§ Order of the Day for the Second Reading read.
My Lords, I am afraid this Bill will not add to the exhilaration of the proceedings this evening, but it is nevertheless an important addition to a very complicated scheme. The only advantage I have in dealing with it is that it is an agreed measure between the two parties chiefly concerned and, therefore, I hope it will not need a very prolonged examination. The great insurance scheme, since its inception in 1911, has, I think, been admitted by all Parties to have been a considerable success. There are now about 16,000,000 insured persons, contributing in all about £25,000,000 a year, and the approved societies distribute about £30,000,000 a year in benefits. In this country, where the traditional domestic habits are so conservative, it is obvious that no scheme of this magnitude could really succeed unless it won the confidence and commanded the co-operation of the strong voluntary insurance organisations and the professional associations which existed before the State came into the insurance field. Apart from the question of whether any particular reform from the point of view of Whitehall might be desirable, it would be sheer folly for the Minister to attempt to ride roughshod over the susceptibilities either of the vast number of insured individuals or of the medical profession who administer the scheme.
I mention those generalisations because most of the criticism which has been so far directed against this Bill is not directed against what it does, but against what it does not do. My right hon. friend the Minister of Health has proceeded on the lines of doing as much as he can to simplify administration, to extend the advantages of medical and other benefits, and also to prevent abuses, without giving offence to suscepti- 351 bilities. Also he has naturally taken into consideration the very important question of expense, for in the present depressed state of industry he has not considered it at all advisable to add to the already considerable burdens occasioned by the social services.
The Bill before the House is based principally on the recommendations of the Royal Commission set up in 1924 which was presided over by the late Lord Lawrence of Kingsgate, whose death everyone, and not least my right hon. friend, so deeply deplores. That Commission sat for a year and a half, and after the examination of some two hundred witnesses produced their Report in 1926. Subject to the two considerations which I have mentioned I submit that the Government in this Bill have gone as far as they possibly could to follow those recommendations. To any one reading the Bill it might not, I am afraid, appear that the drafting makes for very entertaining, or even instructive, reading, but there is a reason for the numerous references that occur in the Bill, in that it is proposed, if this Bill becomes law, to introduce a consolidation measure at the first possible opportunity. But though this method of drafting may make the Bill difficult to understand, there is a most clearly worded explanatory Memorandum, which is on the Table, and I hope that, in view of that, it will not be necessary for me to go through the whole Bill point by point. To do so would take considerable time, but I might perhaps touch upon Clause 1 which is, I think, the most important in the Bill.
This is explained in the Memorandum, but, to put it very simply, I may say that at the present time a man who is unemployed cannot pay his contributions and therefore falls into arrears. He consequently loses some of his cash benefit, according to the length of time that he is in arrears, and he loses the whole of it in twelve months. The medical benefit remains available for a further period of nine months. It appeared to the Royal Commission, no less than to my right hon friend, that it is unfair that a man who is genuinely unable to obtain work should be further afflicted at perhaps the most critical moment by the deprivation of sickness benefit, particularly in view of the fact that genuine unemployment 352 is the very reason why he is entitled to unemployment insurance benefit. What this Bill, therefore, does is to lay it down that a certificate from the employment exchange to the effect that a man is genuinely unemployed will entitle him to the same benefits as if he were having his card regularly stamped up to a period of one year and nine months, and up to a further period of one year on a reduced scale.
Further concessions are made in the case of a man who is unable to obtain employment after reaching the age of sixty, in order to secure him against the possible loss of title to his old age pension at the age of 65. It is obvious that these changes will involve expense, and this expense is estimated at £680,000 a year, but the societies, on whom the additional burden would otherwise fall, are to receive assistance to the extent of about £500,000 a year from the money derived from the sale of insurance stamps for which no claim is made, thus leaving a comparatively small additional burden on the benefit funds of societies.
Another great improvement is made by Clause 11 of the Bill, which provides for the setting up of a special insurance section of the Deposit Contributors' Fund, by means of which insured persons who are unable to obtain admission to an approved society by reason of ill-health can obtain all the normal benefits of the Act on a basis of mutual insurance, instead of being restricted, as hitherto, to such benefits as can be provided out of their contributions only. That amounts to creating a new society specially for the bad lives, which in certain circumstances is to be helped from the Central Fund. Another important clause is Clause 16. This empowers the Minister to make Regulations with respect to the administration of additional benefits in the nature of treatment such as dental and ophthalmic benefits. About £4,000,000 a year is now being spent by approved societies on additional benefits of this character, and it is important that the Minister should be able to make Regulations designed to secure that this large sum of money is properly administered to the greatest possible advantage of the insured person.
