§ 3.9 p.m.
§ LORD MORAN rose to ask Her Majesty's Government whether they are satisfied that the terms of reference of the Royal Commission on the professional remuneration of doctors and dentists in the National Health Service will provide the necessary basis for a full examination of this problem; and to move for Papers. The noble Lord said: My Lords, in the early days of the National Health Service two Committees were appointed by the Government to deal with the remuneration of general practitioners and consultants respectively. Sir Will Spens was chairman of both Committees, and the recommendations of those Committees have come to be known as the "Spens Reports". I do not think that there is any doubt now that the recommendations of these Spens Reports were accepted by Mr. Attlee's Government; I believe that is generally admitted. But since, in this controversy, it seems rather easy to forget events of the past, I should like for a moment to remind your Lordships of the substance of ministerial statements on those recommendations.
In July, 1946, the Permanent Secretary to the Ministry of Health wrote to the British Medical Association stating:
The Minister fully accepts the substance of the recommendations.
Three years later, in January, 1949, the Parliamentary Secretary to the Ministry of Health said in the House of Commons that the remuneration of general practitioners would be adjusted to give effect to the Spens recommendations. In May, 1950, Sir William Douglas, Permanent
Secretary to the Ministry of Health wrote a letter in which the following passage occurred:
The Minister agrees that the Spens Report remains the basis of the remuneration of general medical practitioners until such time as after the usual consultations some other basis is substituted.
Nor is there any doubt that the Government knew the precise meaning of those recommendations. They were interpreted then in the same way both by the Government and by the doctors. I can testify to this because I happened to be a member of the Spens Specialists Committee at that time, and I was in close contact with the Ministry of Health. I say this because the noble Marquess, Lord Salisbury, in announcing the Royal Commission, said that the interpretation put upon the Spens Reports by the profession could not be accepted by the Government. The Government appear to have first expressed doubts about the interpretation of Spens when a Judge of the High Court, Mr. Justice Danckwerts, awarded the general practitioners £40 million in 1952. From that day until now the Government have been anxious to get rid of Spens.
§ I do not want to bring forward these facts in any controversial spirit, but I do want your Lordships to understand how these recommendations appear to the doctors. Mr. Attlee's Government may have been ill-advised to accept these recommendations and to promise to implement them; but the fact remains that they did accept them, and that it was upon that acceptance that many doctors entered the Service. That being so, I think your Lordships may feel that in all the circumstances these recommendations cannot be thrown upon the dust-heap just because they have subsequently proved inconvenient.
§ If the Royal Commission interprets their terms of reference so that they are not required to pay regard to what has happened in the past, if they are going to make a fresh start dealing merely with future scales—if, in a word, they are going to ignore these obligations, then I say deliberately that they are wasting their time; they will not allay the discontent among the doctors, nor will they provide a lasting solution of this question of remuneration. I should like to ask the noble Earl, Lord Home, when he replies, 1099 if he will say whether the Royal Commission will or will not take into account the Spens Reports; and if the answer is in the negative, I trust that, even at this late hour, the terms of reference may be changed. There is, I understand, a recent precedent for this, because the terms of reference of the Royal Commission on Taxation were altered halfway through their proceedings. I press this matter because, with the present terms of reference, we shall get nowhere.
§ As I have said, when the doctors went into the National Health Service they understood quite clearly that the cost of living would be taken into account when their pay was reviewed from time to time. Nevertheless, I trust that the doctors will not try to bind the Government to a literal interpretation of Spens in perpetuity. I know that this will excite the wrath of a section of my profession, but if we are to get a settlement of this dispute that will be mutually satisfactory to the Government and to the doctors, there must be give and take on both sides. However, if the doctors are to give up Spens, or at any rate, the literal interpretation of Spens—namely, that every rise in the cost of living will be met by a rise in the salaries of doctors; if these pledges are to be thrown away, if the doctors are to go into the future with no yardstick with which to measure their remuneration, then I think that your Lordships may feel that they are entitled to some quid pro quo.
