LORD HENEAGE rose to call attention to the present position of the Insurance Act and to the fact that no arrangement has been arrived at by His Majesty's Government to ensure the co-operation of the medical profession in the administration of the Insurance Act, and to move to resolve—
That in the opinion of this House, until such co-operation is ensured, the Government will fail efficiently to provide medical benefits in accordance with the law.
§ The noble Lord said: My Lords, since my Motion was put down a characteristic speech has been made by the Chancellor of the Exchequer, who appears to think that anybody who has taken the trouble to look into the Act and suggest amendments to it is guilty of wilful ignorance. I should like, therefore, to allude to one or two of his remarks and show that it is not those who criticise the Act who are guilty of wilful ignorance but some of those who ought to know a great deal better. Your Lordships will remember that on June 12 I moved a Resolution to postpone the operation of the Act. I asked for more time for proper societies to be formed which would be suitable especially for rural labourers domestic servants and seamen. I asked for more time for the Act to be thoroughly understood, and, if possible, amended so as to make it workable. I also asked for more time for the Government to come to an arrangement with the medical profession in accordance with the Resolution passed by the House of Commons on May 1. On a later occasion I called attention to the mendacious and misleading leaflet and its objects, and the privileged position in which certain friendly societies were placed owing to the leaflet and to the pressure and intimidation brought to bear on workers to become members of those societies. As regards the formation of suitable societies, a great many have been formed suitable to the different classes I have mentioned. I should like to specially mention one—the Domestic Servants' Insurance Society. There have also been formed within the last fortnight several rural labourers' societies, a National Seamen's Society, and others, but they will require time to enrol members and give them their insurance cards.
§ When I called attention to the mendacious leaflet I stated what would be the effect of it and of the Post Office notice, but the matter was treated very lightly by the spokesman for the Government., my noble friend Lord Liverpool, on the ground that it was only a matter of the difference between "must" and "should." But what does Mr. Lloyd George tell us himself? Speaking at a packed meeting held on "Joy Day" under peaceful picketing conditions and with no dissent allowed, he told us that over 9,000,000 members were now enrolled. What does that mean, my Lords? It means that nearly 10,000,000 out of the 12,000,000 possible contributors have been already "raked in" under this 532 scandalous leaflet by the approved friendly societies, and that they have doubled their membership since May 31. I think that entirely proves that our opposition to the leaflet and the intimidating notice in the Post Office was perfectly justified. I do not know whether the amended leaflet has ever been sent out, but I do know that the leaflet to which we objected is still in existence, and that the notice is still up in the Post Office. I think it is impossible, after what we were told by Mr. Lloyd George on Saturday, that there can be any doubt as to what was the object of the leaflet or that it has met with the success with which it was intended to meet.
§ Is the Act any better understood now than it was ten weeks ago? I do not think it is. The various pamphlets and leaflets which have been issued have made confusion worse confounded, and for my part I am coining very rapidly to the conclusion that it is much easier to understand the Act than to understand the pamphlets and leaflets, and for the future I shall let the pamphlets and leaflets go by the board and shall endeavour to understand and act up to the Act itself. Mr. Lloyd George complains of our "wilful stupidity," and then he tells us that it is our own fault, and that if we had spent a halfpenny or a penny on a certain pamphlet it would have made everything clear to us. If there is this very intelligible and clear pamphlet, why has it not been distributed throughout the length and breadth of the land by the Insurance Commissioners instead of these trashy pamphlets and mendacious and misleading leaflets? I can tell Mr. Lloyd George the reason, if he likes. The pamphlet to which he alludes was not framed to deal with the colossal difficulties of which the Lord Chancellor spoke in the course of our recent discussion. It was framed in order to popularise the Act, and to popularise, if possible, the Chancellor of the Exchequer. All the difficulties of the Act were left out of account, and that was the reason why, in going by his own pamphlet, he got into so many mistakes last Saturday. I do not advise anybody to read that pamphlet. There are others which are much better if we are to go to privately circulated pamphlets.