It is intended that these benefits shall be administered by co-operation between the approved societies and the dentists 353 or other professional bodies by whom the services are provided. The Bill makes it possible for dental and ophthalmic treatment to be given in suitable cases through clinics, but it is expressly laid down in Clause 16 (3) that insured persons are to have complete freedom of choice as to the practitioner or clinic from whom, or in which, they are to obtain the treatment they require. The administration of these benefits by co-operation between the societies and the professions is the only satisfactory method while the benefits remain additional benefits which are to be granted only by particular societies at their discretion. But I am authorised by my right hon. friend to give an assurance here that if at any time any of these benefits should become normal statutory benefits available to all insured persons, their administration would be transferred to the insurance committees or other local bodies responsible for the administration of medical benefit. Clause 20 is a small clause which brings within the scope of health insurance and the contributory pensions scheme two new deserving classes of the community—namely, small contractors who themselves are engaged in manual labour, and share fishermen. These persons have hitherto been shut out owing to the nature of their employment.
Considering the full explanation that is given in the Memorandum I do not propose to go further over the Bill. It is not in any sense, of course, a final solution of the whole problem. There have already been seven or eight amending Acts of a major character since the original Act was passed, and no doubt there will be many more. The conditions affecting health, such as the housing situation and the employment situation, are continually varying. The unification of the public health services is an object not only expressed by the Royal Commission but desired and expressed by my right hon. friend. But it must be remembered that unification can only be obtained by a modification of the laws affecting a large number of different subjects; for instance, the factory administration, the Workmen's Compensation Acts, the Education Acts and a considerable proportion of the Poor Law administration. In view of the imminence of Poor Law reform and for various other reasons, my right hon. friend took the view that the time had 354 not come for the transference of the duties of local insurance committees to county and borough councils. This would be only an instalment of the unification plan and he did not think that such unification should be carried out on piecemeal lines.
Another recommendation of the Royal Commission which my right hon. friend would much have liked to see passed was the recommendation that the surpluses of approved societies should be partially pooled in order to enable specialists' services to be made a statutory benefit, but in this Bill that is legalised as an additional benefit. The suggested pooling was the only method whereby the necessary funds could be obtained for financing such a scheme without recourse to the Exchequer. The approved societies have, however, set their faces with such determination against this method that my right hon. friend has been prevented from making this necessary and desirable extension. Apart from these omissions, which of course are important omissions, the Bill carries out many of the recommendations of the Report. It will remove, I submit, many considerable grievances and will simplify administration to a very large extent. The extent to which it encroaches on public funds is very small. In submitting the Bill to your Lordships for a Second Reading, I realise, of course, that a great deal more could be said, although it must be remembered that this is a Bill dealing principally with machinery and that it does not pretend to be a measure to reform the whole of the national health insurance scheme. If your Lordships would like further points to be elucidated His Majesty's Government will make any endeavour they can to give information to those who desire it. I beg to move.
§ Moved, That the Bill be now read 2a.—(Viscount Gage.)
My Lords, at this hour and before an audience in your Lordships' House so sparse it would be wholly unnecessary for me to attempt to make a lengthy speech on this Bill. I can only hope that neither this Bill nor the interest on the Benches opposite can really be taken as symptomatic of the interest of the Conservative Party in a subject so great as that of national health insurance.
The question of proportion does sometimes come in both in interjections as well as in numbers. I can reassure the noble Viscount, Lord Gage, by saying that it is not my purpose to attack the Bill or even to press him to answer questions on what is admittedly an extremely complicated subject. I think we may feel that he has very conscientiously endeavoured to explain the various clauses of the Bill. He has, indeed, been so modest in his claims for the Bill that he has really disarmed whatever criticism one might have brought. I have not noticed in the remarks with which he favoured us anything of that self-complacency which was so noticeable in Ministers in another place. They seemed to think that this Bill was a wholly admirable and wholly complete affair. Not so the noble Viscount. But he is, perhaps, putting it a little high when he says that this is an agreed measure. Technically, perhaps; but not if that is to be taken as meaning that those with whom I am associated can, in any sense, be said to be content with the measure.
