§ 2.44 p.m.
§ Order of the Day for the Second Reading read.
§ LORD SHEPHERD
My Lords, the Bill the Second Reading of which I am moving to-day is only a minor one. I do not mean that it is without importance to the persons who are affected by it, but comparing it with those substantial measures that have passed through your Lordships' House during the last few years, it can only be said to be a small Bill, and, I think, above all, a non-contentious one. The Bill applies not only to England and Wales, but in certain particulars to Scotland also. The objects of the Bill are, first, to elucidate and amend the National Health Service Acts, which prohibit the sale of practices of doctors in the Service and which compensate them for the resultant loss of selling value of goodwill, in regard to partnerships of a mixed character; secondly, to implement promises of amendment made to the medical and dental professions; thirdly, to make certain minor administrative amendments, and, fourthly, to remove certain doubts regarding some of the provisions of the original Acts.
From the commencement of the life of these Acts, great difficulty has been experienced in framing clauses dealing with partnerships and with the sale and purchase of medical practices, and during the passage of these Bills through both Houses of Parliament there have been very keen discussions about the rightness or otherwise of the provisions finally adopted. Indeed, eminent counsel found themselves on opposite sides, and it would seem that even when the Bills had gone through and become Statutes a good deal of discontent remained concerning their effect. My right honourable friend the Minister of Health, giving continuous consideration to these matters, eventually decided to appoint a Committee, under the chairmanship of Mr. Justice Slade, on April 20, 1948, to go into those parts of the Acts which refer to partnerships, and that. Committee reported in November, 1948. The Minister announced complete acceptance of the Report on December 16 last, and the recommendations of that Report are now provided for in the first nine clauses of the Bill which 6 is before us. I am not going to go into those nine clauses in great detail because they are of a most technical character and are not such as a layman would commonly enter into discussion upon; but I am pleased to say that the noble and learned Viscount who sits on the Woolsack will deal with any queries respecting those details that may be forthcoming in the debate. All I, myself, need do, therefore, so far as the first nine clauses of the Bill are concerned, is to deal with the principles involved.
It is desired to give encouragement to the formation of partnerships in the medical profession. It is believed that the establishment of partnerships is frequently a great advantage to members of the profession and to their patients, and there will be as little interference in those partnerships as possible. There is a provision that the prohibition against the sale and purchase of practices shall not be applied to partners who have business arrangements with one another, provided that those business arrangements were concerned in an agreement which existed on July 5, 1948. It will be possible for buying and selling to take place between partners subject to that proviso. Where, as a result of a doctor joining the Health Service, a contract by an outside partner to buy the goodwill of a listed partner is of smaller value than was anticipated in the first instance, then the obligation that may have rested upon the outside partner will be turned into an option, so that he can continue with his purchase or not as he wishes.
Where a partner who had joined the Health Services by the appointed day is required or exercises an option to purchase a share in the business from an outside partner, the former will receive compensation in respect of that share out of a special fund provided by the Government, which will not be derived from the block fund of £66,000,000 fixed in the original Acts for compensation to doctors because of the loss of rights in selling their practices. Where similar agreements exist between an assistant doctor and a doctor owning a practice, similar provisions will be made. It is believed that these principles, if they are operated, will cover most of the instances involved. But in case the principles I have mentioned do not solve all the problems, provision is made in these nine clauses for the appointment of an arbitrator, or a committee of 7 arbitrators, to solve these particular cases. I am informed that while some of these clauses affect all medical partnerships and assistantships there are only fifty of the mixed partnerships which are those principally affected, and the total number of doctors involved in these is only 150. I wish to go no further with the nine clauses, because, as I have already said, they are of an intricate character and can be better dealt with otherwise.
I now come to Part II of the Bill, a much simpler Part for ordinary Members of Parliament and for your Lordships, but none the less important and, I think, of great interest. The first matters I want to refer to are those which arise out of promises made by my right honourable friend the Minister of Health to the professions. There is a question which has agitated the medical ranks for some time, arising out of a fear that there might be established a full-time service under these Acts. Indeed, it is possible under the original Acts to provide that Orders may be introduced into both Houses for the purpose of placing the medical service upon a full time basis; but such a power has existed since the National Health Act of 1912, a day so far back that it preceded the establishment of the Ministry of Health itself. However, the Minister gave a pledge in another place on April 7 which contained these points—namely, that it should be made impossible by regulation to place the medical profession effectively on a full-time basis; secondly, that the Government have no intention of establishing a full-time practice; and thirdly, that the Minister would make this_ clear in any amending Bill that might be forthcoming in a reasonable space of time.