§ This Insurance Act when first introduced was brought in for the "promotion of thrift throughout the nation." That was said to be its great principle. But thrift is gradually beginning to be abandoned. 533 The other day the Secretary of the Treasury recommended that to avoid the unpleasantness of being taxgatherers in their own homes employers should pay both their own and their employees' taxes. Since then we have been told that there is another very much simpler plan—namely, to pay your share of the tax and give a shilling a week more to each of your labourers out of which they are to pay the 4d. I do not see that that gets out of the difficulty of becoming the taxgatherer; and I do not see how it promotes thrift, because the labourer instead of paying 4d., would get 8d. profit—that is to say, would be something like 35s. to the good by the end of the year.
The Chancellor of the Exchequer accused us of wilful ignorance. I think he said there was more wilful ignorance about the penalties under the Act than about anything else. He said that all he cared about was to ensure the payment by the employers, and that if the employer did not pay he would be brought to book; but as for trying to penalise the labourer—that was the last thing in the world he would have thought of. In pamphlet marked "A" for employers, which came out early in May under the authority of the Chancellor of the Exchequer, the Secretary of the Treasury, and their allies at Buckingham Gate, there appears this extraordinary paragraph—
A worker who, without reasonable cause, fails to deliver a contribution card when the employer requires it for the purpose of paying contributions or for production to an inspector, is liable, on summary conviction to a fine not exceeding £10.
That does not apply to the employer but entirely to the worker, so that I do not see how he is going to get out of it. And at the bottom of the first page of the notorious leaflet, by means of which the 5,000,000 contributors were "raked in" to the friendly societies, is this announcement in large letters—
PENALTIES.—The penalties for each offence against the Act or the Regulations made under the Act is a tine not exceeding £10.
So much for Mr. Lloyd George's inaccuracies on this point. It shows that other people are ignorant who ought not to be ignorant. The Chancellor of the Exchequer had a great chance last Saturday if he had been a statesman. He could have explained a great many of the colossal difficulties and made it a great deal easier to understand the Act, and he could have suggested amendments which would have made the Act really workable and of benefit to the poor. But he cares only to have his own
way. He prefers claptrap, inaccuracies and abuse. He wants to bring the Act into operation for the personal gratification of himself, and cares nothing whatever how far the Act will be beneficial to those on whose behalf it is supposed to be framed. We who criticise the Act do desire to get the greatest benefit for the people now that it is the law of the land. That is the real difference between us and the Chancellor of the Exchequer—not wilful ignorance.
I notice in the newspapers this morning that a Question was asked in the House of Commons on a subject to which I called attention on June 12 and to which I did not get an answer—namely, whether or not the contributions under the Act are taxes. The hon. Member for Salisbury asked whether the contributions of insured persons are to be construed as past of a contract or as taxes. The Secretary of the Treasury replied—and I am bound to say I cannot understand the answer—
Contributions are payable by virtue, not of a contract, but of a statutory obligation, and inasmuch as the payments inure to the benefit of the person paying them and do not go into the Exchequer they are not analogous to taxes.
I hope this legal definition will be explained by the Lord Chancellor. To me it is worse than Greek. The payments do not inure to the benefit of the employer, out of whose pocket the greater part of them come. Last week there was circulated in the Press the opinion on this point of a very learned King's Counsel, Mr. Shearman, who is reported to have given an opinion in the following words—
The contributions made payable by Section 4 of the National Insurance Act, 191 L, are taxes—
that is exactly what the Secretary of the Treasury says they are not—
A tax is part of the revenue granted to the Crown by authority of Parliament, and the payment of a tax is not a question of contract between the Crown and a subject.
Of course not. But is this contribution a tax On June 12 I raised this very question, and said that the Act is practically a legislative contract between Parliament and the contributors under the Act. The noble and learned Viscount took no objection to that description, nor did the noble Marquess the Leader of the House. I should like to ask the Lord Chancellor whether he agrees with Mr. Shearman or not. If he does, then all the statements of Radical speakers that it is not a new tax are wrong.
