges come into effect. It has generally been offset by a surge in the treatment before the higher charge comes into effect, and we must wait at least a year, and probably 18 months, before the normal pattern of take-up can be fairly judged. In all past experience there has been a surge before the increase of charge, a dip after the charge has gone up, and then over the next year or two a gradual resumption of the basic growth trend. That is what we expect to happen.

We shall be watching during the period from 12 to 24 months from now to see whether that expectation is fulfilled. We shall be watching the effectiveness of the take-up campaign, and listening to the experience reported to us by the professions. If we find on any of these fronts that our formula for exemption does not meet a need, we shall have to look at our arrangements again. But in the meanwhile I ask hon. Members, after they have made their legitimate points, to reassure their constituents, who come to them for advice, and to give them the leaflets which I shall gladly make available explaining the freedom of the services to those who really need free services, because we all on both sides at least share this, that we definitely want the services to be available to those who need them.

Mr. Deputy Speaker (Miss Harvie Anderson)

Order. Before I call the next hon. Member to speak, may I draw the attention of the House to the fact that the debate is limited in time and that a considerable number of hon. Members wish to speak.

5.33 p.m.

Mr. Alec Jones (Rhondda, West)

During yesterday's debate one of my hon. Friends referred to the Secretary of State as one of the more compassionate members of the Conservative Government. Having listened to the whole of yesterday's debate, including the right hon. Gentleman's speech, and to his speech today, I find little evidence of that compassionate part of his character. He said that as long as the prescription charges did not deter a large number of people they were acceptable to him—even if they deter a small number. This reminds me of a person giving advice to a newly-qualified doctor and saying, "It will be all right if you bury a few mistakes, but do not bury too many". When someone who holds the position of responsibility of the right hon. Gentleman implies that, I cannot see it as evidence of a compassionate nature.

We in Wales have a special reason to be proud of the Welfare State and the two pillars that support it—our system of social security and our National Health Service. The system of social security introduced by our esteemed friend the right hon. Jim Griffiths was savagely attacked in the House yesterday. The National Health Service was introduced by another famous Welshman, the late Aneurin Bevan. To find that service under attack today is distasteful to the majority of hon. Members on this side.

That pride which Welsh people share in the Welfare State and its two pillars, which have brought so much help to our people, turns to anger when we see them being attacked by a Conservative Government who either know little of how they help our people or care very little about them. The attacks yesterday and today place the Health Service and our system of social security in jeopardy. That is why organisations in defence of the social services are springing up in South Wales. They are chiefly promoted by practising doctors, dentists and other welfare workers, and are organisations not prodded into existence by politicians but brought into being by people who care. I hope that they are also springing up elsewhere to defend the essential elements of our Health Service and social security.

We should make our personal position clear. In making my mine clear, I believe that I am also representing the views of those who sent me here. We believe that on social, economic and health grounds the National Health Service should be available to all at the time of need, without any question of payment. It is understandable if Conservative Members take this opportunity to rub into Labour Members that it was a Labour Government who reintroduced prescription charges. I have no objection, if their reminder of our past follies prevents us from making a similar mistake again. Such a reminder will be a small price to pay for the preservation of the Health Service.

It was in the Chancellor's White Paper, Cmnd. 4515, that we first heard the details of the introduction of the charges. The White Paper said that prescription charges should save £32 million, dental charges £14 million and ophthalmic charges £7 million, making a total of so-called savings of £53 million in 1974–75.

But most of us do not need any more convincing that they are not real savings but are mere transfers of money from the majority who will have to pay more for the National Health Service to provide the resources needed to make tax concessions to those who are already better off.

My hon. Friend the Member for Willesden, West (Mr. Pavitt) is missing from today's debate, unfortunately. He has constantly pointed out from his own experience inside the Health Service that the so-called savings seldom turn out to be what they are expected to be. Speaking 13th July last year about the prescription charges then in force, he said that whereas they had been expected to yield £25 million, the true yield was between £7½ million and £10 million. One of the reasons is the extremely elaborate system of checking of exempttions and refunds which must follow the introduction of Health Service charges, or any increase. That it is an elaborate system was evident from the right hon. Gentleman's words today, when he lost one-twelfth of the dental charges.

If the Government are to increase charges, we want exemptions, so we support the Government in that respect. But exemptions must always create anomalies, and it is the anomalies that ordinary people outside find so basically unfair. The anomaly of age has already been mentioned. A number of local authorities in South Wales, headed by the Abertillery Urban District Council, are organising a campaign on behalf of women aged between 60 and 65—those wives over the age of 60 who are receiving an old-age pension. The local authorities in South Wales hold the view, which I hope that many hon. Members on both sides will hold, that such wives should automatically be exempted from prescription charges. Judging by the interest being taken in the debate by lady Members, I should think that every one of them will support the contention that free prescriptions should be available to these ladies once they have reached the age of 60.

Dame Joan Vickers (Plymouth, Devonport)

I have already raised this point with my right hon. Friend, who has told me that he would not do it because it would cost £3 million.

Mr. Jones

I accept the point. I have always appreciated that the hon. Lady has consistently pressed this matter. I realise the cost involved, but perhaps I can suggest that the money could have been found out of the very large sums which were readily made available as tax concessions for the better off.

I want to refer now to exemptions through categorisation of the chronically sick. I have had a letter from the managing director of a firm in my constituency telling me of his visit to a gentleman suffering 100 per cent. from pneumoconiosis, a disease found particularly in coalmining areas. This constituent has not worked for 14 years—and has not yet reached the age of 65. Because he can, when he feels well enough, get out without assistance, he therefore does not qualify for free prescriptions. I find it hard to believe that anyone who has lived with or had any experience of pneumoconiosis cases could say that a man with 100 per cent. certified pneumoconiosis is not chronically sick and is not morally entitled to free prescriptions.

There is, of course, an anomaly. For example, another constituent of mine suffers from mild epilepsy. I very much regret his suffering, but I must in fairness point out that, although he is able to go to work every day and earn a full wage, because his chronic sickness is in one of the official categories, he is entitled to free prescriptions, in contrast to the man who is suffering 100 per cent. certified pneumoconiosis. I use these two examples to show that, as long as we have the ridiculous system of prescription charges, such obvious anomalies are bound to arise.

Mr. Dan Jones (Burnley)

The people who suffer from pneumoconiosis and silicosis have been seriously injured in pursuit of the industrial needs of the nation.

Mr. Jones

My hon. Friend the Member for Burnley (Mr. Dan Jones) knows the problems and conditions of the work of miners in South Wales as well as, if not better than, most of us, and I am grateful to him for his intervention.

In dealing with the categorisation of chronic sickness, it was of some value to hear the Secretary of State indicate that he was prepared at least to consider some re-examination of the exemptions scheme. I believe that one simple method of dealing with this would be for free prescriptions to be available for all who are in need of drugs over a relatively long period. In other words, if a person needs medicines for a longish period of sickness, he should automatically qualify for free prescriptions.

The right hon. Gentleman referred to the low take-up rate in welfare services and rights. He spoke of the Department's Press and television campaign. Although, obviously, we on this side would prefer a better course, we hope that this campaign will succeed in persuading people to take up their rights. I ask the Under-Secretary of State to convey a few words of mine, which I believe are of a special importance, to the Secretary of State. I believe that the newspaper advertisement in its application to prescription charges is misleading. I believe that equally misleading is the official leaflet P.C. 11, issued by the Department.

I am not suggesting, of course, that they are deliberately misleading. I am not even suggesting that they may mislead either the Secretary of State or hon. Members. But they are certainly misleading people who need to know whether they are entitled to free prescriptions. Both leaflet and advertisement imply that a married couple may be entitled to free prescriptions if their weekly income in £16.45. Admittedly, the advertisement says that the table is a guide only and the leaflet contains the notice that the examples given are indeed only examples. But people who need and are making applications for free prescriptions are taking the advertisement and the leaflet at their face value.

Only last weekend in my constituency two married couples came to me about this matter. Their gross incomes were £12.15 and 12.22 respectively, but neither couple qualifies for free prescriptions. I ask the Secretary of State to re-examine the table in order to ensure that it is made perfectly clear that it is not all married couples with an income lower than £16.45 who are to get free prescriptions but that in many cases the income level needs to be lower than £12.15. Not only should the tables be re-examined, but the Department, when rejecting applications for free prescriptions or re- funds, should give the claimants a detailed explanation why, instead of the small note which is customarily issued now.

