§ LORD DERWENT had given Notice that he would move to resolve, That, in view of the fact that the medical provisions of the Beveridge Plan, as it now stands, concerning the future status of doctors and the medical treatment of the population in general do not appear to be designed to further the best interests of British medicine or of the population, His Majesty's Government should not adopt them without careful examination.
§ The noble Lord said: My Lords, in view of the evident fact that a certain element of leisureness which at least seemed to characterize your Lordships' debates up to the outbreak of war has now disappeared, and that there is an increasing and welcome tendency, doubtless induced originally by the winter menace of the black-out, to telescope oratory into as short a space as possible, I am happy to say that my speech will not be long. While my principal intention in rising this afternoon—namely, to criticize the medical provisions of the Beveridge Report—finds so far as I can see no obstacles in its way and continues as entire as it began, my secondary intention, which was to draw attention to what appeared to be, on closer examination, an attempt to sidetrack, or rather to bypass, as we now say, the liberty of the individual, has become more or less invalidated by the debate which took place in your Lordships' House on May 26 on the Motion of the noble Lord, Lord Elton. Everything that I should like to say or could have said on the subject of the dangers of excessive planning and State control were said that afternoon by the noble Lord himself, a great deal better than I could say them; and so I am able to confine myself to the narrower and more precise aim of my Motion—a relief in any case for myself and doubtless also for your Lordships. 730 The aim is to suggest that the medical provisions of the Beveridge Report, as set out in its Assumption B, are virtually a Trojan Horse which the Ministry of Health are attempting to introduce into the camp of the medical profession, and that His Majesty's Government should think twice and even thrice before countenancing this; and, since neither the medical profession nor the public as a whole would stand to gain by such a procedure, to press forward as soon as possible for a correct vision of what is happening.
The Beveridge Report as a whole has been amply debated in your Lordships' House no longer ago than the month of February and I have no desire, as you may well imagine, to go over the old ground. I will merely observe in passing that no more than most people should I dream of attacking its ethical principle. I am merely concerned at the moment with the medical aspect of it, an aspect which was dealt with at some length during the February debate by the noble Viscount, Lord Dawson of Penn. I will confine myself on this occasion to reminding your Lordships that Assumption B of the Plan is based on the view that it is
a logical corollary to the payment of high benefits in disability that determined efforts should be made by the State to reduce the number of cases for which benefit is needed";
it is a logical corollary to the receipt of high benefits in disability that the individual should recognize the duty to be well….
A comprehensive national health service is therefore envisaged which will ensure that for every citizen there is available whatever medical treatment he requires in whatever form he requires it; the assumption that this is necessary being in accord with the definition necessary of the objects of medical service as proposed in the Draft Interim Report of the Medical Planning Commission of the British Medical Association.
The drafters of the Report then proceed to point out that most of the problems of the organization of such a service fall outside the scope of the Report, and at the end of their review of the proposals involved they state, it is only fair to point out, that it suggests the need for a further immediate investigation, in which the finance and the organization of medical services can be considered
together, in consultation with the professions concerned and with the public and voluntary organizations which have established hospitals and other institutions. I mention this in order to indicate that if we are dealing with anything resembling a wolf in sheep's clothing, which I should be myself loath to believe, the clothing at least has been carefully draped, with the possible exception of one corner where we have the impression that something sombre might be seen showing through, a corner which can be found in paragraph 431 of the abridged version of the Beveridge Report from which I cannot refrain from quoting the following passage:
If a contribution for medical treatment is included in the insurance contribution, contributions will cover not ninety per cent. of the population … as is assumed … but one hundred per cent. of the population. This will not, of itself, put an end to private practice. Those who have the desire and the means will be able to pay separately for private treatment, if the medical service is organized to provide that … But no one will be compelled to pay separately. The possible scope of private general practice will be so restricted that it may not appear worth while to preserve it. If, therefore, it is desired to preserve a substantial scope for private practice and to restrict the right to service without a charge on treatment to persons below a certain income limit, it will not be possible to include a payment for medical service in an insurance contribution which all are required to pay irrespective of income.
§ I leave your Lordships to meditate on this passage which seems to me, personally, full of significance, and I will pass on to what, as far as I can see, has actually occurred since the Report appeared. On May 16 the Deputy Secretary of the British Medical Association addressed a special meeting of the members of the Metropolitan County branch of the Association on the tentative proposals of the Government for implementing Assumption B of the Beveridge Report and his address, I should add, was fully reported in the British Medical Journal of May 22. Dr. Hill, the Deputy Secretary, began by saying that non-committal discussions were taking place between officials of the Ministry of Health and representatives of the medical profession. Before long a White Paper embodying the Government's tentative conclusions would be published, and in the light of the consideration by the public and by interested bodies the Government would proceed with legisla- 732 tive preparation for a comprehensive medical scheme at, or soon after, the end of the war. These confidential discussions had received attention in the Press—a sentence which I enjoy—and what was in the Government's mind had been revealed in the Daily Express and in the Evening Standard. In the circumstances he felt compelled to tell the meeting frankly the substance of the exchanges.
§ What the Ministry had put forward were, so far, non-committal suggestions but they represented the workings of the Ministerial mind. On the "dusty subject" of administration the Ministry rejected the conception of a corporate body preferring departmental control under the political leadership of the Minister. The latter proposed that general practice, at least in areas of considerable population, should be based on health centres where—although this was rather vague—such local authority clinical work as normally came within general practice would also be done. Believing that health centres should be the basis of the service and that competition between doctors for patients under the roof of the centre was undesirable, the Minister proposed that, in the main, general practice should be conducted on a salaried basis. Those now in general practice would enter the service if they chose, either as whole-time or part-time officers; in the latter case they would engage in private practice among that section of the community which, although entitled to State services at the health centre, preferred to consult a doctor privately. New entrants would have no choice except between whole-time salaried service and staying out (a curious instance, I suggest, my Lords, of possession being nine points of the law). The proposals included compensation for loss of practice and Dr. Hill then proceeded, apparently with some unwillingness, to mention the salaried scale, which eventually, after eighteen years, would rise to £1,200.
Having sketched the proposals Dr. Hill proceeded to ask, "Why the hurry?" and suggested that if the Government were pressing forward with such energy one section of the Beveridge proposals it might be that they were anxious to do something, and found a body of 50,000 men and women comparatively easy to handle, but in his view the fact was that the Government had decided that before the
major structure of the security scheme could be elaborated, it was necessary to control the medical profession so that certification could be controlled.
Our answer is obvious; the doctor's job is to decide whether a man is fit for work, no matter whether the cash value of his certificate is five or fifty shillings a week.
I omit, for brevity's sake, Dr. Hill's comments on the absence of any apparent intention on the Ministry's part to bring in all the scattered medical services in its departments into a co-ordinated scheme, and I conclude with his summings up:
Before a single health centre had been built, let alone tried out, the Government proposed to recast medical treatment and place it in toto on a health centre basis. They declared the health-centre method to be inconsistent with free competitive practice, but they showed great zeal for the salaried method of service before one health centre was in being! This had been described as the translation of a free profession into a branch of local government service. Whatever might be thought about methods of remuneration, as a profession they could not accept such translation of status. Central and local government might be a sound and delightful theoretical concept of political science, but some of them knew from experience that the calibre of membership of local authorities would not justify the handing over to them of personal, domiciliary and other medical practice.
Dr. Hill concluded by reading some paragraphs from the letter sent to the Minister by the Representative Committee, in which the latter suggested that the only really effective way to deal with the whole problem would be to remove it from the ambit of the present discussions and place it before a Royal Commission. He ended with the following sentence:
Let us await the Government's White Paper. Trust the people who are doing the talking for you, and hold your forces until the time comes, as it may come, for a fight.