§ Now I come to the Resolution standing in my name on the Paper. It is in practically the same words as the House of Commons Resolution of May 1, which was accepted by the Chancellor of the Exchequer and unanimously carried. What has been done in the ten weeks interval to carry it out? If that Resolution was considered necessary ten weeks ago it is more than ever necessary now that July 15 has passed. We have a right to some information from Ministers and should not be left to contradictory statements in the Press. At present we know very little. The position seems to be that the Chancellor of the Exchequer stands firm by the proposals in the Act, and the doctors firmly refuse to accept them. But the House of Commons have unanimously declared that the Act will fail to confer medical benefit until the co-operation of the doctors is assured. That co-operation is not assured; yet July 15 has come and gone. If you study Mr. Lloyd George's apologia which appeared in the Press about ten days ago and also the information which we get from the British Medical Journal it is fair to assume that the Insurance Commissioners apparently admit that the terms of the Act are not fair and reasonable. Well, if they are not fair and reasonable they naturally condemn them. They further admit, we are told, that the remuneration under the Act should be greater than that received under existing conditions from the friendly societies. But it seems that they are as far off a settlement as ever. The Chancellor of the Exchequer has made no suggestion whatever during the negotiations, or so-called negotiations, which have taken place. He only maintains his opposition to what is known as the 8s. 6d. proposal of the doctors and to the £2 limit, and he wants the doctors to leave open the whole question of extras—namely, night visits, mileage and medicine.
§ I wish to say a word as regards the dispensing of medicine. I believe that if the doctors could be allowed to dispense-their medicine they would probably moderate the terms they now ask, and it would be a very great advantage to the poor. It is monstrous to compel poor people in country districts, after they have sent perhaps three or four miles for a doctor late at night when a member of the family is taken ill, to then send perhaps six or seven miles to the nearest town to get the medicine made up. The practice in Lincolnshire is for the messenger to remain 536 at the doctor's house until the doctor has returned from visiting the patient and then the messenger takes back the medicine. If the poor are to have to pay first of all some one to go and fetch the doctor in one direction, and then get somebody else to go seven or eight miles in the opposite direction to get the medicine, the medicine will be very costly before it arrives. Moreover, I think it would tend much to bring the doctors and the Chancellor of the Exchequer together if he would give up the idea that the doctors are not to dispense the medicine. For my part I think it is a very good plan that they should do so.
§ Then there is another proposal—that, if all fails, the sum of 6s. is to be given back to the contributor and he is to find his own doctor. We are told that it is not 6s. to one person but 6s. all round to all the contributors; but when the 6s. is handed back the whole question of general insurance is given up. It is supposed that 4s. 6d. is to be for the doctor and 1s. 6d. for the medicine. Supposing a poor man is taken ill with influenza. Why, the first bottle of influenza mixture would cost a great deal more than 1s. 6d. But we are really in the dark in respect of everything except what we can glean from the newspapers. That is not a satisfactory position. It appears to me that Mr. Lloyd George ignores all the colossal difficulties, and, as I have shown, repudiates his own pamphlets and leaflets. Whilst the whole Act is in chaos there will be the maximum of cost in its administration with the minimum of benefit to the contributors; and the chief principles of the Act—namely, thrift, general insurance and medical attendance—are now abandoned. I beg to move.
§ Moved to resolve, That in the opinion of this House, until the co-operation of the medical profession in the administration of the National Insurance Act is ensured, His Majesty's Government will fail efficiently to provide medical benefits in accordance with the law.—(Lord Heneage.)