§ On this particular subject I do not feel that I am entitled to speak for the general practitioner and I ought to make it clear that even in the case of the specialist, there has been no vote on the subject. In the summer, however, I spent two or three months going round the country, speaking at meetings of consultants, raising these questions in debate; and I think I can assure your Lordships that the proposal I am about to make would receive very substantial support from the consultants. They feel that if they are to get a rise in remuneration, that, by itself, will not be a final solution. Presently the cost of living will go up and there will be another claim; and this will go on and on until the Government and the country become exasperated. The Government may even be led to set up a whole-time Service. What is needed even more than a rise in pay is some reformation of the arbitration 1100 machinery. At the present time, if there is a dispute between the consultants and the Government, it is referred to Whitley Council B. This consists of two halves, the doctors and the officials of the Ministry; and only if they agree, can a dispute go to arbitration. But in all matters of substance they never do agree. The Government see to that. They exercise their veto precisely as Russia exercises her veto in the Security Council. The result is that the consultants generally have lost confidence in this machinery.
§ What would they accept in its place? The pattern is clearly set forth in the Royal Commission's Report on the Civil Service. In November, 1955, the Royal Commission reporting on the Civil Service recommended that a special advisory committee should be appointed by the Prime Minister to supervise the pay of the higher ranks of the Civil Service. That Committee has since been appointed. It is precisely what the specialists need.
§ If such a Committee were set up, I should probably be asked at once "Will the consultants be content with the reformation of the machinery of arbitration, or will they ask also for a rise in the remuneration?" That is a fair question, but it does not perhaps display a very intimate knowledge of the architecture of my profession. It is essential that there should be a balance of proportion between the pay of general practitioners and the pay of consultants, or recruiting to the ranks of specialists will suffer. There comes a time in the would-be consultant's life when he has to choose between two alternatives: between going out into general practice, with the rest of his contemporaries, or staying on at his hospital for four, five or more years in order to obtain the higher degrees and also in order to fill the posts of junior and senior registrar. Those years are years of penury. The salaries are small and it is a period of anxiety, because the would-be consultant does not know whether, in fact, he will ever become a consultant.
§ In these days, when most men marry young, no man is going to ask his family to go through these years of anxiety and penury unless he has some assurance that at the end of it all he will receive some material reward when he becomes a consultant. In 1954 this fact was clearly recognised. It was seen by the Government that when £40 million had been given to the general practitioners and 1101 nothing to the consultants, the whole balance between the two branches of the profession had been upset. The deans of the medical schools were in no doubt that, unless this was set right, the recruiting to the ranks of the specialists would suffer. The Government therefore in that year made a grant to the consultants which I call the Danckwerts equivalent. I think we consultants owe the Danckwerts equivalent largely to the noble Marquess, Lord Salisbury, and that his resignation at this juncture is a mishap to the doctors, because it removes one of whom we came to believe that the merits of the case far outweighed political expediency.
§ Now let me come to the crux of what I have to say—that is, the terms of reference of the Royal Commission. Before doing so, perhaps I may for a moment dwell on the inconsistency of the Government in pressing every section of the community to go to arbitration except the doctors. But let that pass. What is provided in its place? A Royal Commission. Can your Lordships imagine the Minister of Labour facing the shipping and engineering industries, when they are asking for a rise in wages, and fobbing them off with a Royal Commission? The doctors feel that they are being treated differently because they have no political power; and that, of course, produces bitterness. Nor were the doctors better disposed to the idea of a Royal Commission when, on February 20 this year, the Minister said to the representatives of the negotiating committee that if the Royal Commission found in the profession's favour, and if the economic situation of the country remained the same, it by no means followed that anything would happen. Apparently, the findings of this Royal Commission are to be taken seriously only if they are in the Government's favour.
§ But what really aggrieves the doctors is the actual terms of reference. Royal Commissions are generally free to gather in information wherever they can find it; in fact, "all relevant factors" is almost a cliché in the circles that deal with Royal Commissions. But what has happened to this Royal Commission? It is the Government who direct the Commission what they may and may not consider. It is the Government, not the Royal Commission, who decide the considerations that bear on the remuneration 1102 of doctors. And these considerations boil down to a specific comparison with other professions.