So much for the attitude of the British Medical Association. What, then, of another very important organization, the British Hospitals Association? Frankly, I am not in possession of any recent details concerning any conversations between it and the Ministerial authorities; but on "March 23 it held a meeting at which its Council formed, in conjunction with representatives of the King Edward's Hospital Fund for London and of the representatives of the Nuffield Provincial Hospitals Trust, a deputation that would meet the Minister of Health, on his own invitation, and the following resolution submitted by the executive was carried unanimously:
That in the event of the Minister of Health's proposals involving the handing over of the control of the medical services, including hospital services, of the country to the local authorities, this Association will be definitely opposed to such proposals and is of the opinion that some independent body representative of the Ministry of Health, the local authorities, the voluntary hospitals and the medical profession should be constituted as only in this way can the partnership foreshadowed by the Minister be implemented.
I need only quote to supplement this a remark of the chairman of one of the Association's provincial committees to the effect that
the Minister was in control of all the vast public health services, and there was no doubt that he had been subject to considerable pressure by local authorities and their Medical Officers of Health who thought that now was the time to secure control of all the health services. It was the duty of the hospitals, and of the Association on their behalf, to resist to the uttermost, in the interest of the patient. Resistance alone was not sufficient, and the hospitals should have their own alternative, based on the principles of regionalization and co-ordination already advocated by the Nuffield Trust and approved as hospital policy by the Association.
I feel also obliged to quote in support of the Association's theory the admirable observations made to me by one of the functionaries of a well-known London hospital:
So far the only proposal made for the administration of the much extended service suggested in the Beveridge proposals has been that the whole shall be administered through a local authority. This has raised objection in many quarters because of the inelasticity of such administration, and the possibility that general practice under its control would be degraded to 'penny in the slot' medicine" (a phrase that sticks in the mind). "Lip service has been given to the idea of free choice of doctor, but under any scheme of whole-time medical service under local authority it is doubtful if the free choice could materialize. It is also doubtful whether the medical practitioners employed under such a scheme could maintain their high traditions and it is feared that some at any rate would adhere to the rule rather than the spirit of any regulations. Medicine is a progressive science, and for this reason can only perform its best work when it is as free as possible in the conduct of its own affairs. It is singularly ill-fitted to a régime controlled by rigid rules and regulations.
I could, if I wished, give instances indefinitely to show the very powerful reaction of the medical profession to what would seem to be the present attitude of the Minister of Health.
For example, Lord Horder sent a recent letter to The Times, in which he did not hesitate to say:
With nothing yet being done to implement the Assumptions of the Beveridge Report this haste to transfer the doctors and the voluntary hospitals to the somewhat jejune care of the local authorities, as at present constituted, seems almost indecent. In the matter of the medical profession precipitate and wholesale action for the mere sake of action may easily be regretted. We may move our doctors up the hill only to find ourselves later following the historic example of a certain gallant general and moving them down again.
A Dr. Geoffrey Marshall, writing also to The Times, says of his medical colleagues:
While their more active members are serving with the forces and the older and unfit are grossly overworked at home, they are being forced to discuss the re-shaping of a complex and by no means inefficient machine. As a preliminary they are told by the responsible Minister that the medical care of the public will in future be directed by the local authorities. We have had experience of these authorities for years, especially in the treatment of tuberculosis, and the standard of investigation and treatment organized by a number of the county councils has been discouragingly low—far below that provided by voluntary institutions.
And even a paper like the New Statesman—which it seems to me, might very well have been expected to take very much the opposite attitude, and which is usually to such an extent a champion of lost causes that it reminds me of Cato of Utica: "Victrix causa dels placuit, sed victa Catoni"—finds itself championing here what others have gone so far as to proclaim a vested interest. This is what the New Statesman says:
A doctor friend of mine puts the case against what he assumes to be a plan for 'group clinics' at which the patient will be examined by the man who happens to be on duty. 'Medicine', he says, is an art at least as much as a science. The real healer works with the aid of psychology; he inspires the patient with confidence and makes him cure himself. Any system which depersonalizes medicine will reduce its efficiency and waste the skill of the doctors who use their human interest in their patients as an element in treatment.'
It is the New Statesman itself which adds:
This view is certainly confirmed by the complaints of hospital out-patients who know what it is to be treated as 'cases' rather than persons.
§ This word "depersonalized" has for me the double advantage of checking me in my quoting—for your Lordships must have been reminded of the well-known commentary on Hamlet, that it was a very interesting play but too full of 736 quotations—and of forcing me to come out into the open and to stand here as what I really am, that is to say, an isolated and individual member of the British public, a layman who has no connexion whatever with the medical profession, and who has been prompted by none of them and by no one to bring forward this Motion to-day. As for any political axe which I might have had to grind, I am, as probably your Lordships know, precluded from having one by the uniform which I have the honour to wear.
§ I have been prompted to speak to-day on this matter by my solicitude for the future of British medicine, and even more by my anxiety for the common man, the everyday Englishman. I think that I have a right, having lived with him for months on end during the last war and during this war, to put in a word for him. If really the intention of His Majesty's Government is to turn the medical profession into the equivalent of a band of salaried functionaries, of what I hardly hesitate to call State lackeys—I do not say that it is their intention, but everything seems to point that way—then, in my opinion, not only is an ancient and honourable profession going to be degraded from its high calling, and thwarted in its best and most constant efforts to improve itself, but, what in a way is far more important, the everyday citizen is no more going to get a square deal than I am.
§ There is a visible tendency everywhere now for John Citizen to think that the State, as a Universal Aunt, is capable automatically of righting all his wrongs, of acting as his trusted paladin against all sorts of occult and terrifying tyrannies, which are lumped together under the head of vested interests, and of which he is quite capable of considering the medical profession as one. Vested interests may and probably do exist. President Roosevelt could probably give us some news of them, but I dare say that we could reply to him that such what I would call financial and parapolitical Klu-Klux-Klans and Camorras might possibly be found even on this side of the Atlantic. But to give the ordinary man the impression that he is gaining a point by being put into the hands of an indifferent, and perhaps tired and harassed, functionary of a local government board—the "duty M.O.," as it were—when he or those near and 737 dear to him are ill, seems to me a piece of calculated and sinister hypocrisy; for, even if the ordinary man can lay the flattering unction to his soul that that by this time somewhat mythical body, the idle rich, will be obliged to conform, and that cheques for guineas will no longer flow into the pockets of Harley Street, and that therefore everything in the garden will be lovely, what the ordinary man does not realize is that he himself more than anybody will be treated as a cypher, as a face in a crowd, an item in a series, far more than the people whom he thinks he is dispossessing.
§ I cannot help feeling that the functionary is the new tyranny and, as far as I can see, a great deal more ominous than any previous one. The whole tenor of the medical provisions of the Beveridge Report, and of what has leaked through to the public about the conversations and negotiations which have taken place between the Ministry of Health and the medical authorities, show that there is great danger that that is what the Ministry would like the hospital doctor and the general practitioner to become. Of course, I know that fun has been poked at doctors, and harsh things have been said about them, from the days of Molière to those of Anatole France and, to come nearer to present times, down to the contemporary novels of Dr. Cronin. I remember, incidentally, a particularly vicious attack on them by the late Leon Daudet, who had been a medical student himself, in a book of his called Les Morticoles, which I regret to say means "the cultivators of death." But I prefer to remember the names of Æsculapius and Pythagoras, and, to come nearer home, of men like Harvey, Jenner, Lister and Simpson of Edinburgh.
§ I should add, so far as the medical profession as a whole is concerned, that it has long been recognized by the profession itself and its representatives that there is need for improvement in the medical services of the country, and they have demonstrated that they are more than willing to collaborate in any reasonable scheme. All I can say is that what appear to be the Government's present intentions seem to me to represent a very unusual example of encouraging what Lord Halifax, quoting Hitler himself, called the other day "the saving doctrine of the nothingness and insignificance of 738 the individual human being." If they are carried out, I do not hesitate to say, even if this were to be my last utterance in your Lordships' House—and by this time your Lordships may well be wishing that it might be—that I consider that the British public, to use an irreverent but undoubtedly graphic phrase, is being sold a pup. I beg to move.