Clauses 10, 11 and 12 of this Bill cover doctors who have entered the general medical service, dentists who have entered the general dental service, and specialists who are in hospitals and in the specialist services. There is one point I should make clear—namely, that there may be cases where the major part of the income of a doctor is derived from the £300 a year now paid to all doctors within the scheme; but those are among the exceptional cases that are allowed for in the particular clauses I have mentioned. The next point has reference to the panel for the Tribunal which settles whether 8 men ought to be allowed to continue in the Health Service, and which has the power to take out of the Health Service those who may be disqualified. This Tribunal is made up of a legal chairman, an executive council member and a member of the profession concerned. The last-named member, who is appointed by the Minister of Health, is at the suggestion of the medical profession to be taken from panels representing the various interests of the profession concerned. The Minister has agreed to that. It will be found in Clause 17.
The next point relates to the costs involved in the establishment of local committees of doctors, chemists and opticians. The professions concerned have suggested that the expenses of these committees should be borne out of a block deduction from the fees to be paid to them. This will enable it to be done without a great deal of trouble, and it has the distinct advantage of maintaining the independence of the professions. Clause 14, which deals with the removal from the list of doctors no longer available to provide services. On the whole that will be dealt with by the executive councils. Clause 20 extends to three months the time allowed to doctors making a claim for their fees against midwives who might have called them in. Dentists are to have the same rights as doctors in taking into hospitals as paying patients those of their clients who do not want to be Service patients. In this matter the Minister takes the view that as 95 per cent. of the population are in the scheme, the number of people out of which private practices can be built up is now so small that they can be given the advantages of the hospital service without getting them unduly in the way of those who are part of the scheme itself.
My next point has reference to the removal of difficulties in the administration of the Acts. In a great service relating to the hospitals, questions of labour and its remuneration are bound to arise. In Clause 13 it is proposed that the Conciliation Act of 1896 and the Industrial Courts Act of 1919 shall be applied. This will have the effect of introducing a service similar to that which prevails in the Civil Service. A special tribunal of the Industrial Court will be appointed to deal with disputes arising out of remuneration or other conditions of service. The 9 precise details of this attempt to settle disputes have not yet been completed. They will be settled by joint consultations effected through the Whitley Council and later I shall be able to give your Lordships if desired the details and the setup of the whole scheme.
Superannuation is a rather important matter and it is dealt with in Clauses 15 and 16. At present only those men and women employed in the Health Service itself are entitled to superannuation, but it has been felt that in a matter of this kind it is well to treat men and women outside the Service, doing similar work, in a similar way. So provision is made, first of all, for the staffs of disclaimed hospitals—that is to say, for the hospitals who have remained out of the scheme, many of which are doing work under contract for the Health Service. Their doctors, their nurses and other officers may be brought into this scheme. Then it is proposed that the medical, nursing and other staffs employed by the Government in the Departments and in hospitals like that of the Pensions Ministry shall also be brought in, because it will be well if there is an interchange of all this skill as between one section of the work and the other, and it will in itself facilitate hospital services.
Further, it is intended to provide that men who are in the hospital service now and who may want to sever their connection with that service for a period shall be enabled to do so, and still remain in the superannuation scheme. Under this head I would like to read a few words connected with the Colonial Service as an indication of the purpose of allowing men and women temporarily to leave the hospital service in this country in order to take appointments elsewhere. There are persons who would like to leave Britain for a time in order to get experience in a special field, but who will not do so unless they can retain superannuation rights. It is highly desirable, for instance, that medical officers should be able to take short-service contracts in the Colonial Medical Service while continuing to contribute to the Health Service Superannuation Scheme. Such an exchange will be of the greatest benefit to the Colonies and to this country. We must not forget that until the Colonial medical schools are able to provide for the full needs of the senior branches of the Colonial medical ser- 10 vice, and unless facilities can be given to enable doctors to serve a term abroad, the implementation of the health service in the Colonies, which is a major contribution to their prosperity and advancement, will be retarded. Such a tour of service has many attractions and advantages to offer. The work is varied and there is opportunity for the doctor to gain a breadth of experience and to wield a degree of responsibility such as is rarely met with in this country. I feel sure most noble Lords will agree that to permit a temporary departure from the Health Service in this country for that purpose will be good, and that it is desirable that those who go to 'undertake that work should have their places kept for them within the scheme I have just mentioned.