In conclusion, I want to say something chiefly to my own right hon. and hon. Friends. That may be rather unusual but there is not much point in saying it to right hon. and hon. Members opposite. There is some value in saying it aloud to my right hon. and hon. Friends. I say to them that there is a danger that, if we on this side of the House spend too much time and energy in dealing with exemptions, we might again grow to accept as inevitable the principle of prescription charges. Naturally, the level of charges, given that principle, is important—desperately important to those in the low-income groups, although possibly not to those in the lowest group of all, who are to be shielded to some extent. I had hoped to hear from the Secretary of State a clear indication that even the present Government have wisely changed their mind and abandoned their proposals to relate prescription charges to the cost. I remain convinced that all charges discourage and that high charges prevent many people from seeking the medical advice and treatment which they need at the early stages of an illness. Many diseases which can be controlled or cured, can in fact be controlled and cured only provided they are diagnosed at an early stage.

Mr. Timothy Raison (Aylesbury)

I am grateful to the hon. Gentleman for giving way, particularly as he said that he was having a private discussion with his own side of the House. As far as I know, all the advice to which the hon. Gentleman has referred is given free through the National Health Service.

Mr. Jones

I do not quite follow the hon. Gentleman's point. I am concerned not so much with advice as with prescriptions.

Mr. Raison

The hon. Gentleman specifically mentioned advice.

Mr. Jones

Whatever point the hon. Gentleman has in mind, I must leave him to deal with it in his own speech.

Mr. Raison

I am sorry to persist, but the hon. Gentleman specifically complained about charges. My point is that advice in the N.H.S. is given free. It is the treatment which leads to charges being made.

Mr. Jones

I think I know at what the hon. Gentleman is getting, but he will appreciate that there is little point in being given free advice if one is denied the opportunity to benefit from it by receiving the treatment that is necessary.

If these prescription charges or any future increases prevent early diagnosis, the Secretary of State will have failed in his duty to promote and care for the health and welfare of our people. When, as a boy, I lived in the Rhondda Valley, which I now have the honour to represent, it was a feature of Valley life that a person with bad eyesight went to Woolworths to buy a pair of spectacles. If the reintroduction of dental, optical and other charges results in our adopting that attitude towards health matters, there will be strong opposition from the people of Wales.

Mr. Deputy Speaker (Miss Harvie Anderson)

I appeal to hon. Members to restrict their remarks to, at the most, 10 minutes. If they do not do so, many hon. Members who wish to take part in the debate will be precluded from doing so. Dr. Stuttaford.

5.52 p.m.

Dr. Tom Stuttaford (Norwich, South)

I promise to be brief, Mr. Deputy Speaker.

I wish, at the outset, to have it clearly understood that, like any doctors among my colleagues on this side of the House, I am faced with a conflict. It is a conflict between that which is clinically ideal and that which is financially expedient. The hon. Lady the Member for Halifax (Dr. Summerskill) is fortunate today in that she is not faced with this conflict.

There can be few doctors who in any way welcome prescription charges, and I am certainly not among that minority. I have never believed that prescription charges do anything for the doctor-patient relationship. An appreciable percentage of doctors do their own prescribing. The relationship between them and their patients cannot be enhanced when many people remain convinced that they are paying for their pills or medicines.

When prescribing doctors are having to collect these taxes, as it were, their patients will believe that they are meeting the cost of what is being prescribed, when, in fact, no charge that we could possibly introduce could represent the full cost of prescriptions. This point greatly affects the country doctor, though it must also harm the relationship between the chemist and the patient.

I echo everything that the hon. Lady the Member for Hitchin (Mrs. Shirley Williams) said about the anomalies of the exemptions. One need only look at the list with a clinical eye to see that the exemptions might have been chosen with a pin; by chance, from a list of diseases. There seems to be no rhyme or reason to this proposal and I am ashamed that it was my profession which dictated what should go on the list. I therefore welcomed my right hon. Friend's assurance that he will be in touch with the B.M.A. to have it revised.

Also early in my remarks I wish to sound a word of caution about the problem of schizophrenia. In this category many patients do not know from what they are suffering. I agree wholeheartedly with what has been said about the need to get these people to take their treatment. They are even less likely to take it if they see themselves classified as "chronic schizophrenics". It is a disease about which there is a strong social stigma and what is proposed will not be of help.

The prescribing of combination drugs is not necessarily a form of blunderbuss treatment. Combination drugs can be useful, particularly for the elderly, though I accept that they would be exempted. However, they are also useful for the improvident and difficult minority in that they need take only one pill three times a day instead of four or five pills a number of times a day. I accept, however, that the prescribing of combination drugs can be a mistake if they are prescribed to save the patient's purse. It is bad medicine when it is dictated by a charge of this kind.

We must not overlook the grasping or impecunious patient and the fact that it is easy for the doctor to acquiesce by prescribing a large number of pills instead of a few or a large bottle of medicine rather than a small one so that the treatment will last the patient longer. This sort of prescribing increases the problem of bathroom cabinets filled with half-empty bottles, the danger of drugs finding their way on to the black market and the increased danger of suicide—all perhaps indicative of a weakness on the part of the medical profession, but one which is difficult to avoid when charges of this type are imposed.

Although I can support this increase in charges today—[Interruption.]—because they relate to increased costs in the N.H.S., no political capital should be made out of what is being done. Indeed, I can support it only on that basis. After all, hon. Gentlemen opposite re-introduced prescription charges and introduced dental charges. Their record is every bit as bad as ours. They, too, have had this conflict, and when they are in office they come down on the side of the Treasury, and when they are in Opposition they are on the side of the doctors.

Be that as it may, it is clear that we have made much better use of the money that we have collected by this means. In my part of the world there is a geriatric hospital which has been promised closure for the last eight years but on each occasion when the matter has come up we have been told, "Put in an application next year for a new hospital to replace this one, when it is closed". At last the application has been accepted and now we hope for progress with this hospital.

Likewise, we have been trying for some years to get a home in Norwich for the young chronic sick. An order has now gone out to the local regional hospital board to build such a hospital. Thus, when we speak of the evils of prescription charges, let us not forget what can be achieved with the money so collected.

One problem with exemptions is the relating of cost to disease. Although I can just see my way to supporting the increase this time—primarily because of Labour's record in this matter and the increase in the cost of living, coupled with the redistribution of money in the N.H.S.—I could not support a proportional increase in prescription charges by which disease, and not the income of the patient, would be the determining factor. By that means, the disease and the quirks of the doctor prescribing would determine the charge. In other words, if one were lucky and had rheumatoid arthritis, so that the treatment was aspirin, the charge would be small. If, on the other hand, one were suffering from a complaint necessitating expensive prescribing, the treatment would be equally expensive.

Sir K. Joseph

I am bearing up stoically to everything my hon. Friend is saying. He is a doctor of high repute and I would hate it to go out from this House that he has accurately described what the Government have proposed to the professions. We certainly do not intend that anybody should be deterred by the cost of medicines, whatever the disease. I must put in this disclaimer.

Dr. Stuttaford

I accept that completely, but I feel, nevertheless, that the cost of some of these treatments will be very high, with the result that it will probably be a matter of a chosen item.

Sir K. Joseph

And a maximum.

Dr. Stuttaford

Yes, and a maximum.

The last drug which we must consider for exemption is the pill. It has never been included in drugs which must be constantly taken. In fact, it is constantly taken more than any other drug. It should be prescribable on the National Health Service and should be in the exempt list. We have got into the way of thinking of the pill as being something which can be prescribed with safety by the family planning clinics. This is not so.

It is a drug, perhaps the most useful in our armoury, which affects the whole body and not just any one part of it. It has an effect on the brain, blood pressure, heart and lungs. Any of these may show the first signs of damage caused by the treatment. Yet, if we give more aid to family planning clinics, encouraging patients to go there, family doctors will not know what is wrong with their patients when they go to them with the first signs of trouble. We must do everything we can to encourage general practitioners to provide this service for patients, and it should be free, because in that way it will save money.