§ Moved to resolve, That, in view of the fact that the medical provisions of the Beveridge Plan, as it now stands, concerning the future status of doctors and the medical treatment of the population in general do not appear to be designed to further the best interests of British Medicine or of the population, His Majesty's Government should not adopt them without careful examination.— (Lord Derwent.)
§ VISCOUNT DAWSON OF PENN
My Lords, I venture to think that the noble Lord, Lord Derwent, has conferred a signal service as a layman in bringing this very important and critical matter before your Lordships' House. I fear that your Lordships will have to extend a considerable amount of patience to medical speech-making this afternoon. All I can say is that I am sure that the doctors who speak here to-day will endeavour to do so in a constructive as well as in a critical spirit, and I am strengthened in this conviction by the presence of my noble friend Lord Moran, whose appearance in your Lordships' House has received a welcome from the whole medical profession. Assumption B of the Beveridge Report lays down that there must be a comprehensive health and rehabilitation service for the prevention and cure of disease and the restoration of capacity for work available to all members of the community. It lays that down as an essential background of social security, but it does not lay down what that medical service should be. It leaves the devising of such a scheme—which it states incidentally should be further investigated—to those concerned with the health of the nation—namely, the Ministry of Health and the medical profession. And that exploration is in hand.
I would like to make it clear that the organization of a comprehensive medical service is no new subject to the medical profession. It has been under consideration for years—since the year 1920 onwards. The demand for it has always been received by Governments with deaf 739 ears. In 1929, when the Local Government Bill was going through the Legislature, the leaders of the medical profession did their best to persuade the then Ministry of Health to make a forward move and lay the foundations of the service which you are trying to devise in haste to-day, and we found them a stiff-necked generation. They were obstinate and without vision. When the discussion of the Bill came up in your Lordships' House and an effort was made to introduce some machinery for co-ordinating the local government and voluntary hospitals, although the Government put the Whips on, that Motion only succeeded by a majority of nine, and it ended in a compromise in Clause 13 of that Bill, which has done little or no good. What I want to make clear is that it is not the medical profession which has neglected to think of these things. It has been trying in vain to convince Governments of the importance of taking some step towards co-ordinating medical services. The responsibility for its not having been done lies with the Governments, and it was not till the Beveridge Report came out that any idea of a comprehensive medical service was put on the political map.
And what then? After having a rough passage in the House of Commons, the Government were accused by their own followers of not being serious about social security, and they replied, "Oh yes we are, we have already agreed to family allowances and we are going to get on with a medical service." And so what results? They have introduced a state of haste and hustle into what, in the words of the Prime Minister, should be a gradual process spread over four years, and they expect the whole medical profession to be turned upside down in six weeks. All I can say is that it is not going to happen as long as we are there to prevent it. I would point out that the attitude of the social security scheme to a comprehensive medical service is somewhat different from that of the medical profession. May I quote from the Report?The primary interest of the Ministry of Social Security is not in the details of the national health service or in its financial relations. It is in finding a health service which will diminish disease by prevention and cure and will ensure the careful certification 740 needed to control payment of benefit at the rates proposed in this Report.That is an economic outlook on the medical service, and in its own place quite a proper one. On the other hand, in my submission it is not the duty of the medical profession to have in mind such motives as that when devising a comprehensive medical service. It is the duty of the medical profession to devise the best service on its merits, which will bring about that improvement in the health of the nation which we are all agreed in desiring. Indeed, it would be disastrous if doctors were regarded as agents to control benefit in the interests of the social security fund. It is their business, it is true, to say if and when their patients are fit and ready for work, and I am free to admit that at times there may be a bias on the part of the doctor in favour of his patients. He may, out of a motive of generosity, be inclined to be lax at times. but that is easily prevented by a simple piece of machinery which will set up an appeal board in each area. And I am bound to record that in my experience—and I am sure in the experience of my colleagues—I find difficulty more often in preventing people from going back to work before they are fit than I have with the laggards who lazily linger on.
A comprehensive medical service with its vista of a great opportunity for furthering the health of the nation, is a thing that fires the imagination. It is all the more important therefore that the foundations of that service should be well and truly laid, and built upon the rock of agreement, and not on the sands of dissension. Unless we can get an agreement, a square agreement, over this matter, any service devised will be a failure. At the present moment there are real dangers of dissension, and I will give the reasons fog that, as I see them. If I may recall what I had the privilege of saying during the debate on the Beveridge Report, when you come to think of how medical practice is buried in the age-long customs of this country, engaging not only the reason but the sentiments and emotions of the population, no reasonable person can pull all that up by the roots and think he can ever replant it. Do not pull up the roots therefore until you are sure you have something good with which to replace what you remove. For that reason we have to go slowly, we have to go in stages.
741 It is our business now to lay the foundations of this scheme. Go on the principle of planning. Have two years' experience of the foundations and then put up a superstructure in the light of accrued experience.
The design of those foundations is clear to my mind, and I think there is a measure of agreement upon that. The first and most important thing to do is to bring together preventive and curative medicine into a single service, so that the furtherance of health, and especially the personal health service, will be brought within the ambit of medical practice, both individual and institutional. We must see to it that both preventive and curative medicine are brought into the structure of every teaching hospital and occupy an important part of medical education. That is one foundation. The second foundation, as I see it, is this—a pattern of health and inter-related hospital services, distributed according to the needs of the population, in areas sufficiently large to secure a good and efficient service, and at the head of each area a key hospital which would afford intellectual leadership to the whole area. That would be done by close co-operation between the local authority and the voluntary hospitals working together in that partnership to which the Minister of Health has so frequently referred.
When we come to the administration of these areas we come up against our first fence. I admit local government in some form to be the seat of the ultimate administrative authority. That would not only conform to constitutional usage, but would conform to the fact that local government already administers health services and administers its own hospitals. On the other hand the voluntary hospitals, which have the bulk of the experience, demand their partnership, and the medical profession would refuse to accept such local administration unless the latter were guided by representative expert bodies. It is not to be expected, as the noble Lord has said, that a learned profession is going to give up its freedom to think and do as it considers best. Freedom for initiative and individual responsibility are the lifeblood of the profession, and if anything is done to damage that, who will be the first people to suffer? Why, the patients throughout this land. 742 Medical professional men ill fit the bureaucratic machine. That is why the Medical Research Council was placed under the Privy Council and not under the Ministry of Health. That is why the voluntary hospitals have the confidence and affection of the medical profession, for in every well-established voluntary hospital the vocational principle has been recognized for centuries.
There you have two bodies—a medical council, which gives advice and initiative on professional matters, and a lay committee, which constitutes the administrative authority. It is quite true that the lay committee has the last word, but it has a skilled body at its elbow, and they generally work together. The only way of solving this difficulty of the local authority being accepted as the ultimate administrative agent is by having at the elbow of each health authority in each area an advisory council consisting of representatives of the staffs of local government hospitals and voluntary hospitals, a considerable proportion of whom would be medical men. There, in my judgment, lies a solution of the problem. As a profession we would support the proposal that health services and hospitals must be referred to a larger health authority corresponding to each area.
It is quite true that this would involve a combination, in many instances, of major local authorities for that purpose. Provided that new health authority followed the precedent of the education authority and permitted the co-option of a minority of non-elected members—people chosen from among those who have special knowledge and experience of the subject—I believe that along those lines a practical scheme lies. If in addition, side by side with each area authority, you had an advisory body such as that to which I have referred, and if the principles of health and hospital policy were laid down by Whitehall, I believe that in some such alliance is to be found a solution of our difficulties as regards hospital services. I would point out this. Not the least of the merits of these area advisory bodies would be that they would bring together the leaders of all kinds of hospital and health services, whether they belonged to the local government administration or to voluntary hospitals. By bringing them together constantly round a table, in course of time 743 they would get to know each other, and they would end up by becoming colleagues in a common cause.