May I ask the noble Lord who will pay these medical officers? Will they receive the same remuneration in the Colonies as they receive here? What about benefits, and so on? It is a rather important point.
§ LORD SHEPHERD
We are not providing the basis upon which medical officers and others should go to the Colonies. All we are providing them with is a continuing superannuation scheme, should they enter into contract service abroad. That is the point we have before us to-day.
I now want to speak about the clauses which have been introduced at the request of outside organisations. District nursing associations, and other bodies—for whose services we must give hearty thanks—now find much of their work undertaken by the hospitals and other authorities. There is provision in this Bill to permit these authorities to hand over any property for which they no longer have any use to the Health Services. For instance, if a nursing association possesses a motor car it may be that their trust deeds will prevent their handing over that motor car to the hospital authorities. A clause has been put in this Bill to enable that to be done by modifying the procedure to be followed in those circumstances. Clause 21 deals with another detail—namely, that relating to ambulances. At present, under the English Act the chief responsibility for the ambulance services is placed on the local authorities, and it is frequently found that, because the hospitals are greatest in number and in standing in the 11 boroughs, the boroughs have a great deal of the mileage in their ambulances taken up by servicing patients who may live in county areas. There has been agreement between the two local authority associations, and it is now provided that, when this Bill goes through, it will be possible for the local authority in a borough in certain circumstances to recover charges from the local authority in a county district.
I come now to a group of mental health provisions that are of some importance. Clause 22 requires local authorities to pay fees in certain cases for examinations and reports made by doctors in connection with admission for treatment under the Lunacy and Mental Treatment and Mental Deficiency Acts. Clause 23 validates certain detention orders made under the Mental Deficiency Act, 1913. Clause 24, which applies to Scotland only, enables children under sixteen in that country on the initiative of parents or guardians to be treated as voluntary patients in mental hospitals. This clause will bring Scottish law into line with English law on this point. Clause 25, although cast in general terms, is also primarily a mental health matter. It enables a charge for board and lodging to be made to hospital patients who go out to work in the later stages of their recovery. It is permissive only, and is intended to be used where patients go out to occupations suggested by the hospital authorities.
That completes my survey of this complicated measure. I must confess that it is a somewhat disjointed Bill. It is not one which canvasses any wide principle or proposes any startling change. It is, as I said, a minor Bill—a list of small things promised, of little difficulties to be remedied and of frictions to be eased. This is the first of the National Health Service (Amendment) Bills, but it will not be the last. No apology is made by the Government for introducing this Bill so early. Indeed, I think it is a matter for congratulation that the Government, having found that some adjustment is required, have taken an early step to put it into effect. It is anticipated in the course of time, as the service grows and becomes bedded down, that the Government may have to call upon Parliament to make adjustments. In so doing, however, I think I am right in believing that 12 no attempt will be made to undermine the main principles on which the Acts are based. I beg to move that this Bill be now read a Second Time.
§ Moved, That the Bill be now read 2ª.—(Lord Shepherd.)
§ 3.10 p.m.
§ LORD LLEWELLIN
My Lords, this is rather a happy occasion. The noble Lord who introduced this Bill said that is was only a minor Bill, but had not the promises of which this Bill is the fulfilment been made it might well be that the National Health Service would never have started. Although it is a minor Bill, it does a major piece of work. It divides itself into two parts—one consisting of Clauses 1 to 12, and the other of the remaining clauses. I have taken the opportunity of referring to the volume of the OFFICIAL REPORT of the debate when three years ago the National Health Service Bill was discussed in this House, and I recall statements being made that the partnership clauses in that Bill would not work. The same comment was also made in another place. The difference between this House to-day and last time is rather remarkable, in that last time the noble Lords, Lord Horder, Lord Moran and Lord Webb-Johnson, were all here in full cry, if I may refer to those very eminent medical gentlemen in that way. To-day, showing what a far better Bill this is, all three noble Lords, as your Lordships may notice, are conspicuous by their absence. Therefore, it is clear that the medical profession fully agrees with it.