6.2 p.m.

Mr. Will Griffiths (Manchester, Exchange)

I well understand your appeal, Mr. Deputy Speaker, for brevity and I shall do my best to keep within the few minutes which you have recommended for speeches.

I raise the strongest possible objection to the way in which this debate has been arranged. It is absolutely monstrous that the Secretary of State and the Opposition Front Bench spokesmen should, in a twoand-a-half hour debate, take 57 minutes between them and that two other Front Bench spokesmen, presumably, should speak before the end of the debate at seven o'clock. This is not treating the House of Commons seriously on a matter of this importance. I am especially cross about it because the one thing which unites the two Front Benches is the fact that neither of them on any occasion within my recollection has voted against National Health Service charges. It is, therefore, about time that some people who have a different point of view had a little more time to address the House.

I propose to say nothing about the prescripition charges or charges for surgical appliances, and so on. They are important, but time does not permit me to say anything about them.

The Secretary of State's speech was breathtaking. It was inaccurate in some respects, as I shall seek to show. The right hon. Gentleman quoted selective statistics and then, when challenged, went off them. He misrepresented people. For example, it is wrong to say that the British Dental Association has recommended the scheme to its members. It has done nothing of the kind.

Sir K. Joseph

I think that I corrected myself and said that the association had explained the Government's point of view in its communication to its members. I withdrew the word "recommended". If I did not, I meant to do so.

Mr. Griffiths

I apologise to the right hon. Gentleman.

The British Dental Association and the Association of Optical Practitioners are very strongly opposed to these charges. However, I wish to apply myself to charges in two fields where I submit there has been a qualitative change. For the first time, there are cost-related charges for the ophthalmic and dental services. Incidentally, the hon. Member for Norwich, South (Dr. Stuttaford) was right in saying that both Labour and Con- servative Governments had imposed charges at different times. But, in all the time that I have been a Member of the House, I have never voted for any of them. I have always voted against them, and so have some of my hon. Friends.

We have always had flat-rate charges in the ophthalmic service, ever since the Labour Government of 1951 took the first step on the slippery slope. We now have a new factor. We have, not a flat-rate charge, but a cost-related charge. In other words, the worse a person's sight, the greater will be his financial burden. In future, the charges will be calculated in this way. The patient will pay the whole cost of the lenses, a charge agreed between the Department for Social Services and the manufacturers, and a dispensing fee which—and I hope that my professional colleagues will not be offended when I say this—is a euphemism for profit. The patient will pay £2.40 per pair for spectacles with the lowest-powered, simplest lenses. The cost will rise to £6.40 a pair for spectacles with the highest-powered lenses—that is, for spectacles for people with the worst sight. Until 1st April, everybody, except those who were exempted, paid £1.60 per pair.

If right hon. and hon. Members opposite are pleased about that, and if they think that the Budget concessions will console people who are partially sighted or who need very high-powered lenses and regular attendances, they are even worse than I suspected they were in my most unhappy days. For bifocal lenses, the patient will now pay between £4.90 a pair and £7 a pair. Until 1st April, the maximum charge, again taking no account of exemptions, was £2.50. These are swingeing increases, not increases of 5s. or 10p.

I come to the point about which I think the Secretary of State deceived the House; I hope that he will be able to contradict me. He said that examination under the ophthalmic and dental services was free. Paragraph 24 on page 9 of the White Paper entitled "New Policies for Public Spending" states: Charges for dental services will be related to approximately half of the cost of the services actually provided, apart from dental examinations which will continue to be free of charge. The right hon. Gentleman repeated that today. I am advised by the British Dental Association that in examination the dentist looks in the patient's mouth, and I am also advised that, in a very large proportion of cases, the dentist considers it expedient to take at least one X-ray. If he does so, the recoverable fee for an X-ray is 9s. The patient pays 4s. 6d.—half the charge. Therefore, a very high proportion of dental patients will not get a free examination.

Let me give an example from the ophthalmic service. Since 1st April, in many cases more cash is collected from the patient than is recoverable from the executive council. I repeat that: the charges which the patient has to pay exceed the recoverable moneys from the executive council. So we have the position at the end of this month that the optician will have to pay back to the executive council the excess sum of money which he has collected from the patient. I hope I have made myself clear on that. He will in fact be acting as a tax collector.

If I am challenged on this I have all the details here and of other lenses in the range. I estimate that in some cases it is 10p and it can rise to 30p which the optician takes in excess in recoverable charges which would be paid to the executive council at the end. The executive council will say, "Ah, you will not necessarily return this money; we will deduct it from your examination fees which you have paid for what the Minister says is free." If the patient is paying anything from 10p to 30p over the recoverable price it is clear, surely, to everybody that he is paying between 10p and 30p for the allegedly free examination.

Sir K. Joseph

I am grateful to the hon. Gentleman for giving way and I shall be very quick. There has been no change whatsoever in the payment for X-rays, which were included in the chargeable costs before in assessing the cost of £1.50 which the previous Government maintained and as we maintain. Tooth inspection which may lead to X-ray is free and remains free. On the second point, as I explained, there is a banding, an averaging, of lens charges in order to avoid proliferation of different lens charges, and this leads to patients sometimes paying 10p more, sometimes 10p less, for the precise charge for a particular lens. I do not think it goes further than that.

Mr. Griffiths

I challenge the right hon. Gentleman. I challenge him when I say that the majority of the ophthalmic services patients will have to pay a sum over the recoverable price, and, if the price exceeds that, it must be a payment towards the allegedly free examination. That is what I am saying. As the weeks go by and we get a little more experience of this, I will allow the right hon. Gentleman to answer Questions in the House so that we can ascertain where the truth of this matter lies.

I must finish, and I have gone on for rather longer than I intended. I have just two other things to say. The first is—and I say this to the Secretary of State—that because of what I have said about this cost-related service the estimates of the savings on the ophthalmic services and the dental services must be inaccurate. The right hon. Gentleman cannot possibly know what the savings are. How can he know in all the range of dental services from simple treatment upwards? Similarly with the ophthalmic service between the minimum and maximum I have quoted. Therefore I say that the White Paper on Public Expenditure which the Government have put before the House is an ill-conceived policy, certainly, but also a badly thought out, a not properly worked out, paper in financial terms, and to the extent that the House has to determine its attitude on the basis of the White Paper, the House, in this respect at least, has been deceived.

I finish by saying to my colleagues on this side of the House, and particularly to those who were formerly members of the Government and who are on the National Executive of the Labour Party, that nothing will suffice for us at the end of all these arguments about giving exemptions and having selectivity but a return to a genuinely free service. The selectivity and exemptions which the Minister has been talking about this afternoon are a recipe for depriving the poor and the badly educated people. Hon. and right hon. Members opposite do not have any difficulty in reading the small print. They get others to do it for them, and they pay them to do it. I say lo my party that the sooner we get back to the straight concept of the National Health Service as it was in 1948, the better. I apologise for having gone on for so long.

6.15 p.m.

Mrs. Jill Knight (Birmingham, Edgbaston)

I warmly support what my right hon. Friend is trying to do. I believe that we can have either a first-class health service or a free health service, but we cannot have both, and we have to make up our minds which we want. The hon. Member for Rhondda, West (Mr. Alec Jones) has left the Chamber, I am sorry to see, but he said something to the effect that my right hon. Friend did not seem to care very much about people. I want to say here and now that there is no more compassionate Member in the whole of the House than my right hon. Friend, and no one is more conscious of the needs of the poorer people.

I take up a point made partly by the hon. Member for Manchester, Exchange (Mr. Will Griffiths), the question of patients' charges according to the kind of optical lens which is prescribed. The nature and the power of the lens in future, apparently, is to be the criterion of how much the patient pays. I am myself very concerned about the question of this being a penalty on those people with bad eyes. I appreciate that the maximum charge is being laid down at £3.50 but I do not think that this covers the point, and I want to underline that this is the first time since the National Health Service began that charges have been imposed on the basis of how bad a person's eyes are. There have, of course, been variations in cost, according to the style of lens, whether single or bifocal, and that seems fair, because with a bifocal pair of spectacles there are two pairs in one and, therefore, there is a very good reason why bifocals should be more expensive. But I do not think that ever before has difference of power of the lenses been the criterion of cost.