He was perfectly correct in saying that the criticism is not so much with what this Bill does as with the fact that it really does not attempt to do very much. It is, as the noble Lord, Lord Bradbury, said on the measure we were discussing previously, a very small measure and I think it is to be regretted that more was not attempted. The noble Viscount reiterated that the Minister of Health had done as much as he could, but no full explanation has been given either here or in another place as to why the powers of the Minister of Health, with a large majority there and here, are so limited as that, and why it should not have been possible to take a much bigger view of the whole question of national insurance. That is one of the difficulties in speaking at all upon the Second Reading of the Bill. I have always understood that was an occasion for dealing with principles, but it is difficult to discover in this Bill any principles at all. It is solely concerned with minor alterations in machinery, and I think it is all that it claims to be concerned with. As such it is to be welcomed, but also criticised because it is so extremely limited. 356 We accept it with pleasure for what it does. I am especially glad to note the prolongation of insurance, to which the noble Viscount made reference, in Clause 1, and also the free choice given under subsection (3) of Clause 16.
When one has said that it is an improvement in machinery which is to be welcomed I think all has been said for the Bill that can possibly be said, and, indeed, it is all the noble Viscount said. He commented upon the drafting in terms so severe that he really leaves nothing for critics of the Bill to say on that subject. It is a Bill drafted so as to be, according to its Memorandum, intelligible, but at the same time it is a most glaring instance of legislation by reference, as bad as those which have so often come before your Lordships' House. It is not my purpose to take up any more of your Lordships' time, however. I regret greatly that there has been no advance at all as to specialists' services. I regret particularly that the great question of maternity mortality has been left wholly untouched. In my view one of the most important branches of the whole of national health insurance is that dealing with maternity benefit and maternity mortality. I should have liked to see something more done emphasising the necessity for attendance in maternity cases. However, as the noble Viscount reminded us and repeated more than once, this Bill cannot possibly be said to be final. It is a small instalment, it is an improvement of machinery and, as such, we take it and as such we are glad to have it placed upon the Statute Book.
§ EARL BEAUCHAMP
My Lords, the last Bill which was discussed in your Lordships' House dealt with a very abstruse and difficult question and I think we may make the same remark with regard to the present Bill. This Bill is also of a complicated and technical nature and, by just glancing at the arrangement of clauses, your Lordships will see how full it is of detail. A Second Reading debate is not, as the noble Lord who has just sat down said, an occasion for discussing detail. Therefore what I have to say to your Lordships this afternoon is rather in regard to the principles which underlie the Bill. I am very glad to see that His Majesty's Government take an interest in this ques- 357 tion. Some of us remember the time when the Insurance Bills were first introduced and processions of parlour maids were organised to say that they refused to lick stamps for Mr. Lloyd George. The present position is a great advance upon that and I am pleased to know that His Majesty's Government now welcome the institution of the great Insurance Acts and that they are anxious to make them a really integral part of the national life.
In so far as this Bill is a measure of their repentence in regard to that I welcome it, but, as the noble Viscount who introduced the Bill with his usual clarity remarked, and the noble Lord who has just spoken said, our complaint of this Bill is that it does not go far enough. That is not an uncommon complaint to make of Bills produced by His Majesty's present Government. Their Bills do not generally go far enough. The idea was that this Bill should really carry out as many as possible of the recommendations of the Royal Commission. There were 122 recommendations made by the majority of the Commission, but the Bill only contains 32 out of those 122 recommendations. The chief things which they recommended were an extension of sick benefits to the dependants of insured persons, the provision of maternity benefits and the establishment of a new service under which an insured person might have the attention of a specialist and dental treatment. Not one of those promises has been fully redeemed, and the problem has hardly been touched at all.
There is no time to deal or grapple with the heartrending tragedies of maternal mortality to which the noble Lord referred! I do not know that there is anything more important to-day in the matter of insurance than this question of maternity mortality which really ought to be dealt with. And of course no attempt has been made to return to the coffers of the insurance funds the money taken from them by the Act of 1926. And very remarkable the figures are. The total amount available for investment by these societies was in 1925 £8,000,000. Last year they only had £200,000 left to invest—200,000 instead of £8,000,000. Now when the Royal Commission recommends that the maternity cash benefit should be extended to medical and mid- 358 wifery services we find that no mention is made of the money taken then by the Government. No part of it has been restored. It is impossible really to look upon this Bill as being an entity. It is part of the general policy with regard to insurance carried out by His Majesty's Government, and, although perhaps in these circumstances we could not have expected them to carry out all the recommendations of the Royal Commission, those of us who listened this afternoon to what was said by the noble Viscount would have been glad to hear more sympathetic references to the various recommendations of the Royal Commission and to have heard some hopes held out to us of the possibility of carrying out more of those recommendations in the immediate future.
