HL Deb 06 November 1946 vol 143 cc1004-11

Page 26, line 16, at end insert— ("() The remuneration to medical practitioners undertaking to provide general medical services in pursuance of the provisions of this Act shall be fixed by the capitation method except in any cases where the Minister on the recommendation of the Medical Practices Committee considers that exceptional circumstances necessitate remuneration on a different basis.")

The Commons disagree to the above Amendment for the following Reason: Because it is inexpedient that the method of remunerating the doctors providing general medical services should be laid down in the Statute.

11.55 a.m.


My Lords, this is a question of salary, not as opposed to a capitation fee but as an adjunct to a capitation fee. I submit to your Lordships that it is too restrictive to lay down the method of remuneration in the Statute. It has never been done with regard to national health insurance; the method of remuneration has always been left to regulations and settled, as it must be settled, in consultation with the profession. It really would be rather ridiculous if an Act of Parliament were necessary to vary the method of remuneration agreed to by the profession. Secondly, I suggest to your Lordships that it is quite inappropriate that the Medical Practices Committee should be the judge of special circumstances. Under the Amendment we inserted it is for them to make a recommendation to the Minister upon whose shoulders the responsibility for securing the adequacy of the service rests, as it must rest, fairly and squarely.

This question of eliminating the possibility of agreeing that a salary shall form some part of the remuneration would, suggest, be undesirable for other reasons. First of all, there is such a thing as healthy competition between doctors. I do not dispute that, but there is also a danger of that healthy competition developing into a rather unseemly scramble for patients. I have already given your Lordships some illustration of that which came to my knowledge when I was Minister of National Insurance. Secondly, the salary method does assure a modest competence to any practitioner starting practice and it provides a definite vehicle for variation to meet varying circumstances, such as sparsely populated rural areas, for instance, the Highlands and the Highland services and unattractive urban areas. I cannot say what the exact proportion of salary should be in the normal case. That must depend on the consultation which we shall enter into with the profession itself, but the Government's intention, subject to what the profession may say, is clear. It has been said several times. It is that a salary should be an element only, a minor matter, and that the major method of remuneration should be by way of capitation fees. That has been stated by the Minister several times, and was restated when the Commons considered this matter again. In those circumstances I beg to move.

Moved, That this House doth not insist on the said Amendment.—(The Lord Chancellor.)

11.59 a.m.


My Lords, this was an Amendment which I proposed to your Lordships and which was adopted here after a Division on the Committee stage. What some of us were anxious about was to see that there should still be more consideration placed upon the relationship of patient to doctor rather than that of doctor to the State. It was that basic idea which many of us had in mind at the time the Amendment was under discussion in this House. I was supported on that occasion by my noble friend Lord Horder and my noble friend Lord Moran. Both gave similar advice to this House. Let us he fair, however, about this. There is quite a lot to be said for not putting in the Act itself what the exact terms of the remuneration shall be, when the discussions have not been finally concluded between the Minister and his officials on the one side and the medical profession upon the other. There is quite a lot to be said for that, and since we carried this Amendment we have had the statement from the Minister of Health in another place, and repeated by the noble and learned Viscount on the Woolsack to us this morning, saying that it is intended, except, I gather, in exceptional circumstances, that the salary shall be a minor element and the main part of the remuneration shall be by capitation fee. That was an announcement which we had not had before we put our Amendment down, and I think our Amendment has been valuable in bringing those statements both from the Minister and from the noble and learned Lord.

I think we have improved this measure during the course of these discussions in this House. I myself am grateful for the many points on which we were met, most of them without a Division, in this House, and I am glad that the Government have accepted another Amendment of mine on which we were forced to divide in this House. In my original speech on the Second Reading I said—and I think I spoke for all noble Lords who sit with me on these Benches—that our endeavour would be to improve this measure and we were not going to do anything to wreck it. I rise today, therefore, to say that I accept the proposition which has been proposed by the noble and learned Lord on the Woolsack. I certainly would not at this stage wish in any way to wreck this Bill by insisting on an Amendment which just puts in the Bill what probably in any event is going to be the fact.

12.2 p.m.


My Lords, I will not detain your Lordships for many minutes, but I wish to say just a few words in regard to what my noble friend has just said about the spirit in which his Amendments have been received and the attitude taken in another place. I still feel that the principle which underlay this Amendment of the noble Lord when he brought it before your Lordships has not been modified by the Minister, but I do agree that to some extent the position has been clarified. Therefore, when the noble Lord, Lord Llewellin, says that your Lordships have not spent your time in vain in discussing this Amendment, nor in dividing on it, I agree that that is so. The actual words to which the noble Lord has just referred are no doubt as follows. The Minister said that … it is not proposed that the basic element should be the main part of the remuneration. The main part of the remuneration will be by capitation and the basic element a smaller part. That is a statement of faith on the part of the present Minister of Health, and it is true, of course, that he cannot speak for future Ministers.

Nor at present does he say what the regulations may do. If it may be assumed, as I hear it may be assumed, that the regulations on this and other matters will come up for discussion before they are finally put into operation, then I think we may feel more satisfied than we did before this matter was debated two days ago in another place, because it is still possible by regulation to change the percentages of these two forms of remuneration, and I understand it is even possible by regulation to do away with one or other of these two methods. Of course, if the capitation method of payment was done away with at some future time, then the fear which I reminded your Lordships has never been removed from the minds of the doctors, that this was the thin end of the wedge in respect of a national service, would not only remain but would intensify. As to that, again we are assured by the present Minister of Health that we need not be anxious. Mr. Bevan said: Some doctors have expressed fear that this is merely the beginning of establishing a fulltime salaried service … but that is not our intention. Our intention is that the main source of a doctor's remuneration shall be by capitation … and so on. To have got as far as that I think calls for a little gratitude, although perhaps not quite so much gratitude as has been expressed by the noble Lord, Lord Llewellin. Talking to my colleagues in general practice I still find that they are left rather cold by this small morsel of comfort which has been thrown to them. I say in your Lordships' House that if the Minister wishes to have the profession with him, as he said he did and as he realizes is essential to the success of his scheme, he could have gone some way further than throwing this small morsel to, shall I say, the wolves.