If we were to follow this into the charging of prescriptions and were to say that those people with the worst illnesses must pay more for their prescriptions, the House would not accept that for one moment; but in fact that is what we are saying about spectacles. I think that it will be very difficult to get the patients to understand that. Ophthalmic opticians will have a hard job trying to explain to patients that because their eyes are bad they will have to pay more. I very much hope that my right hon. Friend will think about this very carefully. One appreciates that for very poor people there is help available and that nobody is to be deterred because of the cost from having the spectacles he needs. Nevertheless, this is a most important point.

I will take issue briefly with the hon. Member for Manchester, Exchange on one statement which he made. I may have misunderstood him and I am very ready to give way to him if I have, but he said something to the effect that the prescribing charge was profit. It seems to me perfectly fair to make a charge for the technical and professional business of deciding what is wrong with a patient's eyes and what lens he needs for the wrong to be put right.

Mr. Will Griffiths

I agree with that, because I draw such fees myself, but what I was saying when I was talking about the charges to which the hon. Lady is referring was that they included the price of the lens and the dispensing fee, as the hon. Lady very well knows, and I said that the dispensing fee might be said to be a euphemism for profit.

Mrs. Knight

Very well, I accept that point.

One other point which I wish quickly to raise is the question of contact lenses. I think it ought to be made very clear to patients and to the public that the cost laid down for contact lenses refers only to contact lenses prescribed in hospitals. That is not sufficiently clear in the papers which we have at this time, and I hope that something will be done to make that rather clearer.

Otherwise I support what my right hon. Friend is trying to do and I think that the country shows signs that it, too, will support him.

6.20 p.m.

Mr. Neil Carmichael (Glasgow, Woodside)

It is unfortunate that this important debate, which so well illustrates the difference in philosophy between the two sides of the House, has had such a short time allotted to it and that other business of the House, important though it was, ate into that time.

There are Regulations relating to Scotland which are exactly the same as the Regulations which we are discussing. I am well aware that the Labour Government introduced certain charges when they were in power. Although at the time I thought it was wrong and felt sad about it, as a member of the Government I supported those charges because of the prevailing economic situation, but I regarded it as one of the first matters to be dealt with when the economic situation improved. Had we been returned to power on 18th June it was one of my personal priorities to try to persuade my party to get back to a free National Health Service. I realise that there is no such thing as a "free" health service; it has to be paid for.

I am anxious that a person requiring treatment should not be troubled with having to find money to pay for that treatment at a time when he also has to find the energy and the courage to deal with his illness or disability. The concept that the treatment that a patient receives should be decided by his capacity to pay is corrupt. It is a denial of dignity to the sick person. Sick people are frightened, helpless and worried about coping with things that they cannot quite understand and to introduce an additional worry of finding the money for treatment is completely wrong. It brings the alien element of cash into the personal relationship between doctor and patient. It is wrong also for the doctor, who has not merely to make a medical diagnosis but to decide on the treatment partly on the basis of how much the patient can afford to pay for it.

I was told recently by a doctor in my constituency that he had a patient, whose husband had recently died, who needed a permanent course of a certain drug. The doctor decided that in addition to the drug she needed a tranquiliser to calm her down. On closer examination he decided that she also needed an iron tonic. This meant three items on the prescription. Knowing the patient very well, the doctor decided that this would be more than she could afford. To the widow 4s. meant a great deal, and the doctor decided that it was better to allow her run-down condition to await treatment until she had recovered from the effects of her bereavement, so he omitted the iron tonic from her prescription. It is wrong to ask the doctor to make these decisions.

Dr. Stuttaford

Is the hon. Gentleman aware that if the prescription costs less than 4s. the chemist should tell the customer that this is so? An immense bottle of iron tablets can be bought for a few pence. Patients sometimes pay too much when they pay the prescription charge rather than the actual cost of the prescription.

Mr. Carmichael

I am assuming that my informant knew this. He is highly thought of and is a very conscientious doctor. I am sure that he would know, and if he had thought that a tonic could be obtained at less than 4s. he would have told his patient so.

I am sorry that the Secretary of State did not go further on the question of whether 50 per cent. of the cost of the prescription will be reached. I wonder if the Department has in mind what was said by The Sunday Times and the Economist—that the bureaucratic structure needed to collect the charges would cost more than the charges would bring in, and the game would not be worth the candle?

Are the Government thinking of taking the next logical step of increasing rather than decreasing the number of amenity beds? Will there be a demand to introduce more private health insurance? There are very powerful financial lobbies at work on this, and we know that the Government can be susceptible to powerful financial lobbies.

Our National Health Service has a great many flaws. Although it has not developed in the last 20 years in the way some of us hoped it would, it is still a wonderful system in comparison with systems in other parts of the world. Following upon these Regulations, shall we see cash being brought more and more into the doctor-patient relationship? I have been told that in hospitals in Europe—never mind America—it is impossible to get proper service from nurses unless they are given a daily gratuity, and this is becoming an international scandal. It is said that this could not happen here, and I certainly hope it will not, but given the Government's attitude on people's ability to pay, I should not be surprised at whatever they introduce.

A comprehensive health service is very expensive and there are always areas of abuse. We have perhaps spent too much time in the past talking about abuses instead of talking about the importance of the health service as part of the social wage. The next time a Labour Government is in power we must take steps to increase the independence of the health service from direct payment by patients. Instead of succumbing to the notion of the over-burdened taxpayer we must in our propaganda show the taxpayer what taxes are paid for, and that the taxes paid in respect of the health service represent part of the standard of living of our people. I hope the House will give a resounding vote against the proposals of the Government in these Regulations.

6.30 p.m.

Dr. Shirley Summerskill (Halifax)

The Prayer on these Regulations has given the House the opportunity, in a regrettably short debate, to analyse and question both the economic and medical justifications for charging the patient when he is sick. I personally was not convinced with the explanation given by the Minister as to the economic justification for these further increases in health charges. Charges make up only 5 per cent. of the finance of the Health Service. The estimated gross saving in public expenditure arising from these new charges on prescriptions is £13 million a year, on dental charges £12 million a year and on ophthalmic charges £5 million a year. I say "estimated" because the previous Government realised that it could be only an approximate figure.

There are three imponderables in calculating these figures—and they exclude the infamous cost-related scheme with which I shall deal in a moment. First, how many people will be deterred from seeking treatment by the new charges? We were assured by the Minister that the charges will not deter, but how can one possibly tell who is deterred and who is staying at home and not going to the surgery because of the cost? Secondly, how many people who up to now have not sought exemption, either because they have not bothered or because they have been unaware that they were entitled to exemption, will now do so because of increased charges? That is another matter we do not know.

Thirdly, the administrative costs are bound to rise under the new scheme. Here again, as the Labour Government found, one cannot predict the administrative costs. These costs were well brought out by my hon. Friends the Members for Rhondda, West (Mr. Alec Jones) and Manchester, Exchange (Mr. Will Griffiths). Therefore, we have only an estimate of the economic justification for these charges. When the Minister told the House how many people would be exempt, how many people would get free prescriptions, and said that for some it would cost less, we wondered why these charges were being imposed at all.

Whatever sums the charges save, they will be a drop in the ocean in regard to the total Health Service. The money so gained will not go far towards paying for new hospitals, staffing the service, providing expensive equipment, caring for the mentally ill and handicapped, and preparing for the increasing demands to be made on the Health Service. These charges, as any economist would agree, are merely tinkering with the basic grave financial problems facing the Health Service.

The service needs at least another £400 million a year even to prevent a break-down in standards, on top of the £2,000 million now spent. It needs even more if it is to improve its present standards. Therefore, the new charges are of limited and dubious economic value. The fairest way to pay for the Health Service is where 85 per cent. of the money already comes from, namely, through taxation. Each person then contributes according to his ability to pay and pays when he is well rather than when he is ill.