I do not intend to say much about the last part of this measure; it contains some obviously useful amendments which the noble Lord has detailed so carefully to us. Some of them are amendments which might have been made in any event, and with regard to those dealing with partnerships the noble Lord, Lord Shepherd, said that the Government had no apology to make. I should have thought he would wish to pay a tribute to those of us who said that in its original form the Bill would not work. However, here we are, three years afterwards, in the happy position—that is why I said it was a happy occasion—of seeing what we said three years ago not only coming true but recognised by the Government tQ be a fact.
When I come to Clauses 10, 11 and 12, which deal with the assurances about a 13 prohibition of full-time salaried practitioner service, I look back to October 22, 1946, when I moved this Amendment to the original Bill: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.Your Lordships will see that, put the other way round, that does exactly what Clauses 10, 11 and 12, of the present Bill now do. We argued it; we took it to a Division, and in that Division the noble Lords on the Liberal Benches went in with the Government. Be that as it may, we carried our Amendment and back it went to another place. It was only because we did not wish in any way to be regarded as wrecking the National Health Service Bill, as it then was, that we did not insist upon that Amendment. Hence my delight when I see it here presented to us in a Government Bill three years later, and know that that promise had to be made before the Service could come into effect. Therefore I congratulate the Government in recognising, although at a somewhat late stage, what it was right to do in this matter, and I congratulate them on now bringing in this measure. It was, of course, wise of them in the end to put all these difficult partnership clauses before the expert Committee, over which Mr. Justice Slade presided, and to follow the recommendations of that Committee. Therefore, except to say that the noble Lord might have paid a tribute to us for having suggested this so long in advance, we are delighted to adopt it now that it has been done.
I would like to ask one question of the noble Lord who is to reply. Here we have a National Health Service (Amendment) Bill with a very wide title, which enables it to do anything in regard to the National Health Service. I would Like to ask the noble Lord when he replies to tell us whether the Government intend to use this Bill to effect that part of their economy campaign which they announced—that is, the payment of one shilling per prescription—or whether that will be contained in another measure. Many people in the country consider that the Government measures are not substantial enough to deal with the economic crisis which 14 overhangs us. That being so, it seems to me all the more important that measures decided upon should be put into practice quickly. This Bill seems to me to be the quickest vehicle for that particular change, which I believe will require statutory provision. The noble Lord can tell me whether or not that is so, but it seems that this occasion ought to be taken if the Government are in earnest about the matter.
I note that old-age pensioners are to be exempt from the new charge. I would make this plea, which would not cost much money: Will the Government consider also including in this exemption the disabled ex-Service man who needs medical supplies for his actual disablement? I think those people ought to be exempted just as much as the old-age pensioners; they have incurred their disablement in the service of their country, and they certainly ought to be exempted from this charge. I appreciate that the noble Lord will probably be unable to give me an answer this afternoon, but I make the suggestion in the hope that in the end the Government may be able to take that course. As to the other question I asked—whether the Government intend to use this measure for imposing the charge—I think they should do so. If these things are announced they ought to be done promptly, in order to persuade people in the country and overseas that the Government are in earnest. I therefore hope that the Government will take the opportunity of including the necessary provisions in this Bill during its later stages through this House. I end where I began, by saying that this measure is, as the noble Lord said, non-contentious. Parts of it would probably not have been necessary had the Government accepted the advice of some of your Lordships when the original measure was going through Parliament.
§ 3.22 p.m.
My Lords, I have only a word or two to say on this measure. The noble Lord who introduced it said that it applied to Scotland. As your Lordships know, the writ of the Minister of Health does not run north of the Border; the Secretary of State is our Minister of Health. In many cases, however, the two countries conform and in this case the big dog has wagged his tail and the smaller dog has dutifully con- 15 formed; the parent Act was applied to Scotland with little modification. We in Scotland have the Health Scheme with all its benefits—and all its mistakes, some of which need rectification. Some of these mistakes are becoming evident at the present time, and the medical services in Scotland are working under strain. These are early days to see fully what needs to be done, but we shall assist those services by the proposals before us to-day. In the main, these provisions are the result of the recommendations of the Slade Committee, which included among its members an eminent Scottish lawyer who kept an eye on Scottish affairs.