THE EARL OF LIVERPOOL
My Lords, as regards the noble Lord's Motion, I am not going to oppose it any more than a similar Motion was opposed in the House of Commons. It is recognised by all that the co-operation of the doctors in the working of the Act is of vital importance, and everything that can be done is being done to secure 537 that co-operation. It does not mean everything, however, if the doctors do not come in. On this question it is well known that there is strong feeling on both sides. The British Medical Association are going to meet this week and next, and it would be undesirable to make any statement in regard to conditions or as to negotiations beyond that which is already known. Sir William Plender's Report will be considered at the forthcoming meeting of the Association, and I would therefore urge the noble Lord not to press for additional information on the question of the cooperation of the doctors as long as negotiations with the medical profession are proceeding in a friendly spirit. As to the question of which the noble Lord gave me private notice—namely, whether or not the contributions under the Act are taxes I am afraid I can give him no further answer than that contained in the reply given in the other House by the Secretary of the Treasury and read by the noble Lord in the course of his speech to-day.
THE EARL OF CAMPERDOWN
My Lords, I must confess to some little surprise at the answer which has just been given. I entirely agree that the co-operation of the medical profession is vital to the successful working of the Act. But how was it that that co-operation was not obtained from the first? What encouragement was given to the medical profession by the Chancellor of the Exchequer? During the last few weeks it has been stated repeatedly in the House of Commons that a settlement with the medical profession had nearly been reached. I wish to know what foundation there was for that assertion. So far as can be gathered from the newspapers the medical profession have never budged an inch from the position which they at first took up. As the British Medical Association are about to meet and to fully discuss these matters the noble Lord who has just replied for the Government felt that it would be indiscreet and unwise to make any further statement at present. I wish the noble Earl had acted as ear-flapper to the Chancellor of the Exchequer on Saturday last, when Mr. Lloyd George made most positive statements both as to what had happened and as to what he was determined not to do. He made statements of a nature from which Lord Liverpool wisely recoiled. As a matter of fact, there is no doubt whatever that so far as the medical profession is concerned matters are at a deadlock.
538 Then take the question of sanatoria benefit. I do not know whether any of your Lordships have seen Memorandum No. 112, which has been issued by the Insurance Commissioners, and is the joint production of the Commissioners and the Local Government Board. From beginning to end this Memorandum is a complete confession that the administration of sanatoria benefit, whether you regard it as a. permanent institution or from the point of view of how to set the Act in operation, has entirely broken down. In this Memorandum it is pointed out that—A complete scheme for dealing with tuberculosis in any area will fall naturally into two parts, called for convenience the 'dispensary unit' and the sanatorium unit' respectively.With regard to the dispensary unit, they say—The term dispensary' is used in this connection in a special sense as a local centre of expert diagnosis and treatment. As is pointed out in the Report of the Departmental Committee, the essential element is not the building but the expert medical officer to be designated the `tuberculosis officer '—No tuberculosis officer, so far as I know, has been appointed—He should be a person of such experience, attainments, and professional status as are likely to command the confidence of the medical practitioners of the district, on whose effective co-operation the success of the whole scheme must largely depend.In the present temper of the medical profession is it likely that you will find these tuberculosis officers, and is it likely that the medical profession will give them their assistance? At all events, that is more or less beside the question, because they have not been appointed.
The next point is the "sanatorium unit," and there the Commissioners admit at once that these public sanatoria do not exist and cannot for a considerable time. This is what they says—For the reasons already slated it is evident that in most districts the system of dispensaries, sanatoria, will not lie available for some time after time commencement of the Act.No, they are not available and cannot be available, because the Provisional Committees which are now in existence have no power to commit a district to the adoption of any particular plan. Having said that the dispensaries and sanatoria cannot be found, they proceed to what is really the most imporant part of the matter—namely, how they propose to deal with it now. I 539 invite your Lordships' attention to this extract—In making the necessary arrangements for administration at the commencement of the Act the Insurance Committee should, at an early date, place themselves in communication with the county or county borough council with a view to the medical officer of health attending a meeting of the Committee, as provided in Section 60 (2) of the Act, and advising them on the necessary arrangements.Therefore they begin by falling back on the county or county borough council and using their medical officers. It is on these medical officers apparently that they have to rely. The medical officer is to advise them on the method by which