What is the Government's long-term policy for the payment of the National Health Service? The hon. Member for Farnham (Mr. Maurice Macmillan) said in a debate in this House before he became a Treasury Minister: Any foreseeable expansion of the economy, even under a Tory Government, could not, in my view, be expected to produce the full amount which the Health Service requires in addition to what we are now spending."—[OFFICIAL REPORT, 1st July, 1969; Vol. 786, c. 243.] So under a Tory Government we cannot rely on economic growth to pay for the Health Service. Therefore, apart from contributions, that leaves taxation and charges to pay for it.

What steps have the Government taken recently? They have taxed the sick with one hand and reduced the standard rate of income tax with the other. They have penalised the sick who need extra assistance, and have helped the better off with a tax cut. For the sick to subsidise the healthy is neither just nor is it economic sense.

During the General Election hon. Members opposite made a simple and effective appeal which won them the election, namely: tax cuts for the men and price cuts for the women. Yet the tax cut, such as it was, has been subsidised by increased school meal charges, by 6,291 price rises since the election, and by more for prescriptions, dental treatment and spectacles. We heard nothing about these at the election.

Mrs. Knight

Is the hon. Lady suggesting that sick people do not pay taxes? A great many sick people pay taxes and will be helped by the tax cuts.

Dr. Summerskill

Everyone agrees that the tax cuts help primarily the better off section of the community, and the very fact that the sick pay taxes makes it even more unfair that, when they get sick, they should have to pay a second time. The Labour Government imposed charges out of necessity at a time of serious economic difficulties. Now that our balance of payments is strong—and the Government have cut taxation to prove it—this can no longer be an explanation.

The Labour Party in the country and in this House has a history of concern over this issue. We are not ashamed of this. We feel strongly about the principle of charging the sick. At least we imposed charges with reluctance, with distaste and with apology. This Government a few months after coming to power have increased them as part of a package, brazenly, with indecent haste. The difference between us is that this Government regard taxing the sick, with all the hardship caused, merely as a limited money raiser, not worth making a fuss about.

Dr. Stuttaford

Does the hon. Lady not recall that the Attlee Government of 1950 were intending to impose, just before they lost the election, a charge of 85s. for false teeth, since they regarded that figure as being half a working man's weekly wage? This was to be introduced very soon after the start of the National Health Service. It was to be introduced partly for its deterrent effect and it was a very large sum indeed.

Dr. Summerskill

I am trying to illustrate that we imposed charges with reluctance—which is not the spirit we detect in hon. Members opposite. As well as being economically unjustifiable, charges have a deterrent effect both on doctor and patient. The President of the Pharmaceutical Society, Mr. W. M. Darling, has predicted: Many patients will be seeking their cures from the shelves of supermarkets, from old medicines stored away in medicine chests, until the money can be found for the doctor's prescription. Self-diagnosis and self-medication will increase and clearly the clock will be put back to the days when the poor would buy a totally inappropriate cheap medicine from the chemist, or worse still, go without treatment. If a woman with a family that is already trying to make ends meet, falls ill herself, she could postpone or even fail to visit her doctor if she fears that she will be given a prescription containing two or three items over a period of two or three weeks.

So much for early diagnosis and early treatment which is the essence of preventive medicine. Not only will the sick be divided from the healthy by charges, but the poor sick will be divided from the rich sick by these higher charges. The doctor's freedom to prescribe will be affected by the increased charges. And certainly, as the hon. Member for Norwich, South (Dr. Stuttaford) pointed out from his personal experience, prescription charges can seriously influence a doctor's surgery treatment. Patients ask, "Do I have to have all these items? Could you leave one off?" The hon. Member for Glasgow, Woodside (Mr. Carmichael) illustrated this in his speech. A patient may not take his prescription to the chemist until he has more money. With the advent of the new charges, this sort of attitude will become more frequent. Doctors, therefore, will undergo a conflict of professional judgment which is totally unacceptable. They will be forced to carry out their own means tests. They will find themselves deliberately prescribing cheap drugs for the poor and more expensive ones for the others. Dentists, too, will face this dilemma of either giving the patient the treatment that he needs or the treatment that he can afford. These charges are, therefore, a direct attack on medical and dental professional standards, and we have evidence from these professional bodies which agrees with that.

I welcome the Minister's announcement that he will consult again with the B.M.A. about the chronic sick, a subject which has been brought out again and again in the debate. As for the new proposed scheme, the Government are really introducing—apart from dentures, as the Minister pointed out—a totally new principle here.

Sir K. Joseph

Not in these Orders.

Dr. Summerskill

No—as for the proposed new scheme. We hope that it is only a proposed new scheme, because this scheme, we hope, was merely a kite flown by the Chancellor. We hope that the Minister will note that it is opposed by the British Medical Association, the Medical Practitioners' Union, the pharmacists, the patients and even by the hon. Lady the Member for Birmingham, Edgbaston (Mrs. Knight).

The fact that payment of a proportion of the cost of each drug prescribed, up to a maximum of 50p per item, will be expected, is totally unacceptable. We hope that the Minister will pocket his pride and abandon the scheme. I assure him that this side of the House will think far more of him if he does so. Perhaps he would even take the opportunity of this debate to abandon the scheme, because it would impose a totally cruel and callous discrimination against patients who need more expensive drugs through no fault of theirs. Nearly half the drugs prescribed would cost the full 50p, including the modern life-caving drugs and almost all antibiotics. If an hon. Member went to his doctor with a chest infection and needed three kinds of tablets, he could pay £1.50 for treatment. This is discriminating against those who need especially expensive drugs for blood pressure or rheumatism. Instead of encouraging preventive medicine the scheme would be promoting deterrent medicine. The Pharmaceutical Society estimates that to collect the new charges would cost £16 million, which is the same amount that it is estimated that the scheme would raise.

In conclusion, we come back to the same question. What is the long-term principle to be followed by the Government in paying for the National Health Service? Is it that the sick should pay more while taxation is reduced? Are there plans to charge for general practitioners' home visits, for hospital meals and for long-stay hospital patients? Are the new charges only the hors d'oeuvre before the main meal? If so, people have a right to know.

We on this side of the House are proud of the Health Service. These charges are economically irrelevant, administratively cumbersome, medically harmful and socially unjust. They will produce a society which is less healthy, less fair and less civilised. At the Conservative Party conference last year, the right hon. Gentleman declared with great passion We must and will encourage the habit of self-reliance and thrift. The Government tell its that we should stand on our own feet and make our own way in the world. But the sick are not able to stand on their own feet and make their way in the world. Clearly, under a Conservative Government, it can be said that the price of the National Health Service is eternal vigilance. I ask the House to pray against the Regulations.

6.45 p.m.

The Under-Secretary of State for Health and Education, Scottish Office (Mr. Edward Taylor)

We have had a most interesting and thoughtful debate. Some of the remarks made by the hon. Lady the Member for Halifax (Dr. Summerskill) were, perhaps, unnecessarily emotive and were unfair to those on this side of the House. She said that the Opposition were proud of the Health Service and wanted to develop it. I assure her that all of the policies of the Secretary of State and the Government are directed to improving the health and welfare services. The Regulations are part of these proposals.

The hon. Lady asked me about the basis of the Regulations and the justification for them. Essentially, this is a question of priorities. We all want to see the health and welfare services developed. But there are the competing claims of other services. The resources available have to be used to best advantage. Our view is that in the case of certain social services, where the user can afford it he should pay a greater share of the cost, but that more help should be given to those in the greatest need and more resources should be made available for those parts of the health and welfare services which are in greatest need, such as the care of the elderly and the mentally handicapped.

It is all very well to complain about charges which, under these Regulations, will bring in about £33 million, but very little has been said of the extra resources which my right hon. Friend and the Government have made available to the health and social work services, amounting to about £110 million. This is being spent to make sure that we make up as many of the gaps in our services as we possibly can. There are enormous demands on the services. The services are expanding and it is essential that the very best use should be made of the available resources.

Mr. Alex Eadie (Midlothian)

The hon. Gentleman has informed the House that the charges will bring in about £33 million. Has he calculated the administration charges or is this a net figure?

Mr. Taylor

£33 million is the net figure of N.H.S. saving to the Government. It will be £33 million in a full year. The sum of £4 million to which my right hon. Friend referred is for the increased payments for supplementary benefit to take account of the increased charges. The resultant figure of £29 million represents extra resources available to the Government as part of a contribution to expanding the services.