With regard to the first Part of the Bill, Clause 1, the noble Lord indicated—and it was also indicated in another place—that it had been shown that the numbers of mixed partnerships affected were very small—he spoke of approximately fifty mixed partnerships. But that is not the whole story. The point is not the number of mixed practices that exist but the number of partners up and down the country who were in doubt and perplexity as a result of the parent Act. The British Medical Association were asked if they could give the number, and they were unable to do so exactly, but it seems that there must have been thousands who were in doubt and perplexity about the parent Act. This Bill allays some of that anxiety and provides machinery for deciding by arbitration matters under dispute. The Bill is an important one, and the noble Lord who introduced it was perhaps underrating its importance. It is a case of the child leading the parent—indeed, I think the parent could hardly get along at all if this child did not take him by the hand and lead him over the right road.
As regards the second Part of the Bill, in Clause 12 there is a provision that regulations should not require specialists to be employed whole-time. This is a point which may be developed in Committee; I cannot expect the Minister to deal with it fully now. But I have heard that there is some anxiety amongst specialists in Scotland as to whether this clause is wholly watertight. A case has been instanced to me of a Scottish hospital in which, as a result of administrative action, by advertisement, the door was closed to anything but full-time employment of specialists. The noble Lord 16 might consider whether the wording of this clause is fully effective as a safeguard. I do not desire to make any further points, except to echo the words uttered by the noble Lord, Lord Llewellin. We are glad that the Bill has come forward, and we feel that it is in no way a Party measure—indeed, all Parties have had a share in its making. I hope the Government will take the opportunity afforded by this measure to deal with these changes in the Scheme which they have already foreshadowed in the statement made in another place, and that we in this House shall endeavour to improve the Bill in this way.
§ 3.27 p.m.
My Lords, there is one small point on Clause 24 to which the noble Lord, Lord Shepherd, referred, and into which I should like him to look before the Committee stage. As the noble Lord probably knows, in Scotland a boy of fourteen is considered to be capable of carrying on his affairs in respect of everything except the ownership of a heritage. It is possible that as a result of this practice a boy may not have a "parent or guardian," if he were over the age of fourteen. And in any case it would seem that paragraph (b) of the clause is an interference with what may be the boy's Common Law right—for instance, he might wish to remove himself from a mental home. I do not know that this matter has any great importance, but I am sure that the noble Lord would not wish to alter in any material way the Common Law of Scotland, which is the expression of the independence of its people.
THE EARL OF CORK AND ORRERY
My Lords, in view of a remark made by the noble Lord, Lord Llewellin, concerning what might be included in this Bill as regards economies in the Health Services, may I make a suggestion which has come to me from two different sources—the source in each case being a man of repute and a highly-skilled mechanic? I asked each of them what he thought about this proposed tax. They both said: Why not arrange for the patient to pay the tax on his first visit to the doctor? That would limit the number of people going to see the doctor in the first place, thereby cutting down the mob in the waiting rooms, and it would obviate the need for the doctor to go on prescribing 17 coloured water. It would reduce the number of old women sitting there talking and making a great noise, when probably all they needed was a Beecham's pill.
§ 3.29 p.m.
§ LORD KERSHAW
My Lords, I am not sure whether to regard myself as fortunate or unfortunate in having to reply to this Second Reading debate. There is little that needs to be said, after the remarks of noble Lords who have spoken. We do not cavil at Lord Llewellin's taking some comfort from his belief that he told us these things some years ago. In view of the noble Lord's attitude towards this Bill, we gladly allow him to take any pleasure he can derive from his memory. As I have just indicated. I think there is little I need add, and I feel that it would be abusing the courtesy of the House if I were to make anything in the nature of a speech. I am unable to tell the noble Lord, Lord Llewellin, whether the one-shilling charge which he mentioned will be brought into this Bill, but I can tell him that the matter is under consideration and is regarded as one that should he dealt with promptly, as he suggests.
We noted, too, his suggestion with regard to disabled ex-Service men. He may be assured that that will be considered sympathetically by my right honourable friend. I am not sure from his remarks whether the noble Lord, Lord Clydesmuir, meant that England or Scotland was "the big dog," but we all pay tribute to the progressive services that have been operating in Scotland, long before we had many of them in England. I am unable at this moment to reply to the noble Lord, Lord Saltoun, with regard to the age of children in Scotland under the Mental Deficiency Acts. Therefore, having regard to the great welcome that has been given to this Bill and to the fact that no point, of dispute appears to have arisen, I need do no more than commend it to your Lordships for a Second Reading.
§ On Question, Bill read 2ª, and committed to a Committee of the Whole House.