What I have said so far I regard as foundations. Anybody who knows the difficulties which I have so far set out in the course of my remarks would agree that we have quite enough to do to set these foundations firmly and strongly, and we should stop there. There are many conflicting interests to be resolved, ancient prejudices to be reconciled, and it would take, in my judgment, two years of undisturbed and patient work and statesmanship to bring about that agreement. On those foundations will depend the success of the services. We should then be able to build a superstructure in the light of accrued experience. He would be a bold man who would say what was going to happen in this country four or five years from now. The social changes will be deep and very difficult to forecast. To attempt anything more than these foundations now would be sheer political folly and asking for trouble.
Meanwhile hospital and consultant services would be remunerated by appropriate salaries, and holders of these posts would serve on a part-time or a whole-time service, according to choice and circumstances. There is a lot of controversy over whole-time and part-time services. During the foundational two years we shall come to see where lie the advantages and the disadvantages. As regards hospitals, though every patient would have the same essential treatment, it would be wrong for them all to have the same dead level of amenities and accommodation. The Beveridge Plan only provides essentials for the hospital service. It is a maintenance benefit, and the Beveridge Report gives the warmest encouragement to the building up of voluntary insurance schemes on the top of the social security scheme. It would be a very proper thing for contributory schemes to step in and bring to patients who go into hospital on the social security scheme benefits and amenities and comforts in accordance with the standards of life to which they have been accustomed. But be it understood once more, one of the things we are most proud of in our hospitals is that every patient in essentials receives the same standard of treatment; but, while we secure equality, for heaven's sake let us avoid a deadly uniformity.
744 Now I pass to consider health centres. Perhaps I may be permitted to speak of them since I was one of the pioneers of the idea, as my noble friend will bear witness, in the year 1920. Originally the health centre was regarded, so to speak, as a miniature hospital or institution for bringing institutional provision to the aid of general practitioners and bringing preventive and curative medicine together. When my noble friend was Minister of Health we provided him with drawings of model health centres but, alas! through the indifference and sheer idleness of successive Governments, not a single health centre was tried out. Government after Government treated them with complete indifference, and now at the last moment the Minister of Health wakes up and talks about health centres dotted about the country when we have never put the health centres to the test of experience. Although I believe they open a big field of usefulness for the public, he would be a foolish man who would put health centres into service till he had tested them out and proved whether they were good or bad and had also improved them in the light of experience. Therefore when I see health centres being used as an excuse for the bringing in of a whole-time salaried service, I begin to be suspicious, and confidence is sadly shaken.
One other matter. If I may I will refer to the comprehensive medical service. That service to be any good has to be really comprehensive, I mean by that that all the medical services which are sponsored by the different Government Departments must come in under the same umbrella and be governed by the same broad principles of policy under the Ministry of Health. We can have no contracting out. I refer, for instance, to mental health, to the school medical services, and to industrial medicine of the Ministry of Labour, which is one of the most promising branches of medicine as regards the future for it will afford a wonderful opportunity for research, medical education and also for bringing to the individual worker guidance in health and illness at the time he most wants it. Industrial medicine will have to come into the one comprehensive medical service. No contracting out. It may reside here or there but it has to be identified with the one service at the Ministry of Health.
745 Though aware of all the difficulties, I am one who desires to see the realization of a comprehensive health service for the benefit of the future of the nation, and I believe it could, if properly founded and built, be productive of great national good. But I do profess my discouragement and dismay when I find that the Ministry of Health has given way to the hustle of political exigency and is trying to put up a structure in a few weeks which it is beyond the wit of man to do. It will be nothing but a jerry-built structure if anybody tries to build it in its completion now. If that is attempted it will arouse a degree of antagonism and distrust—and I warn the Government of this—which will bring any scheme to the ground. I refer in particular to our discovery of the idea of a whole-time salaried State service for all doctors as being in the departmental mind. 'Without the foundations of the service even being laid, to endeavour to enclose all doctors within a bureaucratic ring fence is sheer madness. It may be right ten years hence, I do not know, but it is sheer madness now. The very mention of it has already produced a degree of distrust and antagonism which, unless something is done to allay it, will bring permanent harm to the prospects of peace.
Take for example what I have already said in my previous remarks about a carefully thought out endeavour to reconcile differences. The local authority has the ultimate administrative authority, and I suggest means whereby that can be made agreeable and possible as between the local authority and the medical profession, for doctors will not take employment with a local authority naked and unadorned, at any rate not now. There is too much distrust. The medical profession will not consent to be pawns on the local government chessboard. They will not consent to have a highly skilled profession governed by laymen ignorant of medicine who have been elected on a totally different ticket.
In the endeavour to be constructive, a great deal of time has been given to reconciling these two difficulties and I believe it could be done by each local authority setting up a special local health authority with a co-opted minority—whether it votes or not does not matter—to act as an advisory council. Its members should include doctors in private 746 practice and hospital experts including representatives of local government hospitals, because the doctors in those hospitals suffer from having too little power. They have no medical council, and are under the medical superintendent and all the tyranny that that represents. They want a change. Let them all meet as an advisory council. Make it statutory that local authorities must give serious attention to their advice, and then I shall be content to leave the decision to the local authority. But all that machinery would come to the ground if anybody suggests such a ridiculous scheme as whole-time State salaried service for the whole medical profession.
I have dealt with this so far as a matter of policy, and I am quite free to admit that with the passage of time many of us may alter our ideas with regard to the relative merits of whole-time and part-time service. I believe that in the course of the next few years professional earnings will consist of a larger proportion from salary than hitherto and a smaller proportion from fees. That does not frighten me, provided it is done freely in the light of experience. I have tried to deal with the question of whole-time salaried service in the light of policy, and may I say something in conclusion on its merits? There are many branches of medicine which are run better by whole-time service—I do not want to waste your Lordships' time by enumerating them—but there is one part of medical practice where you must have individualism. Where the doctor is dealing with a sick man there is a relationship that is peculiarly intimate. There is individual responsibility on one side and reliance and confidence on the other. Can it be supposed that these qualities would be as forthcoming from the State salaried doctor who arrives on duty at 9 a.m. and leaves at 6 p.m. as from a doctor whose good work brings reputation, and later, maybe, material reward?
A healthy thought of self is a spur and consorts well with a desire and an endeavour to help others. This intimate relation of doctor and patient where the individual sick are concerned, brings out all the attributes which belong to the practice of medicine at its best. First, the doctor has to be abreast of knowledge and cultivate the scientific approach to his problem without bias. For that 747 he requires a reasoning mind. Then he has to relate his knowledge to the background of that particular patient—to his make-up and circumstances. For that the doctor requires understanding. Having understood, the doctor must feel, and care, if he is to help his patient back to health, and herein lies his vocation. I ask the Government to think long and wisely before they do anything which would prevent the fostering of these cherished ideals.
§ LORD MORAN
My Lords, I wish I had been able to address your Lordships for the first time on a subject about which any conclusion I reached was less provisional and less liable to revision. On that account, and also because of inexperience in debate, I ask your Lordships' indulgence. I think we doctors can help those who are not doctors if we try to explain what we believe to be the essential minimum of any scheme that aims at the reformation of medical service, particularly if, in the course of that explanation, it becomes apparent why the medical profession has been so perturbed—I might almost say so dismayed—by the proposals which the Minister of Health has brought forward. The first essential, surely, is sound central machinery. I agree with my noble friend Viscount Dawson of Penn, that it is essential that all activities concerned with health should come under one Department and not under six Departments, as at present. It is not right that the Ministry of Health should look after the child until he goes to school, that then the Board of Education should look after him while he is at school, and that when he becomes a factory worker the Ministry of Labour should take him over. The same Department and the same records should follow that boy from the day he is born to the end of his life. I agree also with my noble friend that the industrial worker and the doctor must come under a comprehensive service. It is quite hopeless to have them under separate Departments.
