NATIONAL HEALTH SERVICE (SCOTLAND) BILL [Lords] (Hansard, 26 July 1972)

HC Deb 26 July 1972 vol 841 cc1959-2016 1959

§ Bill, as amended (in the Standing Committee) further considered.

Mr. Hughes
We are setting up comprehensive area health boards to run the health services, boards which will have the possibility of supplying health centres, of being the sole agent to build health centres and premises in which many general practitioners will practise. Still we have the fiction that the general practitioner is an independent contractor. I do not believe that any but a small minority of general practitioners believe that the National Health Service is a menace to them or their status as professional medical practitioners.
The whole future of medicine lies in a full-time salaried service, the kind of health service we are trying to achieve, an integrated health service. Therefore, 25 years after the passage of the initial Act, the possibility should have been examined of at least discussing the matter thoroughly with the general practitioners, not of asking their views and leaving it at that. If the Government of the day were prepared to discuss the matter urgently with the representatives of the medical profession, who could in turn consult their members, the younger members in particular, those who know no other health service, those who are coming into the service and whose future lies within the new integrated service, would surprise them by the amount of feeling within the profession in favour of a proper service in which everyone is fully employed on a salaried basis.
I hope that the Government will accept the Clause, so that the investigation for which we asked is carried out to see how and when the ideas about which we have talked tonight and in Committee can be carried into law.

§ Dr. M. S. Miller (Glasgow, Kelvingrove)
I welcome the opportunity to speak in favour of the Clause. In the Health Services in Scotland Report for 1971 we see that in Scotland there are 2,665 principals in general practice. On page 41 there is a table clearly indicating the ratesand kinds of payments made to general practitioners, family doctors, in Scotland. I do not want to go into 1960 them in detail. I can illustrate very well what I want to say when I tell the House that there is a long list of rates and kinds of payment which medical practitioners can receive under our National Health Service. There are six separate categories on page 41, some of them divided into sub-categories. On the same page are other schemes and areas of payment, and on the following page are many forms of payment available to general practitioners under the National Health Service Act.
I mention this because more than £18 million is disbursed to general practitioners in Scotland. That is about £7,000 per annum per principal. We are now talking about the reports for 1971, and there have been substantial increases since then. No doctor would argue with the rather mild contention that this compares very favourably with other professions. I am sure that my hon. Friends will agree that £7,000 per annum per principal in 1971, which has risen to about £8,000 to £8,500 in the current year, compares very favourably with other professions.

§ Mr. Dempsey
In developing this argument, would my hon. Friend refer to the other miscellaneous income which general practitioners receive, for example, the charges for various types of medical lines following examinations or without examinations? I should be most grateful if my hon. Friend would give some information about that element of income.

§ Dr. Miller
I am glad that my hon. Friend has raised that matter. It is a matter between the individual practitioner and the Chancellor of the Exchequer. I do not know the extent to which payments are made in the areas my hon. Friend has mentioned, but in some instances they are considerable and in others they do not amount to very much. Private payments made to practitioners are not included in these figures. I hasten to add that the figures I mention are gross figures because they include payment in respect of surgery premises and ancillary assistance. But they do not include, as my hon. Friend pointed out so well, the private payments which are made.
I am not gainsaying the right of the medical profession to earn this kind of salary. The general practitioner performs a very valuable service to the community in Scotland. There is no 1961 doubt about that. I am not in any way objecting to his being paid properly for what he does. None of my hon. Friends objects to the general practitioner being paid in this manner. But one has to take into account what the GP does for this payment and what we should expect him to do, and what could develop under a salaried service.
What do general practitioners do for the average of £8.000 to £8,500 per annum that they earn? First, as we know, they consult. Patients come to see them in their surgeries. In addition, family doctors are always prepared to make emergency visits even while they are consulting. They also make routine visits. They are prepared to accept responsibility for emergency visiting after their normal routine of surgery consultation and their normal visits. They are also expected to keep up-to-date in then-profession. They are not over-paid for a 24-hour a day job.
The medical profession should be considering ways by which it can take advantage of modern trends in trade union matters. The profession should be considering exactly what it does for its rewards. In my experience, to a large extent younger doctors—those who have graduated within the last 10 or 15 years—have come to realise that, if they contracted with the State and accepted a salaried health service, they would be making a firm basis for the valuable work they do in society and gaining the benefits of conditions of work and service enjoyed by other workers in the social services.
The old objections to a salaried service are rapidly fading in the minds of doctors now practising. The Government should be alerted to a situation in which more and more younger doctors recognise that the so-called contractor element forms a shackle preventing them from performing the work they should be doing to help the community. If a salaried service were gradually introduced for younger practitioners, it would be long before it was accepted by the majority of doctors.
I agree that for quite a time there will be many doctors who will not accept a salaried service and who will say that they will not for any consideration agree to changing their status as independent 1962 contractors. I accept that these people are entitled to their view, but their view is not entirely representative of the profession, certainly not of the younger element in the profession.
10.15 p.m.
It calls for no great imagination to realise that there are distinct advantages in encouraging acceptance in the medical profession of a salaried service in which doctors would no longer each have to provide the separate parts of the service as contractors but in which they would, so to speak, be released from the shackles of the way in which the profession has been harnessed in the past to provide the kind of complete service which it has hitherto supplied.
The same goes for dentists. At present—I take this from a report issued in 1971—there are 1,095 dentists providing general dental services in Scotland. There are attractions in the private practice of dentistry, but, as many of my hon. Friends will know, some of those attractions have been greatly exaggerated in recent years by certain elements in the dental profession, and there is a considerable proportion of younger dentists who would be willing to accept, especially in respect of National Health Service treatment, that there should be a salaried service.
I draw attention next to the position of the hospital consultant. Hon. Members will know of the problem which prevails as between the part-time consultant and the full-time hospital consultant. Suffice it to say that we believe—I am sure that my hon. Friends agree—that the part-time consultant system should be a thing of the past. It is an anachronism. The consultant physician, consultant surgeon, orthopaedic surgeon, paediatrician and the rest should all form part of a comprehensive salaried service within the National Health Service—