persons applying, for sanatorium benefit should be medically examined, and, secondly, as to the institution and means of treatment available for patients. I should have thought that was the business of the Insurance Commissioners themselves. The Memorandum proceeds—When a provisional scheme of arrangements has been arrived at the Insurance Committee should submit their proposals to the Commissioners for approval.So that in every single county before you can proceed to deal with any of these cases of tuberculosis you have to obtain the approval of the Commissioners themselves. The Memorandum goes on—As regards the first of the above matters, viz., the method of medical examination and report, the Commissioners have consulted the Local Government Board, and are of opinion, the Local Government Board concurring, that the following procedure will enable the Committee to deal with the administration of the benefit, so far as it can be dealt with at the outset, in those districts where a tuberculosis officer has not been appointed"—that is, everywhere—and the agencies available are very limited. It is suggested, briefly, that in these areas the medical officer of health of the county or county borough might properly, if on the Committee's application the Council agree to such arrangement, be appointed to act temporarily as the expert adviser of the Committee in dealing with individual applications for sanatorium benefit.The Committee are therefore absolutely dependent on the medical officer of the county or county borough. The Memorandum proceeds—Where such an arrangement is made, an insured person who believes himself to be suffering from tuberculosis and wishes to obtain sanatorium benefit would apply to the Clerk (or Acting Clerk) of the Insurance Committee.I wonder who that is going to be. Is he to be the clerk to the county council? 540 They have already taken the medical officer. Whoever the clerk is, he will furnish the person with—a blank form of medical report, which the patient will 1.e advised to take to his ordinary medical attendant or any other medical practitioner he may prefer.Then the Memorandum states that—A fee should be paid by the Insurance Committee for the examination and report, and the Commissioners are advised that a fee of 5s. will be regarded as suitable for this purpose.That may or may not be agreed to by the medical officer in question. But when he has made his report—On his advice the Committee will select the cases that stand most in need of sanatorium benefit and decide what hind of treatment should be provided in each case.That is substantially the whole provision by which it is proposed to work this sanatorium benefit at the commencement of the Act. In other words, there is no central administration at all. I can assure your Lordships that this Memorandum from beginning to end is nothing but a confession of failure. No doubt the Commissioners have been overworked. We were told that sanatorium benefit must be started at once. Well, you cannot start it at once. Is not this another proof of the haste and undue precipitation with which this Act, I will not say has been brought into operation, but has been nominally started? As to what may be the ultimate result of the conference between the Chancellor of the Exchequer and the medical profession of course we know nothing. At the same time, I think that the Chancellor of the Exchequer would do well, when he professes to be negotiating with the medical profession, not to deliver such a speech as he did on Saturday last.
§ EARL BEAUCHAMP
My Lords, I am glad to think that our action to-night is likely to be more harmonious than the speeches to which we have listened, because although noble Lords opposite and ourselves hold different views on the subject under discussion we are going to agree unanimously to pass the Resolution before the House. I think that relieves me of the necessity of entering into anything controversial on the matter. Nothing could be more unfortunate than to attempt to discuss, on the one side or the other, matters which ate still the subject of negotiation between the two parties, and if I refrain from answering 541 the attacks made upon my right hon. friend I hope the House will not imagine that it is because I have not an answer to give. I know that noble Lords opposite are just as anxious as we are that arrangements should be come to with the medical profession. Therefore I will, with your Lordships' permission, say very little on that particular point. The noble Earl who has just sat down complained that the benefit of sanatorium treatment would not be immediately available to those who needed it. I am sure it will be a satisfaction to those who are responsible for the Act to know that the noble Earl is so very anxious that the benefits should become available at once and that his complaint is that they are not available yet. I confess I am not wholly able to agree with what seemed to me to be at any rate the result of his criticisms with regard to the medical officers and the fact that their advice will be sought by these Committees. These medical officers clearly have special knowledge of the circumstances of the county or county borough in which they themselves live, and they will be able to give to the Committees advice which at the beginning will be particularly valuable to them, and more valuable than the advice would be of an officer specially appointed and not acquainted with the district. Because this matter is not treated wholly from the central authority in London, that is not an admission of failure. From the beginning it was never contemplated that the Act should be centrally administered from London, but that its administration should, as far as possible, be decentralised in the various districts.