There is another and I think even more important consideration about such machinery, and that is that it should enjoy the confidence of the medical profession. It is essential that in the Ministry of Health civil servants who are not doctors and doctors who have long been 748 divorced from the work of medicine by administrative duties, should keep in close touch with those actively engaged in the practice of their profession. How can that be done? I think advisory committees have become rather discredited in the profession. They appear to have little power, and when they have served their first function of reassuring the public the Minister is apt to lose interest in their activities so that sometimes they do not meet for six months or even a year. I have served on various advisory committees and I have not found the work a serious tax on my time. What I have in mind is a medical council which should help to frame the policy of the Minister. It should meet regularly and not deal with a fragment of policy every six months. It should deal with all questions of general policy that come up. It should be free to publish from time to time uncensored reports of its activities. Such a council might be composed, say, of twenty medical members, fifteen perhaps elected by the profession and five appointed by the Minister, including the Ministry's chief medical officer. The council would elect its own chairman. I hope that the Minister will give this council real power. At first sight it might appear to him that this body would have too much liberty to publish criticisms of draft regulations, but it would pay him in the help it would give him and the confidence it might inspire in the medical profession. If the power given to it was real power the whole relationship between the medical profession in Whitehall and the profession throughout the land would be improved.
It would also have other functions. The real opposition to the proposals for a comprehensive medical service are based on the objection of the medical profession to become employees of local authorities. Now if that is to be overcome it is clear that there will have to be some machinery for referring disputes between the authority—whoever that may be—and the doctors working for that authority to some central court of appeal, and this council might very well act as that court of appeal. Further, and finally, a sub-committee of the council could act as an appointments bureau, finding posts for doctors in the parts of the country in which they desire to settle and providing lists for the authority of suitable applicants. It could also administer a super 749 annuation scheme for every doctor in the service, if the service does eventually come.
Leaving this question of central machinery I think that the second essential is clearly that the conditions under which the rank and file of the profession work must be made as perfect as we can make them. Is that so at the present time? I think that many doctors would probably answer "Yes." But is that answer final, and is it quite convincing? I was Dean of a London medical school for twenty years and this was my experience. Every student after three years spent in the study of the basic sciences, anatomy and physiology, served another three or four years in the wards of a hospital. There they were submitted to intellectual discipline of this sort. A diagnosis, however eminent was the person by whom it was made, was considered to be sub judice until it had been put to the proof. Half a dozen departments would try to pick to pieces that diagnosis. One department, perhaps, took and examined a sample of the patient's blood, another examined some other portion of his anatomy, yet another took X-ray photographs. Perhaps a surgeon opened the abdomen, and it may even have been that the last word rested with the pathologist who made a post mortem. Now that was done daily, almost hourly, for several years and there grew up in the student's mind the opinion that every diagnosis was sub judice until proven. Then what happened? The men qualified and went out into the world to practice. The majority never entered the hospital again to work there—if they did enter it again it was as patients. Their diagnoses were seldom put to the proof and it was inevitable that after some years the scientific humility and craving for proof of the men's student days was replaced by confidence born of the knowledge that they had learnt how to deal with human nature.
How is this going to be altered? If doctors, instead of practising at their own houses were to be banded eight or nine together, and were to see patients at some house built for the purpose, with facilities for diagnosis and with consultants' services at their elbow, they would breathe again that atmosphere of their student days in the wards, and it would be a great gain to the community. I think we have to face the fact that the 750 majority of doctors, at the present time, are opposed to these health centres. Certainly members of the public are highly suspicious of them, and on very good grounds. They feel that if nine or ten doctors are gathered in one house seeing patients, soon a system will develop under which two or three will be left on duty and when patients telephone for Dr. Jones it will be Dr. Green who attends to them. Thus free choice of doctor will be gone with all that that means. That surely can be overcome if we have an efficient secretarial organization. The doctors' opposition, I hope, will disappear after a time, and I think we shall have an ally in his wife. With domestic servants becoming more and more difficult to obtain, and the doctor's wife finding herself glued to the telephone for hours at a time, I think it is likely that she will become a real convert to health centres. We need not fear that this is coming overnight. None of these centres have been built. There will be plenty of time to try them out. If they fall short of what I hope they will be they need not be gone on with. We cannot get away from the fact that under present conditions doctors, when they qualify, leave the hospitals en masse. Is it not desirable that some means should be devised whereby they will be able to keep in touch with the hospitals and see patients at hospitals under hospital conditions?
I revert to the question of this local authority. It is really a thorn sticking in the flesh of the profession now. The doctor feels that he will become the playboy of local politics. How is that going to be prevented? I am quite certain we have got to give up any idea of local feeling and local influence coming into this matter. Perhaps the country could be divided into ten or twelve regional administrative units, each working with a university, and from which all local feeling and influence would be excluded. That would, I think, get over the feeling against the present suggestion. But I am quite certain it would be useless to try and dragoon doctors to work under local authorities unless some measure of reassurance can be given them that what is to be done will not interfere with the proper work of their profession. You may say that that is merely due to the conservative instinct which is in all of us. I do 751 not believe that it is. I believe that it is due to the intuitive understanding on their part of the personal relationship between patient and doctor on which everything depends and a feeling that it will be imperilled if these arrangements are carried through. I have said nothing of hospitals. Napoleon used to say: "There are no bad battalions; only bad officers." Now there are no bad hospitals, only bad staffs. If you get a really good consultant service you will get a really good hospital service. Equipment is something, but a good staff is everything.
Leaving this one comes to the third essential—that there should be a really good consultant service. If we are ill and the nature of our illness is in doubt we do not leave that doubt to time to resolve. We ask for a second opinion, and if a panel patient requires a second opinion he must go to a hospital. I think there is general agreement that everyone, whatever his means, must be able to get consultant opinion when necessary. The question arises: Are there enough consultants? The answer, I think, is that there are not enough at the present time, and those available are not distributed according to the needs of the community. To get over the difficulty in this connexion we must know how many consultants there are and where they are. We must have a list. No such list exists at the present time. Three royal colleges have agreed to draw up such a list for the Ministry of Health. One would be glad if in the drafting of this list it were possible to ensure that only those go on to it who have had the requisite special training and so forth. That is clearly impossible. If a middle-aged man has practised as a consultant with the approval of the profession in his neighbourhood for many years, you cannot disenfranchise him overnight, and say that he cannot practise as a consultant because in his youth he did not receive the training which is now considered necessary, or because he does not possess the requisite degrees.
In the first instance, this list or register must be drawn up on one criterion only: the approval of the profession in the man's neighbourhood that he is a proper consultant. It follows, therefore, that all these lists must be drawn up locally; and in the twelve university cities in England, Wales and Northern Ireland those committees are now sitting. I count 752 it very fortunate that the Vice-Chancellors of all those universities have consented to act as chairmen of those committees. When this list is complete, a very different state of affairs will follow: any man who aspires to be a consultant after that, and to have his name added to this list, will have to pass the very strictest scrutiny. He will have to satisfy a board that he has done the years of special training required, and that he is competent to act as a consultant.
All this is not pure theory. In America there are special boards which decide whether a man should become an ophthalmic surgeon, a general surgeon, a physician, a children's physician, and so forth. There is a separate board for each special branch, and these men have to pass a very strict scrutiny. Ten days ago I was a patient in a New York hospital, and had plenty of time to study the fat volume which contains the list of these consultants. We must have a similar list in this country, because what are going to be the results? They are going to be two-fold. In the first place, such a list will guard the public against a man practising as a consultant who has not had the necessary training. At the present time any man can be a consultant. He may have the most modest degrees, he may have no special experience, but he can go to a house agent and rent a room in Harley Street and, writing to his patients from that address, he will be accepted by many as a consultant. Now all this is going to end, with very great gain to the community. Secondly, if we know where the consultants are, and how many there are, we shall be able to arrange for that redistribution which is absolutely essential. When all this is done, and when everyone is able to obtain the services of a consultant who has had a proper training, it will be the greatest single step in advance in my lifetime. It will mean that everybody will be able to get a trained man. Is that so at present? You may be surprised to hear that there are great areas in England, towns with a population of 100,000, where the major surgery and everything else is done by general practitioners, and where no consultant ever comes. One of the largest counties in England a few months ago had not a single gynaecologist. All this must end; it is one of the greatest evils of our time in the medical world.