§ I have no doubt that if the Royal Commission have access to the Inland Revenue files, as I presume they will have, it will be possible for them to compare the incomes of members of various professions. But the hours of work differ completely: the doctor is at the beck and call of the public at any minute in the twenty-four hours. Moreover the length of the training varies enormously as between one profession and another. Then—and this is the crux—the responsibilities are not comparable. We all make mistakes; but if doctors make mistakes their patients may pay for them with their lives. There is nothing like that in any other profession. A leading architect, who agreed with me on this point said: "At least we cannot kill people." But what really aggrieves the doctors is that these terms of reference have been so drawn up that they limit discussion; they exclude points which are greatly in the doctors' favour, and prevent them from bringing forward their case properly. I am sure that that was not the intention of the Government, but that is how it is going to work. It is surely quite wrong.
§ For a moment I must digress to a detail. Your Lordships may already have surmised that the doctors do not expect very much good to come out of this Royal Commission. But I am concerned that harm does not come from it. I am thinking, in particular, of what are called "merit awards". These awards were brought in, at the beginning of the Service, by Sir Will Spens, a layman, and were approved by a Committee comprising a majority of laymen. They were introduced as an incentive. It was seen that by going into a Service the doctors would lose the competitive stimulus. These merit awards, were given to a third of all consultants and made a substantial addition to their income.
§ At first, the idea of these merit awards met with some suspicion in the profession. It was felt that the London medical schools might swallow them all up, and that the consultants in remote parts might be forgotten. For the last seven years, for two months every year, I have been holding meetings of consultants to show them precisely how this 1103 system is worked, to let them ask questions and to gain their confidence in its working. There can be no doubt that at the moment the system enjoys the confidence of the great majority of the consultants, and they would be most aggrieved if anything happened to these merit awards. Is this delicate plant now to be taken up by the roots to see whether it is growing well? I would ask the noble Earl who is to reply whether the Royal Commission will go into details of this kind; whether, in fact, they will consider these awards.
Before I end, I should like to give your Lordships some of the background to this dispute, because it is a symptom of a good deal of unrest in this Service; and if your Lordships are to understand that unrest you must for a moment get into the minds of the doctors. When certain industries were nationalised, the workers welcomed it. But when medicine was nationalised, it was carried over the heads of the doctors by the politicians; the great majority of consultants were aghast that their whole way of life was being altered and that they were being put into a Service. I was one of a minority—I think a small minority—which supported the National Health Service Act and tried to work for its good. I did that, not because I believe that doctors necessarily work better in a Service than as individuals, but because I felt that it was politically inevitable; that all three Parties were committed to a comprehensive Service for the whole country, and that if such a service were to come into being the doctors must help to shape it. This attitude of a minority created great bitterness. A doctor in the North of England, whom I did not know, wrote to me to say:
I am glad you will not live to see the result of your sins.
I mention that to your Lordships because I want you to grasp that the situation we are discussing this afternoon goes far deeper and is far more fundamental than any question of finance.
§ We hoped that the doctors would be won over by an enlightened policy. I think we dreamt of another Morant whose imagination would enable him to put himself in the shoes of these disgruntled doctors. We had in mind the kind of man who is still upset when he reads Defoe's story of a child of four in full 1104 employment—though he has long ago forgotten the details of the Battle of Blenheim. It worked out otherwise. It has been heartbreaking to see all this bungling and mishandling of the human element. I do not think Her Majesty's Government can be acquitted of blame. Successive Administrations have been more concerned with the cost of the Service than with putting their minds to making it work.
§ Forty years on, the Trevelyan of that time, when he is writing the social history of our day, will be puzzled by the levity of our behaviour. While we boasted of our Welfare State, we banished the Ministry of Health from Whitehall and dropped the Minister of Health from the Cabinet. The historian, with his eye for significant detail, will probably unearth the fact that while Sir Russell Brain was President of the Royal College of Physicians for seven years, he had to deal with six different Ministers. He may even go on to unearth another fact: that another President worked with sixteen Ministers since Mr. Neville Chamberlain's time. I recall two of these with gratitude and admiration. For the rest—well, all I can say is that their average life as a Minister of Health was twenty months; nine of them served for less than a year. I have the impression that if they had stayed a little longer they might have caught a glimmering of what it was all about.
§ The faults, of course, were not all on one side. Some of the doctors were un-co-operative. Many had spent half a lifetime under other conditions working as their own masters, and they were not likely to be reconciled in their lifetime completely and fully to the very different conditions that obtain in a Service. Nor did it help that in some regions they were treated as employees, instead of being called in as partners in a great enterprise. It is from the fringe of this section of disgruntled doctors that we get appeals from time to time for a rise in remuneration—appeals which are in themselves just, but which are not always made at the most expedient time. I myself regret that this question was brought up at this time.