I shall attempt to answer as many of the points raised as possible. We had a knowledgeable contribution from the hon. Member for Manchester, Exchange (Mr. Will Griffiths), who asked about optical charges and sight testing. He said that we have a situation when we have limited averaging under which some will pay a little more of the actual costs and some a little less. He asked if it would be the case that under this system there would be a payment for sight tests. I assure him that, obviously, under an element of averaging in the new charges, some will pay a little more and some a little less than the cost. But it is not the case, overall, that payments by patients will exceed the cost of provision of glasses to the N.H.S. The charge will be made for the provision of glasses but not for sight tests. This is laid down as part of our policy and is being implemented.

Mr. Will Griffiths

I apologise for interrupting the hon. Gentleman. First, how on earth does he know how many people in the next 12 months will have to pay more to the optician than the recoverable charge and how many will have to pay less? We cannot know until the scheme has been in operation for some months. Second, would the hon. Gentleman agree that, to the extent that people pay something over the recoverable charge, they are contributing to something other than the price of the appliance? Surely that is clear.

Mr. Taylor

Under a system of limited averaging, as opposed to some other policy, a situation must arise in which some people pay a little more and others a little less. We have made the best estimates possible, and there is no question of a general sum being used for this purpose. Overall, there is no question of the income making a contribution towards the cost of sight testing.

The hon. Gentleman also referred to dental charges and said that in many cases people are getting free attention by way of examinations and that it follows that in many or most cases an X-ray may be required. In 1969, there were about 18 million inspections by dentists free of charge, and only 3 million X-rays. In other words, X-rays were taken in only about a sixth of the examinations. Under the previous arrangements brought in by the last Government, an X-ray would have cost 9s. on the basis of charging the full sum. Under the new arrangements, the charge will be only 4s. 6d., which is half the total. Even in the case quoted by the hon. Gentleman where there is just an inspection and an X-ray, instead of paying more, the patient will actually pay about half the sum.

Many questions were raised about other matters. The hon. Member for Rhondda West (Mr. Alec Jones) asked why women aged between 60 and 64 were not being exempted from prescription charges. This matter has been raised on many occasions. However, people are exempted at the age of 65 not because men become eligible for the retirement pension at that age but because, at that age, people are likely to need an increasing number of prescriptions. Clearly it would be an anomaly to allow a different exemption age for women or to exempt all people receiving retirement pensions. There are cases where a single or widowed woman pensioner could not afford to pay prescription charges, but the arrangements enable help to be given where it is needed.

The hon. Gentleman also referred to the categories of the sick who qualify for exemption. Whenever a formula is laid down, anomalies may extend from it. But it has proved difficult to establish the right categories. The co-operation of the medical profession is essential, and its representatives consider that doctors should not have to decide arbitrarily which patients should be exempted. This could lead to arguments between doctor and patient, with consequent harm to the doctor-patient relationship. We are willing to look at almost any proposal, but it would be misleading to suggest that any change would be easy.

In view of what has been said about hardship, perhaps I might refer to the importance of exemptions. The wide range of exemptions is retained, covering about 23 million people or roughly 42 per cent. of the population. In addition, anyone with an income below a certain level is entitled to exemption or refund. One half of all prescriptions are exempt from charge.

It has been argued, quite rightly, that there may be cases where people are eligible for exemption and do not apply for it. We are aware that there are cases like this. We have had and will continue to have an extensive campaign to try to make everyone aware of his entitlements and rights. My right hon. Friend referred to a number of leaflets on the subject, and we have the little red book, "Family Benefits: Your Right to Claim Then", which sets out the position simply and clearly. In the first few weeks of this new campaign, we have seen some dramatic results. Taking prescription charge claims alone, these have increased from an average of 346 a week before 1st April to 1,800 after that date. We hope that that will continue.

Then we have the cases in the margin. We have been urged to forget about exemptions and to concentrate on people in the margin who need a lot of prescriptions. We have the system of season tickets. For a cost of £3.50, people can obtain total exemption from charges for 12 months, in the sense that they can get any number of prescriptions for that cost. It has been suggested that £3.50 a year or £2 for six months is a lot. It represents a penny a day—for that sum anyone can be eligible for total exemption from charges.

We have had many discussions on these matters. I suggest that we are still in doubt about where the Opposition stand. In a debate of this importance, I believe that we are entitled to have some indication. We have had only one so far, and that came from the hon. Member for Halifax, who said that the difference was that the Labour Party imposed charges reluctantly. That reminded me of the old headmistress who told a child whom she was about to punish, "This will hurt me more than it will you." But, on a matter of this importance, that is not sufficient to enable people to know about the differences between the parties.

The crunch occurred when several propositions came from the hon. Member for Glasgow, Woodside (Mr. Carmichael), the hon. Member for Hitchin (Mrs. Shirley Williams), the hon. Member for Rhondda, West and the hon. Member for Halifax, who said that it was anomalous to introduce new charges, albeit with exemptions, and at the same time to cut taxation. She suggested that this was wrong. She wanted to know why we made concessions in one direction and imposed new charges in another. But surely, in the long term, the policy of right hon. and hon. Members opposite would have the same stultifying effect on the country's future as previous Socialist policies, which drove the nation to crisis after crisis and to economic stagnation.

As the junior Minister responsible in Scotland for health and education, I have become increasingly aware of the desperate needs in our health and walfare services. We need to do more for the elderly and infirm. In the long term, the need will be met only by increasing the size of the national cake so that all the slices are larger and, in that way, providing more for the wage earner and the essential public services. That is what we did in our previous 13 years of office. We made substantial cuts in taxation, while achieving a massive increase in spending on the social services.

The opposition to these Regulations has been short sighted and irresponsible. The Opposition have had their chance. They condemned Health Service charges and then reintroduced them. We still do not know where they are. They created an economic climate in which real growth was virtually impossible and in which we could not have a major expansion in the social services without massive increases in taxation.

Under these Regulations, we are imposing additional charges. At the same time, we are making sure that the money obtained from them will come from those who can afford it, and we are also ensuring that much more will be made available for the health and social work services.

The Opposition had their chance. They wavered, bungled and failed. Our proposals are fair, just and reasonable. They give help where it is needed and contribute to a great leap forward in our expenditure on hospitals and social work services. I have no doubt that the House will approve these Regulations and reject the Motion.

Question put, That an humble Address be presented to Her Majesty, praying that the National Health Service (Charges) Regulations 1971 (S.I., 1971, No. 340), dated 3rd March, 1971, a copy of which was laid before this House on 10th March, be annulled:—

The House divided: Ayes 251, Noes 280.