753 When this consultant service has been dealt with, what is left? I think that all we want to do is something like this. A short time ago the committee which represents the profession met the Minister of Health and told him that they were very reluctant to admit to him that his proposals were wholly unacceptable to them, and they asked him to set up a Royal Commission. He said that that would take two years, and that he could not wait. A Royal Commission is not required to say that change is necessary—I think we all agree that change is necessary—but it will tell us how that change can be made without disturbing the relationship between the doctor and his patient on which the patient's confidence is based, and which is the whole basis of the practice of medicine in this country.
§ LORD GEDDES
My Lords, I am sure that every one of your Lordships would wish to express your thanks to the noble Lord who has just sat down for his most informative, most valuable and most interesting speech, and I am sure that you will all hope that on future occasions, when such topics as this come up for consideration, you will have the benefit of his experience and advice. I think that at the present moment there is a very great deal of alarm among the medical profession. I can speak of it only from samples, because I am not actively engaged in the practice of medicine; but I do meet a great many doctors, and I think that the only thing that can be done at present to get the medical profession out of this state of alarm is for the Government to make it quite clear that they do not intend to turn every registered medical practitioner into a whole-time servant of the State—because that is what is feared. It is feared not by members of the medical profession alone. It will be within the recollection of your Lordships that not very long ago I had the honour of addressing your Lordships' House on the subject of positive health. That has produced, through my letter box, the most extraordinary correspondence, and in large numbers of letters the question has arisen of the loss of the sacred relation between doctor and patient which would inevitably follow upon the adoption of what are wrongly described as "the Government proposals." That is a misdescription, because the Government have no proposals; but the statement indicates what people have in mind.
754 It seems to me that it would be utter folly—"lunacy," I think, was the word used by the noble Viscount, Lord Dawson of Penn—to attempt to convert the whole of the medical profession into a service comparable—of course with the necessary variations—with the R.A.M.C., the Royal Naval Medical Service or the Royal Air Force Medical Service. It is quite impossible. There are all sorts of deep-rooted prejudices and privileges which would have to be utterly destroyed before that could be done, and prejudices and privileges not on the part of the medical profession but on the part of the people of the country as a whole, became the majority of my letters have come from people who have nothing whatever to do with medicine.
I am quite convinced in my own mind—it would be hard to produce evidence of this in detail—that there is now developing in this country a rather violent reaction against bureaucratic interference in private life. It is the fear of that bureaucratic interference in private life which is making a very large number of people very anxious about the Government proposals, and about negotiations which are now proceeding between the Government and the medical profession. This is a country of individualists, and one of the really cherished relationships in countless homes is the relationship which exists between the family and the family doctor. I should not like to be the Minister who disturbed that relationship. I think that before very long he would find out what he had done to anger the people. I suggest to the Government, therefore, and to whoever is going to reply on behalf of the Government to-day, that if possible it should be stated to your Lordships that any idea of converting the whole body of the registered medical practitioners of this country into a salaried medical service—and such an idea is supposed by many of us to have existed—has been entirely abandoned. If they can say that, then I think the atmosphere will have been somewhat cleared.
Coming to my next point, I am certain that the noble Viscount, Lord Dawson of Penn, is right when he says that progress must be made slowly. The foundations must be carefully laid, and from the foundations can arise later the new edifice. But there is a great deal of work to be done in laying the foundations, and I am 755 quite sure, too, that there ought to be an authoritative Commission examining the whole process of constructing this new medical service which we all desire to see. Please remember, as the noble Viscount, Lord Dawson, has already pointed out, that the medical profession has been pressing for it for a generation and the Government have been idly refusing to consider it. I do not think that is an over-statement of the position which has existed since the time I ceased to be President of the Local Government Board, of which I was the last President before the Ministry of Health was formed. It is a long time ago, but there has been a resistance to the development of a proper, comprehensive service providing for the health needs of the community and unifying the medical services which exist. That point has been emphasized both by Lord Dawson and by Lord Moran—that there must be a cessation of this multiplicity of Government Departments dealing with questions of health. It can never be satisfactory as it is.
And so, I venture to add my voice to those that have already been listened to with such interest by your Lordships to urge upon the Government (1) that they make it clear that they are not going to attempt to turn the whole medical profession into a salaried whole-time service—and I believe they have abandoned that intention; and (2) that they are going to hold, through a Royal Commission, if that be the most suitable way, a progressive investigation as to what are the best steps to take in order that these ideas which are put forward by the Department and by the profession outside, should be examined by a competent body of people, representing not only the Government Departments and the medical profession, but representing those to whom this matters most—the public, the people who are going to be treated by the medical service.
If that can be said, then I think we can move forward. But let us never forget that medicine is not yet—perhaps it never will be—a science. It is based on science, and its scientific foundations grow stronger day by day, but medicine in the sick room, the relation between the doctor as healer and his patient, is a relation of art. No science can explain the full intricacy and import of that rela- 756 tion, and no science that we know of can explain all the reasons for illness. Sometimes you may suggest what they are, but sometimes they arise not in the ordinary physical side at all but in the spiritual side of man, which quite separately affects the body. We cannot expect medical officers on duty to know about the intricate family story—all the relations that exist inside a house. That is a thing that is known to the family doctor, and ultimately you must rely on the family doctor, a product, I think, peculiarly British. I have never met in any other country a relationship so intimate as that which I have known here in this country between the doctors and the families they look after. Certainly I never found anything really like it in the United States, nor anywhere on the Continent, nor in the Dominions in which I have been. It is one of the great cherished possessions of British medicine and also one of the great possessions of the British public. I am certain that, with their individualist minds and characters, they intend to hold on to it and will not allow any Government to destroy that relationship.
§ THE EARL OF HUNTINGDON
My Lords, I should like to add a very humble but sincere tribute to the extremely learned speech we have heard from Lord Moran. I think I can associate the whole House with me in wishing that he will often take part in our debates, and that we may have the benefit of his wisdom and experience. I do not know whether your Lordships realize the disappointment that was felt throughout the country when the Beveridge Plan was not accepted by the Government. I think the greatest consolation given us was that Assumption B of the Report was accepted in principle. Assumption B, if I may remind your Lordships, covers a comprehensive health service for prevention and cure of disease and the restoration of capacity to work to all members of the community. This is further elaborated in paragraph 437, which states:From the standpoint of social security, a health service providing full preventive and curative treatment of every kind to every citizen without exceptions, without remuneration limit and without an economic barrier at any point to delay recourse to it, is the ideal plan.I think it is difficult to see how there can be any real opposition to the aim or the ideal of that assumption.
757 In fact, in the speeches this afternoon there has been a genuine agreement on all sides that we must have a reorganization of the medical services. The real point in dispute is how these services shall be reorganized. I would like to suggest that this can only be done by a unified medical service. The real question that we have got to face is: Are we going to mobilize all preventive measures in a campaign against disease, or are we going to let the bacilli keep the initiative and then try to remedy the damage later? That is the fundamental issue. Because if we are going to unite this country in one campaign against disease I submit that this can only be done under a united General Staff. Prevention is not only better, but cheaper, than cure. Disease germs spread, the conditions become aggravated, and for that reason I should like to suggest that no question of ability to pay should prevent early application for treatment. That is very important. A preventive campaign of this sort can only be conducted by a General Staff. The weakness of our whole fight against disease now is surely the fact of the many Departments through which our health service is administered. The Ministry of Health, the Mines Department, the Home Office, the Board of Trade, the Ministry of Labour, and the Board of Education all have a finger n the pie. Then you have the different kinds of hospitals—voluntary hospitals, municipal hospitals, asylums, etc.—and doctors, specialists, medical officers of health, working sometimes in very close co-operation, sometimes, I am afraid, in no co-operation at all.