I am bound to say that I do not think adequate justice is done to the insured people of this country and will not be done until the money which was taken from them has been restored. Although noble Lords opposite take full credit and deserve full credit for the pensions they have given to widows and orphans, yet we are bound to remember that the larger part of the money which they used for that purpose was taken from the insurance funds. I hope that the noble Viscount will feel himself justified in representing to his right hon. colleague the anxiety of this House for a real amalagmation of the whole system of insurances. I trust that the noble Viscount will feel justified in saying that he heard from certainly one or two colleagues in this House a hope expressed that the matter should at any rate be taken into grave consideration and that we should be given some assurance that the time is not far distant when something will be done to amalgamate all these confusing and different things into one organic and complete whole.
My Lords, this Bill as far as it goes certainly improves the great system of national health insurance and for that reason I welcome it, but I regret that the Government have not had the courage of their convictions in regard to some of those extensions of medical benefit which on all hands are regarded as urgently necessary. Many of those extensions must properly await more prosperous times, but the Royal Commission has pointed out ways 359 in which others could be carried out without bringing any additional funds into the national health insurance system. The Commission reported:—That while it has been inevitable hitherto that medical benefit should be confined to a general practitioner service, this limitation has detracted from the value of the benefit and its removal is urgently desirable.The extension which the Royal Commission placed first in order of urgency was the inclusion of specialist services and the Minister of Health has stated in another place that he holds very strongly that the provision of a specialist service is the greatest improvement that could be made at this stage to the general scheme of national health insurance.
The noble Viscount has explained that the Minister did not feel it possible to include this extension in the Bill because the Royal Commission's recommendation that the cost should be met by a partial pooling of surpluses was opposed by the approved societies. Whilst admiring the very efficient way in which the approved societies have carried out the administration of the cash benefits under the Act, one cannot overlook the fact that the interests of those who in practice control some of the societies are not by any means limited to the provision of national health insurance benefits. For instance, the national health insurance connection of the large industrial approved societies, covering many millions of the insured population, undoubtedly serves as an introduction to other and more profitable forms of insurance. Such large societies not unnaturally tend to accumulate the largest surpluses and can consequently give more additional benefits, in that way attracting more members.
It is my personal opinion that when those who in practice control such societies are considering any question of the pooling of surpluses, it would be beyond human nature not to have present in their minds that any such proposal must tend to decrease their advantages in competing for profitable commercial in- 360 surance business as well as national health insurance business. In those circumstances, remembering that approved societies claim to speak for a large part of the electorate, it needs a strong Government, to run counter to their wishes, especially when a General Election is in sight. I regret that the present Government, whilst agreeing with the Royal Commission's recommendation as to the inclusion of specialist services, have not had the courage to embody it in the Bill. Perhaps I am not wrong in interpreting some remarks of the Parliamentary Secretary in another place as tantamount to an intimation that after the General Election the Government may have the courage of their convictions. If, at the same time, the Government will tackle the vexed question of co-ordination of the health services of the country it will have an arduous and difficult task, the successful accomplishment, of which will do much for the health of the nation.
There is one other short point in regard to Clause 16. Under the present arrangements for medical benefit the insurance committee has to set up statutory subcommittees to investigate complaints concerning the services included in medical benefit, whether relating to doctors or chemists. These medical and pharmaceutical service sub-committees do very useful and important work. Complaints of this nature can only be investigated satisfactorily locally, and I trust that the noble Viscount will be able to give some assurance that provision for similar machinery for investigating complaints in regard to any such local services will be made, whether those services are statutory or additional benefits. In particular I hope that the noble Viscount will give some assurance that insurance committees will be required to set up a dental service sub-committee on the same lines as the medical service sub-committee.
§ On Question, Bill read 2a and committed to a Committee of the Whole House.
§ House adjourned at a quarter past seven o'clock.