Division No. 350.]	AYES	[7.0 p.m.
Abse, Leo	Darling, Rt. Hn. George	Griffiths, Will (Exchange)
Albu, Austen	Davidson, Arthur	Gunter, Rt. Hn. R. J.
Allaun, Frank (Salford, E.)	Davies, Denzil (Llanelly)	Hamilton, William (Fife, W.)
Allen, Scholefield	Davies, G. Elfed (Rhondda, E.)	Hamling, William
Archer, Peter (Rowley Regis)	Davies, Ifor (Cower)	Hannan, William (G'gow, Maryhill)
Ashley, Jack	Davies, S. O. (Merthyr Tydvil)	Hardy, Peter
Ashton, Joe	Davis, Clinton (Hackney, C.)	Harper, Joseph
Atkinson, Norman	Deakins, Eric	Harrison, Walter (Wakefield)
Bagier, Gordon A. T.	de Freitas, Rt. Hn. Sir Geoffrey	Hart, Rt. Hn. Judith
Barnett, Joel	Delargy H. J.	Hattersley, Roy
Beaney, Alan	Dell, Rt. Hn. Edmund	Healey, Rt. Hn. Denis
Benn, Rt. Hn. Anthony Wedgwood)	Dempsey, James	Heffer, Eric S.
Bennett, James(Glasgow, Bridgeton)	Doig, Peter	Hooson, Emlyn
Bidwell, Sydney	Dormand, J. D.	Horam, John
Bishop, E. S.	Douglas, Dick (Stirlingshire, E.)	Houghton, Rt. Hn. Douglas
Blenkinsop, Arthur	Driberg, Tom	Howell, Denis (Small Heath)
Booth, Albert	Duff, A. E. P.	Huckfield, Leslie
Boyden, James (Bishop Auckland)	Dunnett, Jack	Hughes, Rt. Hn. Cledwyn (Anglesey)
Bradley, Tom	Eadle, Alex	Hughes, Mark (Durham)
Brown, Bob (N 'c' tle-upon-Tyne, W.)	Edelman, Maurice	Hughes, Robert (Aberdeen, N.)
Brown, Hugh D. (G'gow, Provan)	Edwards, Robert (Bilston)	Hughes, Roy (Newport)
Brown, Ronald (Shoreditch&F'bury)	Edwards, William (Merioneth)	Hunter, Adam
Buchan, Norman	English, Michael	Irvine,Rt.Hn.SirArthur(EdgeHill)
Callaghan, Rt. Hn. James	Evans, Fred	Janner, Greville
Campbell, I. (Dunbartonshire, W.)	Faulds, Andrew	Jay, Rt. Hn. Douglas
Cant, R. B.	Fisher,Mrs. Doris(B'ham,Lady wood	Jeger, Mrs.Lena(H'b'n&St.P'cras.S.)
Carmichael, Neil	Fitch, Alan (Wigan)	Jenkins, Hugh (Putney)
Carter, Ray(Birmingh'm, Northfield)	Fletcher, Raymond (Ilkeston)	Jenkins, Rt. Hn.Roy (Stechford)
Carter-Jones, Lewis (Eccles)	Fletcher, Ted (Darlington)	John, Brynmor
Clark, David (Colne Valley)	Foley, Maurice	Johnson, Carol (Lewisham, S.)
Cocks, Michael (Bristol, S.)	Foot, Michael	Johnson, Walter (Derby, S.)
	Forrester, John	Jones, Barry (Flint, E.)
Cohen, Stanley	Freeson, Reginald	Jones, Dan (Burnley)
Coleman, Donald	Galpem, Sir Myer	Jones,Rt.Hn.Sir Elwyn(W.Ham,S.)
Concannon, J. D.	Garrett, W. E.	Jones, Gwynoro (Carmarthen)
Conlan, Bernard	Gilbert, Dr. John	Jones, T. Alec (Rhondda, W.)
Corbet, Mrs. Freda	Ginsburg, David	Judd, Frank
Cox, Thomas (Wandsworth, C.)	Golding, John	Kaufman, Gerald
Crawshaw, Richard	Cordon Walker, Rt. Hn. P. C.	Kelley, Richard
Crosland, Rt. Hn. Anthony	Gourlay, Harry	Kerr, Russell
Crossman, Rt. Hn. Richard	Grant, George (Morpeth)	Kinnock, Neil
Cunningham, G. (Islington, S.W.)	Grant, John D. (Islington, E.)	Lambie, David
Dalyell, Tam	Griffiths, Eddie (Brightside)	Lamond, James
Latham, Arthur	Mulley, Rt. Hn. Frederick	Small, William
Lawson, George	Murray, Ronald King	Smith, John (Lanarkshire, N.)
Leadbitter, Ted	Ogden, Eric	Spearing, Nigel
Lee, Rt. Hn. Frederick	O'Halloran, Michael	Spriggs, Leslie
Leonard, Dick	O'Malley, Brian	Stallard, A. W.
Lestor, Miss Joan	Oram, Bert	Stewart, Rt. Hn. Michael (Fulham)
Lever, Rt. Hn. Harold	Orbach, Maurice	Stoddart, David (Swindon)
Lewis, Ron (Carlisle)	Orme, Stanley	Stonehouse, Rt. Hn. John
Lipton, Marcus	Oswald, Thomas	Strang, Gavin
Lomas, Kenneth	Owen, Dr. David (Plymouth, Sutton)	Strauss, Rt. Hn. G. R.
Lyon, Alexander W. (York)	Palmer, Arthur	Summerskill, Hn. Dr. Shirley
Lyons, Edward (Bradford, E.)	Pannell, Rt. Hn. Charles	Taverne, Dick
Mabon, Dr. J. Dickson	Parker, John (Dagenham)	Thomas,Rt.Hn.George (Cardiff,W.)
McBride, Neil	Parry, Robert (Liverpool, Exchange)	Thomas, Jeffrey (Abertillery)
McCartney, Hugh	Pendry, Tom	Thomson, Rt. Hn. G. (Dundee, E.)
McElhone, Frank	Pentland, Norman	Thorpe, Rt. Hn, Jeremy
McGuire, Michael	Perry, Ernest G.	Tinn, James
Mackenzie, Gregor	Prentice, Rt. Hn. Reg.	Tomney, Frank
Mackie, John	Prescott, John	Tuck, Raphael
Mackintosh, John P.	Price, William (Rugby)	Urwin, T W.
Maclennan, Robert	Probert, Arthur	Varley, Eric G.
McMillan, Tom (Glasgow, C.)	Rankin, John	Wainwright, Edwin
McNamara, J. Kevin	Reed, D. (Sedgefield)	Walden, Brian (B'm'ham, All Saints)
MacPherson, Malcolm	Rees, Merlyn (Leeds, S.)	Walker, Harold (Doncaster)
Mahon, Simon (Bootle)	Rhodes, Geoffrey	Wallace, George
Mallalieu, E. L. (Brigg)	Richard, Ivor	Watkins, David
		Weitzman, David
Mallalieu, J. P. W. (Huddersfield, E.)	Roberts, Albert (Normanton)	Wellbeloved, James
Marks, Kenneth	Roberts, Rt.Hn.Goronwy(Caernarvon)	Wells, William (Walsall, N.)
Marsden, F.	Robertson, John (Paisley)	Whitehead, Phillip
Marsh, Rt. Hn. Richard	Roderick, Caerwyn E.(Br'c'n&R'dnor)	Whitlock, William
Mayhew, Christopher	Roper, John	Willey, Rt. Hn. Frederick
Meacher, Michael	Rose, Paul B.	Williams, Alan (Swansea, W.)
Mellish, Rt. Hn. Robert	Ross, Rt. Hn, William (Kilmarnock)	Williams, Mrs. Shirley (Hitchin)
Mendelson, John	Sheldon, Robert (Ashton-under-Lyne)	Williams, W. T. (Warrington)
Mikardo, Ian	Shore, Rt. Hn. Peter (Stepney)	Wilson, Alexander (Hamilton)
Millan, Bruce	Short, Rt.Hn.Edward(N'c'tle-u-Tyne)	Wilson, Rt. Hn. Harold (Huyton)
Molloy, William	Short, Mrs. Renée (W'hampton,N.E.)	Wilson, William (Coventry, S.)
Morgan, Elystan (Cardiganshire)	Silkin, Rt. Hn. John (Deptford)	Woof, Robert
Morris, Alfred (Wythenshawe)	Silkin, Hn. S. C. (Dulwich)
Morris, Charles R. (Openshaw)	Sillars, James	TELLERS FOR THE AYES:
Morris, Rt. Hn. John (Aberavon)	Silverman, Julius	Mr. Ernest Armstrong and
Moyle, Roland	Skinner, Dennis	Mr. James Hamilton.
NOES
Adley, Robert	Chapman, Sydney	Fookes, Miss Janet
Alison, Michael (Barkston Ash)	Chataway, Rt. Hn. Christopher	Fortescue, Tim
Allason, James (Hemel Hempstead)	Chichester-Clark, R.	Foster, Sir John
Amery, Rt. Hn. Julian	Churchill, W. S.	Fowler, Norman
Archer, Jeffrey (Louth)	Clark, William (Surrey, E.)	Fraser, Rt. Hn. Hugh(St'fford & Stone)
Astor, Hn. John	Clarke, Kenneth (Rushcliffe)	Fry, Peter
Atkins, Humphrey	Clegg, Walter	Galbraith, Hn. T. G.
Awdry, Daniel	Cockeram, Eric	Gardner, Edward
Baker, Kenneth (St. Marylebone)	Cooke, Robert	Gibson-Watt, David
Balniel, Lord	Coombs, Derek	Gilmour, Ian (Norfolk, C.)
Barber, Rt. Hn. Anthony	Cooper, A. E.	Gilmour, Sir John (Fife, E.)
Batsford, Brian	Corfield, Rt. Hn. Frederick	Glyn, Dr. Alan
Bell, Ronald	Cormack, Patrick	Godber, Rt. Hn. J. B.
Bennett, Sir Frederic (Torquay)	Costain, A. P.	Goodhart, Philip
Bennett, Dr. Reginald (Gosport)	Critchley, Julian	Goodhew, Victor
Benyon, W.	Crouch, David	Gower, Raymond
Biffen, John	Crowder, F. P.	Grant, Anthony (Harrow, C.)
Biggs-Davison, John	Curran, Charles	Gray, Hamish
	Davies, Rt. Hn. John (Knutsford)	Green, Alan
Blaker, Peter	d'Avigdor-Goldsmid, Sir Henry	Griffiths, Eldon (Bury St. Edmunds)
Boardman, Tom (Leicester, S.W.)	d'Avigdor-Goldsmid,Maj.-Gen.James
Body, Richard	Dean, Paul	Grylls, Michael
Boscawen, Hn. Robert	Dixon, Piers	Gurden, Harold
Bossom, Sir Clive	Dodds-Parker, Douglas	Halt, Miss Joan (Keighley)
Bowden, Andrew	Drayson, G B.	Hall, John (Wycombe)
Boyd-Carpenter, Rt. Hn. John	du Cann, Rt. Hn. Edward	Hamilton, Michael (Salisbury)
Bray, Ronald	Dykes, Hugh	Hannam, John (Exeter)
Brewis, John	Eden, Sir John	Harrison, Col. Sir Harwood (Eye)
Brinton, Sir Tatton	Elliot, Capt. Walter (Carshalton)	Haselhurst, Alan
Brown, Sir Edward (Bath)	Elliott, R. W. (N'c'tle-upon-Tyne,N.)	Hastings, Stephen
Bruce-Gardyne, J.	Emery, Peter	Havers, Michael Hay, John
Bryan, Paul	Eyre, Reginald	Hayhoe, Barney
Buck, Antony	Farr, John	Heseltine, Michael
Bullus, Sir Eric	Fell, Anthony	Hicks, Robert
Burden, F. A.	Fenner, Mrs. Peggy	Higgins, Terence L.
Butler, Hn. Adam (Bosworth)	Fidler, Michael	Hiley, Joseph
Campbell, Rt.Hn.G.(Moray&Nairn)	Finsberg, Geoffrey (Hampstead)	Hill, John E. B. (Norfolk, S.)
Carlisle, Mark	Fisher, Nigel (Surbiton)	Hill, James (Southampton, Test)
Channon, Paul	Fletcher-Cooke, Charles	Holland, Philip