Finally, I would like to say that it is still a matter of doubt as to whether or not the doctors are going to come in willingly and enthusiastically to work this scheme. I hope they will. It is odd that so much should be said about their security when they say so little about it themselves. This attitude of the Government of doing certain things under the Act for the sake of the doctors, for example, so that they shall do their work without financial anxiety, and they shall be freed from competition, is odd when, as I say, no clamour in respect of either of those two matters has been heard from the rank and file of the profession. They are not dissatisfied with a certain amount of insecurity when they start, and they are certainly not dissatisfied with a healthy spirit of competition as they go on. So they remain not enthusiastic about this scheme in respect of their freedom and the way of doing their own work. However, as I say, I agree with the noble Lord, Lord Llewellin, that the Amendment which your Lordships passed in this matter has not been without at least some effect.

12.9 p.m.


My Lords, I sometimes fancy that the noble and learned Lord on the Woolsack is as averse from violent and extreme measures as I am myself. I would like on behalf of the profession to which I belong to thank him for the reasonableness which he has shown in the discussions on this Bill. I am sorry that the noble and learned Lord has called this Amendment, which we considered fundamental, a blemish on the Bill. I am sorry because I think not only that it is fundamental but that it is very important even at this late hour that we should know exactly what is the doctor's attitude towards this particular thing.

I have read and reread Hansard and I have listened to all that has been said in defence of this basic salary. It really boils down to two arguments, if your Lordships would consider the word "argument "to be not too weighty to describe what has been said in support of it. The first argument is that it is a measure of security for the young practitioner beginning practice. I notice that the noble and learned Lord on the Woolsack has not used that argument. In his profession the casualties in the early years are, I believe, much heavier than they are in my own. One might have imagined that he would have gone to his own profession and suggested a basic salary to prevent those casualties, but he has not done so. I imagine that he has not done so because his judicial sense would be affronted by providing security for the youth of one profession and denying it to the youth of another. Again, he has not done it, because barristers do not want a basic salary. Neither do the doctors.

As the noble Lord, Lord Horder, said, that is almost a unanimous opinion. The doctors find it very difficult indeed to know why the political world is so anxious to provide them with security for which they have not asked. I was Dean of a Medical School for twenty-five years, and each year about sixty or seventy men qualified and went into practice. Throughout those years I never once heard the question of security discussed; it was a fundamental belief throughout the profession that there was something profoundly wrong with a man if he could not make a livelihood in medicine. I would go so far as to say that this question of a basic salary is a figment of the political imagination and has no support in the facts of the doctor's life. I would say that it is a debating point and no more.

The second argument fiat has been used in support of the basic salary is that payment by capitation fee leads to abuses and undesirable practices. The noble and learned Lord has said that there have been instances of lax and even dishonest certification. In another place the Minister said the panel has frequently become undesirably swollen because some doctors have apparently made enormously long prescriptions, including many drugs—not so that the blunderbuss should hit the target but so as to impose on the credulity of their patients. I do not for a moment say that there are not black sheep occasionally, but these storms which come up from time to time are not really evidence. But even if they are, let us accept them. The noble and learned Lord said that it does not apply to many doctors, and in another place the Minister said it does not apply to anything more than a very small proportion of doctors—I think those were his words. So we have their case built on isolated instances. Because there are a few black sheep, we are going to have the whole of the remuneration of all the rest of the honest members of the medical profession altered, and altered in a way which the profession almost unanimously feels may result in a deterioration of medical practice in the future.

Perhaps your Lordships will allow me to make two final observations. The first is that I am very glad that the noble and learned Lord says this refers only to a very small minority of the profession, because presently this Bill will become law, and when it does become law, the vast majority of the profession will work under it. It is of enormous importance that they should have confidence in the Ministry of Health and it would not really contribute to creating that confidence if there were any impugning by the political world of the honesty of the great body of the profession.

The second observation I wish to make is simply this. There has been a considerable amount of puzzling in the medical world about this particular Amendment. The debates on it have seemed to them to be almost unreal because, generally speaking, doctors do not believe that the reasons which have led to the introduction of a basic salary are the reasons to which I have been referring. They do not believe that the zeal and fervour of the rank and file of the Labor Party for this basic salary is inspired solely, or even mainly, by solicitude for young practitioners starting practice. In a word, they think it is an instalment—an instalment which they profoundly believe may conveniently be added to from time to time—towards a condition of affairs which will ultimately result in the basic salary becoming a whole-time salary. I accept entirely what the Minister said in another place as to his intentions; but Ministers of Health come and go, and this principle remains as a basic faith on the part of the Party which has so often expressed it. That is why there is this great anxiety. Let me say that if ever this basic salary does become a whole-time salary, you will embark upon a condition of affairs whose effect upon the proficiency of the profession it will be impossible to calculate.

On Question, Motion agreed to.

[House adjourned at seventeen minutes past twelve o'clock and resumed at two o'clock.]