This must be remedied if we are going to make any progress at all. No one would suggest that our North African campaign would have been better carried out under various guerrilla bands each with a different leader, trained in different methods and different traditions, cooperating with Regular units. But that is the state of our forces in this fight against disease. One can appreciate the viewpoint of the guerrilla leader who is on his own and brings off a brilliant and successful exploit, but modern warfare demands the co-operation of a unified staff. In the same way so does modern medicine if we are to be successful. I should like to make it clear that I do not belittle in any way the magnificent work which the voluntary hospitals have done in the past, or the magnificent work 758 of the doctors attached to these hospitals. The great devotion of the medical profession to the community as a whole has been magnificent. I would not like your Lordships to think for a moment that we do not all appreciate that. But times have changed. The general practitioner with his black bag and kindly manner can no longer bring all scientific treatment with him. He must have apparatus, opportunities for consulting specialists and for specialist treatment. The whole paraphernalia has become so vast that it is important that the doctor should have these things in his hand to use and make use of.
Above all, he should be up to date and know all the latest theories and discoveries in connexion with medicine, which an overworked, sometimes underpaid, general practitioner has often no time to acquire. His life is an exceedingly hard one. His education, I imagine, will have cost something like £1,500, and unless he is a man of means he will probably have had to borrow money to buy his practice. He must devote practically all his working hours to trying to get enough money to pay off this debt, to educate his children, and to save a little for his old age. In my opinion, such a man would be infinitely better off in a State salaried service with a fixed good salary and pension to look forward to than he often is under present conditions.
To suggest that the doctor would not work as well or as efficiently if he received a salary instead of being driven by economic hardship is a gross libel on the personnel of the medical profession. No one suggests that our naval officers or even our Cabinet Ministers do not do their best because they are paid a salary, and I do not see why it should be suggested of doctors. A doctor should only have to work a reasonable number of hours, and it could be done, as has been suggested, in a health centre which would have a team of doctors with whom he could consult, exchange opinions, and discuss difficulties. If a doctor preferred, obviously he should be allowed to practise privately, but he should have to commit himself either to private practice or to the State salaried service, because we do not want to have the position which sometimes occurs of the State patient not receiving the very best treatment. If a doctor is relying on his paying patients, the ten- 759 dency is that the State patient may consequently suffer. It has to be remembered that the existence of the medical profession is fundamentally for the benefit of the community and not only for the benefit of the doctors.
What is the position of the community? Most people will agree that on the whole it is deplorable. We cannot judge the position completely under present conditions, which are obviously abnormal, but even before the war there was a large proportion of the people of this country under-nourished, diseased, and inadequately cared for. I should like to draw your Lordships' attention to that classic report of Sir John Orr on nutrition in which he claimed that 13,500,000 people were gravely under-nourished, having less than six shillings a week per head to spend on food, and that another 4,500,000 had less than 4s. per head for the same purpose. No wonder that the pre-war health of the nation was at such a wretched level. Under-nutrition and poverty are the greatest causes of ill-health that we have. National health insurance was in its clay a tremendous step forward. Before that there was little enough in that direction, and we ought to pay tribute to, and realize, what a great asset it has been to the health of the community. But it has drawbacks which have become apparent and need changing.
The trouble with the national health insurance scheme is that it was never national. In 1938 it covered only 36 per cent. of the population, although the average income of about 66 per cent. of the people was somewhere about £100 per annum for a family of four, or £25 per head. National health insurance, in other words, provided this limited insured population with insufficient means to maintain them in sickness, and furnished a medical service which stopped short of the absolutely necessary specialized treatment, and cut down the benefit when it was most needed. But the fundamental fault that has become apparent is that the doctor has to rely on his paying patients, and in certain cases has to skimp the attention he gives to his panel patients. Surely the wrong principle of this must be obvious. Approved societies have done something to mitigate conditions, but there again you have got a wrong principle when an unequal benefit is given for equal pay. It 760 turned the whole thing into a lottery where you paid your money to one society, hoping it would have excessive funds to provide the benefits. The fundamental thing for the people of this country is free examination and, if necessary, free treatment for the millions who may badly need it and cannot afford it. The loss to the community, the wasted hours, the suffering and deterioration cannot be estimated, and must be far greater than any additional costs of a reorganized national medical service.
It has been alleged, and a lot has been made out of the suggestion, that in a big reorganized national service the relationship between the doctor and his patient will be altered and worsened, perhaps even completely destroyed. I think that this is a fallacy. I can see no reason why, under a system of health centres with teams of doctors working and as the noble Lord, Lord Moran, said, with proper secretariat work, a patient should not be able to choose his doctor just as much as he does now. Look at the position to-day. A doctor buys a practice and takes over the patients of his predecessor. They all go over. Patients then can ask to be removed from the panel and if they can find another doctor who can accept them they can change; but in practice the choice is usually exceedingly limited and there is not a very large percentage who do change. Panel patients go over quite happily in a mass to the new doctor. I do not think there is any harm in that and I submit that the same thing would happen under a system of health centres. With teams of doctors people could choose which doctor they wanted. Occasionally, in an emergency, you might have to take Dr. Jones instead of Dr. Green, but that might well happen to-day, for if your doctor is away on holiday you have to accept his partner or the services of some other doctor. I think a great outcry has been made about something which has no basis in fact. In all this the important thing is that the doctor should be efficient and up-to-date, and that he should have the resources of medical science at his command.
The question that really is arousing everybody's attention is the thorny one of who is going to work the new scheme. I suggest that it should be entirely planned by the Ministry of Health, but that it should be administered by 761 enlarged democratically elected local authorities, not necessarily the local authorities as we know them to-day, but enlarged and divided into regions or areas. But whatever happens, I submit that we must keep to the democratic practice that a service financed by public money must be administered by public representatives. At the same time I emphatically suggest that the medical profession should be called in to co-operate in the fullest possible extent in the management. Obviously a doctor under this condition would be in a supreme position of trust, and his knowledge and learning and experience would be invaluable. Doctors would be called to the highest positions of responsibility, and I feel sure that the medical profession, if the matter were put to them in this way, would respond to this vital demand. This is really not the time to discuss the full details of the working of this scheme. It is, after all, being prepared by the I Ministry, of Health, and I think it is better to leave details of discussion till later on; but I should like to emphasize that I think the nation as a whole has confidence that the Government have accepted Assumption B of the Beveridge Report in principle and that they are going to carry it out in fact. I should further suggest to your Lordships and the medical profession that the Beveridge Plan furthers the best interests of British medicine and is vital to the wellbeing of the population.
§ LORD SNELL
My Lords, the noble Lord, Lord Derwent, has presented to your Lordships this most important problem in a speech which makes me regret that other duties so seldom allow him to appear and speak in your Lordships' House. He has the satisfaction of knowing that his speech enabled your Lordships to hear a notable contribution from the noble Lord, Lord Moran, in whose welcome as a speaker to your Lordships' House I warmly join. The problem before your Lordships is one which is everybody's concern. It affects all of us, both as prospective patients and as legislators. The sick and the well, parents, doctors, local authorities, are all concerned in the physical wellbeing of the nation. I have the onerous task of having to meet the expert and formidable battalions of the medical profession, but I shall do so in perfect good faith know- 762 ing that when next I have to seek their help what I have to say to-day will not be quoted as evidence to my disadvantage.
This matter is important to the individual because health is more desirable than riches or fame or any other blessing that life can bring to us and to the community, because health is the surest and the best form of wealth. I have not really gripped what particular sin the Government have been guilty of in this matter. The principle enunciated in the noble Lord's Motion—namely, that any proposal for comprehensive health service should be carefully examined and that no hasty decision should be taken—is precisely the policy of his Majesty's Government. It was enunciated with perfect clearness by Sir John Anderson in the House of Commons on February 16, and by other Ministers. The Motion does not rest on fact, it seems to me. It implies that the Beveridge Report contained detailed proposals about the future status of doctors and the medical treatment of the population, but the Beveridge Report itself expressly declares in paragraph 428 that the problem of the organization of a complete health service is outside the scope of the Report.