Holt, Miss Mary	Meyer, Sir Anthony	Shaw, Michael (Sc'b'gh & Whitby)
Hordern, Peter	Mills, Peter (Torrington)	Shelton, William (Clapham)
Hornby, Richard	Mills, Stratton (Belfast, N.)	Simeons, Charles
Hornsby-Smith,Rt.Hn.Dame Patricia	Mitchell, David (Basingstoke)	Sinclair, Sir George
Howe, Hn. Sir Geoffrey (Reigate)	Moate, Roger	Skeet, T. H. H.
Howell, David (Guildford)	Molyneaux, James	Smith, Dudley (W'wick & L'mington)
Howell, Ralph (Norfolk, N.)	Money, Ernie	Soref, Harold
Hutchison, Michael Clark	Monks, Mrs. Connie	Spence, John
Iremonger, T, L.	Monro, Hector	Sproat, Iain
James David	Montgomery, Fergus	Stainton, Keith
Jenkin, Patrick (Woodford)	More, Jasper	Stanbrook, Ivor
Jennings, J. C. (Burton)	Morgan, Geraint (Denbigh)	Stewart-Smith, D. G. (Belper)
Jessel, Toby	Morgan-Giles, Rear-Adm.	Stodart, Anthony (Edinburgh, W.)
Johnson Smith, G. (E. Grinstead)	Morrison, Charles (Devizes)	Stoddart-Scott, Col. Sir M.
Jones, Arthur (Northants, S.)	Mudd, David	Stokes, John
Jopling, Michael	Murton, Oscar	Stuttaford, Dr. Tom
Joseph, Rt. Hn. Sir Keith	Neave, Airey	Sutcliffe, John
Kaberry, Sir Donald	Nicholls, Sir Harmar	Tapsell, Peter
Kellett, Mrs. Elaine	Normanton, Tom	Taylor, Sir Charles (Eastbourne)
Kershaw, Anthony	Onslow, Cranley	Taylor,Edward M.(G'gow,Cathcart)
King, Evelyn (Dorset, S.)	Oppenheim, Mrs. Sally	Taylor, Frank (Moss Side)
King, Tom (Bridgwater)	Orr, Capt. L. P. S.	Taylor, Robert (Croydon, N.W.)
Kinsey, J. R.	Osborn, John	Tebbit, Norman
Kirk, Peter	Page, Graham (Crosby)	Temple, John M.
Kitson, Timothy	Page, John (Harrow, W.)	Thatcher, Rt. Hn. Mrs Margaret
Knight, Mrs. Jill	Parkinson, Cecil (Enfield, W.)	Thomas, John Stradling (Monmouth)
Knox, David	Percival, Ian	Thomas, Rt. Hn. Peter (Hendon, S.)
Lambton, Antony	Peyton, Rt. Hn. John	Thompson, Sir Richard (Croydon, S.)
Lane, David	Pink, R. Bonner	Tilney, John
Langford-Holt, Sir John	Pounder, Rafton	Trafford, Dr. Anthony
		Trew, Peter
Legge-Bourke, Sir Harry	Powell, Rt. Hn. J. Enoch	Tugendhat, Christopher
Le Marchant, Spencer	Price, David (Eastleigh)	Turton, Rt. Hn. R. H.
Lewis, Kenneth (Rutland)	Prior, Rt. Hn. J. M. L.	van Straubenzee, W. R.
Llovd,Rt.Hn. Geoffrey(Sut'nC'dfield)	Proudfoot, Wilfred	Vaughan, Dr. Gerard
Lloyd, Ian (P'tsm'th, Langstone)	Pym, Rt. Hn. Francis	Waddington, David
Longden, Gilbert	Quennell, Miss J. M.	Walker, Rt. Hn. Peter (Worcester)
Loveridge, John	Raison, Timothy	Walker-Smith, Rt. Hn. Sir Derek
Luce, R. N.	Ramsden, Rt. Hn. James	Walters, Dennis
McAdden, Sir Stephen	Rawlinson, Rt. Hn. Sir Peter	Ward, Dame Irene
MacArthur, Ian	Redmond, Robert	Warren, Kenneth
McCrindle, R. A.	Reed, Laurance (Bolton, E.)	Weatherill, Bernard
McLaren, Martin	Rees, Peter (Dover)	Wells, John (Maidstone)
Maclean, Sir Fitzroy	Denton, Rt. Hn. Sir David	Whitelaw, Rt. Hn. William
MoMaster, Stanley	Rhys Williams, Sir Brandon	Wiggin, Jerry
Macmillan, Maurice (Farnham)	Ridley, Hn. Nicholas	Wilkinson, John
McNair-Wilson, Michael	Ridsdale, Julian	Wolrige-Gordon, Patrick
McNair-Wilson, Patrick (NewForset)	Roberts, Michael (Cardiff, N.)	Wood, Rt. Hn. Richard
Maddan, Martin	Roberts, Wyn (Conway)	Woodhouse, Hn. Christopher
Madel, David	Rossi, Hugh (Hornsey)	Woodnutt, Mark
Maginnis, John E.	Rost, Peter	Worsley, Marcus
Marten, Nell	Russell, Sir Ronald	Wylie, Rt. Hn. N. R.
Mather, Carol	St. John-Stevas, Norman
Maude, Angus	Sandys, Rt. Hn. D.	TELLERS FOR THE NOES:
Maudling, Rt. Hn. Reginald	Scott, Nicholas	Mr. Paul Hawkins and
Mawby, Ray	Sharpies, Richard	Mr. Keith Speed.
Maxwell-Hyslop, R. J.