§ From the same section come threats of violent action. I think that somebody in my calling should get up and say, as I say now, that many doctors are completely out of sympathy with any violent measures of that kind. We must look 1105 to public opinion for justice. As doctors, we can do no other. During the war, General Eisenhower found that unless British and American officers were friends, and worked together without criticising each other, he could get nowhere; and anyone who transgressed this unwritten law just disappeared. We desperately need a General Eisenhower in the National Health Service. We need a different spirit, we need to make a fresh start. Let the new Minister, who has an immense opportunity, leave his desk; let him take wings and go out into every part of the land, making friends everywhere with the doctors. I think he will be surprised at the response. Then, and only then, will the country get some value for the immense sums it is spending on this Service. At the end of my life, with some experience of doctors, I beg the Government to think again. My Lords, I beg to move for Papers.
§ 3.34 p.m.
§ VISCOUNT ALEXANDER OF HILLSBOROUGH
My Lords, I am sure that noble Lords in all parts of the House will feel that they have listened to a very remarkable speech. It was a speech delivered by one who reached the highest peak that could be reached in his profession, especially on the physician side, and who has given unstintingly from his life, not only to the service of his profession but to the service of the nation, as was evinced by his own personal self-sacrifices from his other duties in the course of the war. One cannot but have been struck as we listened to the power of the speech. It seemed to me all the time that the noble Lord would have been equally successful as a great counsel at the Bar, as he mastered his subject and presented it in such complete sequence and in so convincing a manner. I felt that all the time that he was speaking. Moreover, it seemed quite clear that the noble Lord, as was evinced in the latter part of his speech, was not speaking with any kind of bias. His quite free remarks about certain aspects of the views taken by members of his profession made it clear that he seeks no more than, first, the good of the health of the nation, and, secondly, that justice may be done in the matter which has now been put under the review of a Royal Commission.
1106 I have taken little part in the Ministry of Health and its various operations in the course of my own ministerial life, but I have watched with considerable concern the development in the medical profession, in the last two years especially, of the feeling that they were not being, or were not likely to be, treated properly. I have a great many friends among doctors. I have been the President for thirty years of a hospital which is still outside the National Medical Service and which is entirely self-suporting, and needs to choose its doctors, consultants and various representatives of the profession with great care and to watch closely the effect of the treatment and the way in which the treatment is carried through.
I would say that the background to which the noble Lord, Lord Moran, drew attention towards the end of his speech was properly and, I think, accurately presented by him. I have watched the medical service grow since it was first as a whole placed under State control. There were serious objections to the scheme at the time in the profession. But I am bound to say that, looking at it largely as one who was at the head of a great voluntary hospital, I believe that in every respect the service in the medical profession within the National Health Scheme has steadily expanded and improved at every point, and that the effect upon the health of the nation has been magnificent. In these circumstances, what have we to do about the request which is being made by the noble Lord, Lord Moran, to-day? It seems to me that it is incumbent upon us to urge upon the Government that the terms of reference of the Royal Commission should be so amended as to bring each one of the cases cited by the noble Lord within the consideration of the Royal Commission, and that they should not, as a Commission, be in any way hamstrung by the special tags in the terms of reference which prevent them from looking at the matter with the wide, broad outlook that surely ought to be adopted if we are to deal with the grievance of the profession as it exists to-day.
Now what is the grievance? I think the grievance is largely in the same kind of spirit, but not engendered from exactly the same causes, as one sees in the major disputes that have occurred in our country. It seems to me fairly clear that, 1107 from the time of the Danckwerts judgment in 1952, the medical profession as a whole, in spite of the constant rise of the inevitable costs in their profession, took no real steps to ask for a steady annual review of their remuneration in relation to costs. It is only within the last eighteen months to two years that they have drawn attention to these serious rising costs, and they have had little sympathetic consideration of those claims. If my recollection is right, as I think it is, at the end of 1956 the doctors were quite coldly and coolly told that nothing was to be done for them in spite of the rising costs. As I meet a good many of the doctors both in London and in different areas, I can see that that gave rise to a very serious grievance.