§ Mr. Dempsey
Full time, yes.

§ Dr. Miller
—full time. I am glad to have my hon. Friend's agreement. There can be no place for a system under which a group of people devote a small proportion of their time to the National Health Service and a large proportion of their time to lucrative private practice.
1963 I know that some of what I am saying will not be popular with the medical profession, but I am sure that it will not be unpopular on any ground other than the salary aspect of it. Here, perhaps, I may beat variance with some of my hon. Friends, for I believe that a doctor, be he physician, surgeon, paediatrician or obstetrician, should have remuneration commensurate with his value to society and the skill which he can show. I do not object to a high rate of pay. What I object to is the double standard involved—the short cut, the way in which an operation may be performed without much delay as a result of people getting to the head of the queue because they are willing to pay a fee to a consultant who is operating, to a great extent, out-with the National Health Service.
This is an aspect of the reorganisation of the service which is fundamental to the concept of what a health service should be.

§ Mr. Dempsey
I am very interested in the argument my hon. Friend is adducing. It is well known that if people go privately to a consultant they can have their medical examination, analysis and everything else in a matter of days, whereas if they go to the same person employed in the hospital service on a part-time basis they may wait weeks. The solution to the problem is to ensure that priority cases are given urgent attention.

§ Dr. Miller
My hon. Friend raises a point which is of extreme importance in the National Health Service. Although the possibility of people getting to the head of the queue does not apply in respect of urgent conditions, it applies in respect of non-urgent conditions, and most of the operations which are performed are non-urgent. It is wrong that there should be two separate branches of the National Health Service—one which permits a person to go to the head of the queue because he pays a fee to a consultant, and the other in which it is impossible for a person to do that because he cannot afford to pay the fee and therefore must go to the end of the queue and wait several weeks, sometimes months and occasionally years before an operation is performed.
We have to tackle this aspect of the service. If we believe that the National 1964 Health Service was instituted for the benefit of people as a whole, we cannot believe other than that there should be no form of queue jumping or preferential treatment based on people's ability to pay. The only way in which we can obviate the problems which develop in the Health Service as presently constituted is to make it a completely salaried service in respect of the general practitioner, the general dental practitioner and the consultant, whether he be a paediatrician, obstetrician, physician or surgeon.
I commend to the Under-Secretary of State the new Clause which touches upon the basis of the health service in Scotland and, indeed, in the United Kingdom. I know he is a man of very considerable compassion. He followed the proceedings in Committee avidly and answered in a very competent way the points we on this side made to him. I am positive that he himself believes that this is the kind of service which has to be developed and which will be developed before we can truly say that the National Health Service in the United Kingdom and in Scotland is really a national service.