It further states that it does not express any opinion on such questions as free choice of doctor, group or individual practice, or the place of voluntary and public hospitals respectively in a national scheme. Again the Report states that no detailed proposals even as to the financial basis of this service can be submitted in the Report It suggests, further, an immediate investigation, in which the finance and the organization of the medical services can be considered together, in consultation with the professions concerned and with the public and voluntary organizations which have established hospitals and other institutions. The proposals, therefore, as paragraph 437 says, are provisional only, subject to review in the light of the further inquiry suggested. The broad Plan of the Beveridge Report has its relevance not in any detailed suggestion but in the assertion of the principle that, however organized, a comprehensive medical service would be available to every citizen and that it is an essential element in the establishment of social security.
The Report rests on three main assumptions: first, the maintenance of continuous 763 employment; secondly, the institution of a system of children's allowances; and, thirdly, the introduction of a comprehensive medical service. A comprehensive health service is defined in paragraph 427 as one whichwill ensure that for every citizen there is available whatever medical treatment he requires in whatever form he requires it…That seems to me to be an entirely commendable attitude and it is that broad principle which His Majesty's Government have accepted. Paragraph 427 also says that the service should not be left to be organized, as has been suggested this afternoon, by the Ministry concerned with social insurance, butby Departments responsible for the health of the people and for positive and preventive as well as curative measures.My noble friend Lord Geddes should rejoice in his heart at the mention in the Beveridge Report of positive medicine. Your Lordships may remember how a short time ago, in that tone of benevolent admonition which patients know so well and which frightens me almost to death, he reproved me for not knowing very much about positive medicine. I do know just enough about it to feel that to keep well is better than to be cured by the best doctor on earth, and I doubt if anybody knows much more about it than that.
The noble Lord, Lord Moran, spoke in his admirable speech about the reluctance of medical men to become servants of local authorities. With some knowledge of English local government I state quite firmly that that is not my experience. It is not the experience of any member of a selection committee of a local authority. I think it was the noble Lord, Lord Moran, who stated that there are no bad hospitals but only defective staffs. That again is not my experience. Some of the hospitals—or buildings which serve as hospitals—have been very out-of-date, very unsuited to their task, in great need of reconditioning, and the best staff in the world could not have overcome the difficulties that they there had to confront. The noble Lord, Lord Geddes, suggested that the whole idea of a salaried service should be abandoned. In regard to that I have to say that the Government have made no final decisions about this matter in any way. To the suggestion that a Royal Commission should be appointed 764 without delay, the answer is that discussions are proceeding with the medical profession, and if it should turn out that a Royal Commission would be the best instrument, His Majesty's Government will look at it in that sense.
The Beveridge Report states, in paragraph 427, that:Restoration of a sick person to health is a duty of the State and the sick person, prior to any other consideration.That is one of the affirmations which appeals to us all, and it is the kind of affirmation which His Majesty's Government have found acceptable. The noble Lord, Lord Derwent, seemed to suggest in his speech that what is proposed arouses the hostility of the British Medical Association. Paragraph 427 of the Report goes on to state:The assumption made here is in accord with the definition of the objects of medical service as proposed in the Draft Interim Report of the Medical Planning Commission of the British Medical Association.It might be advisable for me to state chronologically what the attitude of the Government has been and is to the problem. The first step taken was to consider whether the principle of a comprehensive medical service was acceptable, and that was accepted by Sir John Anderson on February 16, when he said the aim was to ensure that for every citizen there was available whatever medical treatment he required in whatever form he might require it. The Government on that occasion indicated certain features which they regarded as essential—availability of the service to all, the fullest use of all existing resources, the duty placed on some form of public authority over a wide area to administer such a plan, proper safeguards for the welfare of the medical profession, and the maintenance, as far as possible, of a free choice of doctor.
The second step was to work out the shape of a reorganized and comprehensive service on the basis of those principles in consultation with the medical profession, the voluntary hospitals and the local authorities. The third step was that the way thus prepared would lead to the publication of a statement of the general ideas of the Government for discussion by Parliament before any legislation on the matter was undertaken. There is therefore no justification at all for the suggestion that the Government are rushing heedlessly down a steep and slippery place in 765 this important matter. Consultations are taking place. The medical profession is being consulted at every stage. The Government have initiated discussions with groups representative of the medical profession, the voluntary hospitals and the major local authorities, and it is expected that before long the Minister will be able to review the question of organization and to formulate further proposals for public discussion. It is not intended that the decisions so far made should be final or binding.
It may be desirable in view of the statements that have been made for me to refer briefly to the part played in this discussion by the medical profession itself. The profession was represented by a committee brought together by the British Medical Association in collaboration with the royal colleges. No commitment was desired on either side and discussions are still proceeding. I assure your Lordships that the Government are not trying to rush this question. They are allowing full opportunities for calm and full discussion. Indeed, the suggestion that the Government are hurrying in this matter is an entirely new one, and it must be—or would be if he were here—a source of great embarrassment to my noble friend Lord Nathan, who, only three months ago in your Lordships' House, said:Now, the Government have led this country back to the side lines, to think again, to ponder and consider and take care, while hope burns low and enthusiasm gutters.The Government case is that they have been neither heedless in their pace nor have they been too hesitant to move.
The noble Viscount, Lord Dawson of Penn, himself spoke of the haste and hustle in this matter and of the desire of the Government to overturn the medical profession in six short weeks. He has said that we have to go slowly. No, "slowly" is not the right word. We have to go carefully—as slowly as we roust, but as quickly as our experience will enable us to go. The noble Viscount suggested that it might take two years. Suppose it does; if it is the right thing in the end the two years will not have been misspent. I hope the noble Viscount will forgive me if I say—in the kindest possible way—that his speech was really a good trade union speech such as I have been accustomed to hear and enjoy all fie years of my life.
§ VISCOUNT DAWSON OF PENN
My Lords, will you excuse me for intervening for a moment? I did not say wait two years; what I did say was lay the foundations now and try them out for two years before you try to put on a superstructure.
§ LORD SNELL
I am sorry if I misinterpreted the noble Viscount. All I wish to say now is that a good deal of work has been done, and there is a great deal of knowledge available. We do not lack information. Memoranda have been submitted, and there are many reports, all of which need to be analysed and considered. But there is a wide measure of agreement about the broad lines on which reforms should be made. I do not to-day feel that I can, or perhaps I should say that I do not feel that I ought, to go into the great question as to the free choice of doctor. Lord Derwent complained that a man might go to a public hospital and be compelled to have whatever doctor happened to be on duty. Well, I am not quite sure how far the "free choice of a doctor," as it is called, is a free choice. If you are a member of a friendly society, as I am, when you are ill you go to the doctor appointed by your society, not to one of your own choosing, and he is usually quite satisfactory. Certainly I have never known many complaints about doctors so appointed. If it is true, as the noble Lord said, that there are tired and harassed functionaries, it is no less true that there are sometimes tired and harassed private practitioners doing their work under very grievous difficulties.
I will go so far as to say that the free choice of a doctor is desirable whenever it is possible. The family doctor knows his patient both in health and in sickness; the patient is usually satisfied, and that is a great part, I imagine, in the process of being cured. It establishes a relationship between the patient and the doctor which is more than a six-ounce bottle or a mustard plaster. But, though I say that, I am not among those ultra-loyal souls who would prefer to die under the care of a doctor whom they know and like rather than be cured by a perfect stranger. I think most people are in that condition. Patients are temperamental; they have preferences like other people, and, sometimes, they are, perhaps, unreasonable and irritable. I have been told—I do not know—that doctor- 767 patients are as bad as anybody, and that, sometimes, nurses are the worst of all.
Those who have been good enough to speak in this debate to-day may rest assured that what they have said will receive the most careful attention of the Department concerned. The Government have previously made clear, and they now reaffirm, their decision that they have no intention of seeking to impose upon the medical profession and the existing health services hasty and ill-considered proposals. The Government's procedure is based on the sound principles of concentration, of consideration, and of discussion before action is taken. But the Government are also resolved that while there shall be no irresponsible haste there shall also be no unreasonable delay.
My Lords, in view of the reply given on behalf of His Majesty's Government, which seems to me to be relatively satisfactory, I should prefer to withdraw my Motion.
§ Motion, by leave, withdrawn.