On the other hand, I entirely agree with the noble Lord, Lord Moran, that, so far as my own soundings go, there are a good many doctors who do not wish a special organisation to be made in order to try to bring extra special pressure at the moment. At the same time, however, they ask that justice shall be done in the inquiry which the Government have now decided should be set up. I feel that the Government—I can say from this side of the House what the noble Lord would not wish to say from the Cross Benches—in this as in some other matters have been a little ham-fisted. Not the present occupant but the prior occupant of the office of Minister of Health made that non possumus statement to the medical profession that nothing could be done except to set up a Royal Commission on the matter. He did not show the kind of sympathy and judgment to be expected in a Minister or in a Government which had in their hands two such grave questions—the future of a great profession and the health of a great community.
§ 3.42 p.m.
§ LORD AMULREE
My Lords, before I begin the few remarks I wish to address to the House, I should like to thank the noble Viscount who has just sat down for the staunch support he has given us. He has spoken for my profession in a way in which we ourselves would feel debarred from speaking because we are members of that profession. It gives us encouragement to know that the Leader in this House of one of the great Parties feels so strongly about what the medical 1108 profession has done and deserves. One of the things which I think should come along fairly soon, now that the National Health Service has been running for about nine or ten years—I think it came into being about ten years ago next year—is some kind of Commission or Committee of Inquiry. This should be set up to go into the various aspects of the Service, not because I think it is fundamentally unsound or wrong but because, when a great experiment has been running for ten years, it is due to those engaged in it that some stock should be taken as things go along. Therefore, I should like to see some sort of inquiry taking place in the fairly near future.
But what the Government have done is to set up a Royal Commission only upon the payment of the doctors. That, I feel, will not get very far. It will leave a great deal undone. I do not think it is going to be very easy to compare the wages or salaries paid to the medical profession with the wages or salaries earned by other people, because, as one of the two noble Lords who has just spoken pointed out, the work of the medical profession is so different from that of the other professions. If you are going to try to correlate, from an official point of view, salaries and work, it will be difficult.
I should like to call your Lordships' attention to two facts which I hope the Commission will take care of, one of which may come into the terms of reference for the Commission. The first point is very important: that is, to go into the question not only of remuneration but also of the method of remuneration. That may not sound very clear, and I will explain it. In the times before the Act came into force, it was possible for a general practitioner who was a good and popular doctor to move up in the quality of his practice. Although possibly he did not have to see a great many more patients, he did contrive to make more money, because the patients he saw were prepared to pay him more as he was a good doctor. That went on for a long time, but there were certain drawbacks to it. It may be said that a person could get a better type of medicine if he could pay than if he could not pay. I do not think it worked out like that, because a large number of doctors in the poorer 1109 practices gave better service. There was a possibility that a good general practitioner would make a substantial amount of money, possibly more than his colleagues. He could do that without being forced to take on more patients than he could possibly treat carefully.
That is one of the difficulties here. If a doctor wishes to increase the amount of money he gets from his practice, he has to take more people on to his list. With these large lists of 4,000 or so people, it is difficult for many doctors to give proper service. That is what I meant when I said that I should like the possibility of making some change in the method of payment of the general practitioner to be considered. I do not want to suggest what that should be—that is the point for the Royal Commission to consider.
With due deference to the noble Lord, Lord Moran, I would point out that a system was worked out whereby consultants had more money given to them. That was an incentive to them to do more work. At the present time, the practitioner has no such incentive, because the only way for him to make more money is to take on more patients than he can properly cope with. One of the difficulties is that when people are paid from public funds it is important to come to some satisfactory arrangement whereby their money can be increased. If they do not get paid extra salaries, they in a way pay a higher standard of taxation to the Government than other people do. They pay less of the ordinary standard tax, but they pay a concealed tax because they do not get enough money to enable them to cope with the increasing cost of living.
One has to be careful not to insist that one profession alone should be tied to a regular increase when the cost of living goes up. That would not be fair. Speaking as a member of the medical profession, I would not suggest that. I cannot talk either for the consultants or for the practitioners, but I am sure that none of us would wish to be put in a special privileged position as opposed to that of other people. We are in our present: frame of mind because we feel we have not been given what we were promised.