§ The Under-Secretary of State for Health and Education, Scottish Office (Mr. Hector Monro)
I expect the House will have heard that we had a very constructive Committee on this Bill and that with the kind of harmony we had we were able to make a lot of progress. A number of the Amendments which we shall be discussing tonight have been put down by the Government to meet the wishes of the Opposition—and I shall accept one of theirs.
However, I am afraid that this Amendment is one I am not able to accept because it would make a cardinal change in the principles of the National Health Service. In any event, a change of this magnitude should not be made by this Bill, which is concerned with the reorganisation of the Health Service administration and does not seek to change the financial basis on which the service is founded and on which facilities are provided. The Bill is, basically, a Measure agreed between the professions and the Government, and in the light of the previous Government's Green Paper, in which there was no provision made for a wholly salaried service. Indeed, in the 1965 paragraph dealing with the general practitioner service it said: The existing procedures for the provision of professional services and the terms and conditions on which they are provided need not be affected by the change. The change proposed in this Amendment would undoubtedly be resisted very strongly by the medical profession and by the other practitioners, such as the dental practitimners whom the hon. Member for Glasgow, Kelvingrove (Dr. Miller) mentioned and on whom the success of the reorganisation largely depends. I think that it would adversely affect the morale of the professions. If we were to accept the Amendment they would doubt the good faith of the Government's long-term intentions in this Bill.

§ Mr. Dempsey
Can the hon. Gentleman answer just one question, please? Can he say whether he has had any strong representations from the general practitioners objecting to the principle proposed in this new Clause?

§ Mr. Monro
Yes. Indeed I have.
In Amendment No. 3 as well as in this new Clause the Opposition claim, in particular, that the independent contractor status prevents the full integration of the health services. There is no evidence that the special form of remuneration adopted for general practitioners hinders integration in any serious way.
I have noted what the hon. Gentleman the Member for Kelvingrove has said about pay, and particularly the long hours he works, and I am sure that all of us are very appreciative of the general practitioner service. We must also take into account a point which he did not allow for—the long period of training which doctors undertake. I do not think anybody in this country would grudge the medical profession the pay which it receives at present.
10.30 p.m.
The question whether private practice on the part of consultants acts to the detriment of patients or of the NHS was recently considered by the Select Committee chaired by the hon. Member for Wolver Hampton, North-East (Mrs. Renée Short). The Committee concluded that there was no widespread abuse and that on the whole the NHS benefited. The absence of the flexibility provided by part-time consultants would almost cer- 1966 tainly make recruitment to certain posts more difficult.
We have argued many of these points, and it is unnecessary for me to go over them again in depth. I have, of course, taken note of what hon. Gentlemen have said, and I know the hon. Member for Aberdeen, North (Mr.Robert Hughes) holds particularly strong views. But I think all hon. Members will realise that this is a fundamental change that I cannot possibly accept at the moment or in the foreseeable future. With reorganisation on the threshold, this is no time to bring in a change of such magnitude.
I hope that the hon. Gentleman will feel able to withdraw the Amendment.

§ Mr. Carmichael
We had a good Committee stage which went very smoothly. The Under-Secretary of State in replying in Committee raised several points which if he had repeated them tonight might have extended the debate for longer than he wishes. For instance, he spoke of the form of remuneration adopted for the general practitioner and dental services being not so different from that which applies ina full-time salaried service. He was on extremely dangerous ground in talking of consultants in hospitals attached to the National Health Service.
The hon. Gentleman referred to the report of the Select Committee chaired by my hon. Friend the Member for Wolverhampton, North-West (Mrs. Renee Short). There was dispute within the Committee whether the part-time nine-elevenths consultancy type service was necessarily a good thing for the service as a whole. We on this side of the House are unanimous in our desire that ultimately the part-time consultancy service should go.
My view is that we must wait until more general practitioners realise the benefits of a full-time salaried service. They are virtually a full-time salaried service now. More than half their income comes direct from the Treasury in capitation fees. The cheque arrives each month, and they know exactly what they will get. I am sure they would be horrified, as we all would, if the cheque did not come at the end of the month. General practitioners have nothing to lose by ultimately coming into salaried service; on the contrary they have a great 1967 deal to gain. Once they were in salaried service they would no longer be concerned about trying to keep their own little corner going, but would be able to join the rest of us in demanding that the Government devote a bigger share of national resources to health.
For instance, the health centre programme is a great concept, going back to the 1948 Act, which needs to be expanded. We are learning about health centres and the need for certain modifications. We are learning of the dangers of health centres which are too big. We feel that a salaried general practitioner service could help more than the present contractual service. I realise that this would mean putting forward legislation for reconstruction of the service, but it is at least important that we should take this opportunity to air our views on these matters.