THE EARL OF CAMPERDOWN
I stated that this Memorandum is a confession that there are no means of bringing the Act into force, either as a permanent institution or at its first commencement.
§ EARL BEAUCHAMP
Among the various points which the noble Earl brought forward to show that the Act had not been brought successfully into operation he instanced the fact that it was not going to he administered centrally, and I was pointing out to him that it was never intended that the Act should be administered from a central authority in London. Lord Heneage complained very much of the attitude which the Chancellor of the Exchequer had taken up on the question of 542 allowing doctors to dispense. In reply to that I would point out that there is power under the Act for the Commissioners to permit the Insurance Committees in exceptional cases to arrange with medical practitioners for the supply of medicines and drugs.
§ LORD HENEAGE
What I object to is that this is only to be in exceptional cases. I maintain that in country districts generally it is absolutely essential that doctors should be empowered to dispense.
§ VISCOUNT MIDLETON
My Lords, if the noble Earl is going to take his stand, has he has done, on the delicacy of the negotiations, which a discussion in this House might prejudice, he ought to be in a position to assure us that the language which was used by his colleague, which has accentuated these differences, will not be continued. The failure to come to an agreement is not due to criticisms from us but to the extraordinary and unprecedented language used by the Chancellor of the Exchequer. At the Opera House he referred to the action of the Royal Colleges of Surgeons and Physicians—bodies of scientific men who represent a profession which, with the exception of the clerical profession, has done more unpaid work and displayed more generosity towards the poorer classes in this country than any, other—as an example of "rude ineptitude which is utterly without parallel, fortunately, in the history of the country," and "behaviour so extraordinary on the part of great societies as to absolutely unfit them for the position they assume." I protest against our being asked to abstain from criticism which might embarrass the Government in carrying out a great national measure while the author of the measure is himself to be allowed complete latitude to attack everybody and to foul his own water.
I am most anxious to see this Act put into operation as rapidly as possible, and I have not the slightest sympathy with those employers who have said that they will not work the Act and will rebel against the law. I, and I believe I can speak for every one on this side of the House, desire to conform to the law, and to show those whom we employ how they can get the best advantage out of the Act. But in the speech to which Lord Heneage referred the Chancellor of the 543 Exchequer made an attack on the whole body of employers, who, he told the employees, were endeavouring to do them out of the benefits of the Act. That is a most gross insinuation. I will tell the noble Earl the position in which I find myself at this moment. A labourer of mine comes to me and says he has paid under the Act and is entitled to sanatorium benefit for tuberculosis. I ask the noble Earl, How, when the Advisory Committee is not constituted, when the doctor has not been appointed, when the machinery is not in existence—how is that man to have the benefits of the contract which Parliament has made for him and the payments for which have been enforced from him?
One other point. I do not think that the Government have realised that the mere fact of giving a man a money payment instead of the medical benefits which were promised is not in any respect an equivalent. The medical benefit at present may work out, under some scheme, at 6s. a year. If you pay that 6s. to a man who is ill, it will be eaten up in the first few hours of his illness. But that is not all. The medical benefits are calculated on preserving a man in medical attendance for the rest of his life. If you pay it in money to the individual you can only pay it up to the age of seventy, and a man who conies in now at the age of sixty-seven or sixty-eight, unless some arrangement is made with the doctors, will terminate his medical benefit at seventy and will remain without it during the years he most requires it. I hope that if my noble friend rests satisfied by the acceptance of this Motion it will not be held that this brief discussion exhausts the points we have to make. I personally would wish that everything should now be done to smooth the path of the measure. I cannot help registering my conviction, having had myself in the past some official relations with the heads of these great Colleges, that there is no body of men more willing to meet the public interest in the most generous manner and with the most complete self-sacrifice, and I venture to say there is no man in your Lordships' House who does not feel that such language as Mr. Lloyd George has used about the doctors, coming from a man who is both a politician and a statesman, is neither politic nor statesmanlike.
§ On Question, Motion agreed to.