I have one more point which is a minor one but which is causing a certain amount of disquiet amongst practitioners. It is the question of holidays. It is fairly 1110 simple if a person has a partner or if he is a member of a group practice; he can take a holiday, because it is possible for the other partner to carry on without his having a locum tenens to assist him in his work. I was talking the other day to a doctor who is a youngish doctor in London and who is doing quite well. He has no partner. When he wants to take a holiday he has to pay a locum tenens for the time he is away. If he wants to get a good locum tenens, he has to pay him the sum of £25 or 25 guineas a week, which adds considerably to the cost of the holiday. Most people now get holidays with pay. This is a minor point, I agree, but it is one which is of some importance to the medical profession. There are many more points that I could bring forward, but I do not wish to take up your Lordships' time. It is because of the two facts that I have mentioned that I feel that something should be put into the terms of reference of the Royal Commission, to enable them to deal not only with remuneration but also with the method of remuneration.
§ 3.50 p.m.
§ LORD HADEN-GUEST
My Lords, I am glad to have an opportunity of taking part in this debate because I was once a doctor (and medically speaking, I still am, although I have not practised for many years), my father was a doctor, and I was brought up in a doctor's house. I lived in, Manchester in the days before panels and that kind of thing were in existence, and my father had a large practice. Frequently I have assisted a dispenser on my father's premises at half-past ten in the evening—my father did all his dispensing at the surgery. I suppose that he had the largest practice in Manchester, so that I may claim to have been brought up surrounded by the influences of the medical profession.
But I never thought, and I know that my father never thought, primarily of the income that he was going to get. He did get a substantial income. If he had been present at this debate he would have found himself in a strange atmosphere, because I am quite sure—and I believe Lord Moran would agree with me—that normally a doctor is not a person who thinks primarily of the amount of money he is going to get. Of course he wants an adequate income, but he is not primarily concerned with making money. 1111 And, as I say, I know that my father was not primarily concerned with making money. The professional doctor is a quite different person from somebody who is in big business and who is making a lot of money. He is in a quite different position from that of the purely business man. Even at present, when many complaints are being made, I feel that the doctor is in a better position than many people who are in other professions.
I feel that we ought not to exaggerate in this matter. A person who is really a doctor loves his profession. He does an immense amount of work, a great deal of it as a volunteer, and frequently without being paid for it. That, I believe, is the attitude of a large proportion of people who go in for medicine as a profession. They want to do this work; they are interested in it, especially from the scientific point of view; and they find in it a satisfaction of their desire to be doing something useful, something interesting and, if they go into various sidelines of the profession, something which may take them a long way. For instance, I spent a large part of my time as a doctor in military service. I spent a great deal of my time in South Africa, and for a long time I was chairman of the medical committee which looks after the provision of doctors for the Services, in the course of which occupation I visited all the places in the world where British troops are employed, and reported on what they were doing. That is a career which is open to a doctor. There are doctors in the Services. They have not been mentioned so far but they do extremely good work, and the level and value of their work is certainly increasing.
It is also true, I think, that in the public health service, as medical officers of health and so forth, there is opened another line of work upon which doctors can be employed and can do the most valuable work. There is the work of the school doctor, which is now one of the most important features of doctoring carried on in this country. A good many years ago now the London County Council asked two other doctors and myself to visit the schools in London and to report on whether it was desirable to have a school medical service. At that time there was no school medical service 1112 and no school treatment service. As a result of the report which we made to the London County Council, these two services were set up. I instance that only as one of the numerous types of work which can be done. There are not only medical practices of the ordinary sort—specialists sitting in consulting rooms in Harley Street, and in other parts of the country, such as Edinburgh. We have in the medical profession a wealth of work connected with the health of human beings which is of the greatest possible value and, moreover, to anyone who takes an interest in his fellow citizens, of immense interest.
Primarily speaking, as I have said, a doctor is not a man who is thinking about money. Quite often, a doctor makes a lot of money; but he is not like the man in big business, sitting in his office intent on the amount of money which he can earn. He has no particular desire to make a lot of money. Of course, a doctor wants an adequate income, but I am convinced that he is a man who, to a large extent, has to live, whether or not he wants to originally when he starts on the work, a life dedicated to his profession. That is not so with somebody in the big office in the City carrying on large financial transactions. It is a different kind of life—the money is earned in a different way. The amount of money which can be earned by a doctor in any kind of practice or in any kind of appointment, whether it be a colonial appointment or some other sort, may be much less than would be earned in any ordinary business. The life of the doctor is something to which he dedicates himself.
I came into politics because I did a large part of my work as a school doctor—in fact, as one of the three school doctors who laid the foundations of the London County Council school medical service as it is at present. Our report was accepted and the Service came into existence. I believe that the doctor has to live a professional life and to consider only secondarily the amount of money he earns from it. Of course, he must get enough to live on. He must get enough to bring up his family in a proper way, and of course he must do work which is valuable to the community, There are many ways of doing that—ordinary medical practice is only one. There is the practice of a specialist, as well as that of the general practitioner. 1113 I will not emphasise further my particular point of view, but I say that a doctor must be a dedicated person. He must be someone who works very hard indeed—in fact, my father killed himself; he died at the age of fifty from overwork and other illnesses. I think that this profession will need to be treated differently from that of, let us say, stockbroking or other work of that kind—not that I have any objection to stockbroking in its proper place. I only emphasise that the medical profession is a different thing altogether and should, I believe, be treated in a different way altogether.
§ 3.59 p.m.
§ EARL JOWITT
My Lords, may I add a word? I do so, first, because, I am sorry to say, my noble friend Lord Silkin, who was to have taken part in this debate, has been called away for other important public business and is not able to be here. The second reason why I wish to say a word is because ten or eleven years ago I was the Minister responsible for piloting the National Health Service Act through your Lordships' House. Believe me, it was not an easy task at that time. At the request of the Minister of Health I went to see and to address meetings of doctors in various parts of the country, so that I feel some little responsibility at the present time to see how this service is working.
May I expressing a purely personal point of view, just say this: whatever happens, I very much hope that the doctors will abandon any idea of what is called a "strike". For my part I believe that these strikes are getting far too common in this country. They are really an effort of pressure to advance private interests without due regard to the public interest concerned. Though it may be an unpopular thing to say, and especially unpopular on this side of the House, I feel that everybody must consider his own claim in the light of its impact on the general well-being. Therefore I would pray that we may accept far more generally the principle of arbitration, rather than resort to force, pressure and the like to win the desired ends. I say that whatever may be the answer to the rest of this matter, for that is my sincere personal hope.
I have tried in the past to show myself a friend of the medical profession. I am certainly a profound admirer of what that 1114 profession has done, and of the ethics of that profession. So let us try in this connection not to talk of strikes, for I believe that is beneath the dignity of the doctors. On the other hand, I think it follows from that—as I believe the noble Earl the Leader of the House will agree, for he is always fair-minded—that if there is to be arbitration, or its equivalent, each side has a right to make its claim and put forward its case. Then the tribunal adjudicates on the two cases put forward.
I have no word of complaint against the tribunal selected in this case, but our trouble at present is that the doctors are dissatisfied with the tribunal's terms of reference. They think that the terms of reference do not give the arbitrators that freedom of opportunity to decide which the doctors desire them to have. They may be right or wrong, but I feel that they have some reason for thinking that. If one compares these terms of reference with the terms of reference of the Spens Committee, one cannot but be impressed at once with the difference between the two. If there is to be arbitration, as I devoutly hope, my only plea would be that we should start by having the doctors reasonably satisfied with the terms of reference under which the arbitrators are going to sit. If they are not, then they are not really being given the benefit of arbitration.
Speaking for myself, I am by no means in favour of a sliding scale whereby the remuneration of doctors automatically varies with the cost of living. I do not think that that is practical, but I would not limit the arbitrators in any way. I would let the doctors put forward their case as they want it put forward, and let Her Majesty's Government put forward their case without any strings at all. Let those cases go before the arbitrators (I believe that we have very good arbitrators here) and let them strike a happy balance between the two and find out just what is right. It seems to me that the whole benefit of arbitration is destroyed if you put before the arbitrators a remit which one side, not unreasonably, considers an unfair remit. That is not arbitration of any value at all. I beg the noble Earl, in the difficulty in which we are in—for this concerns all of us—to accept that principle, to grasp the principle of arbitration; and I beg the doctors to do 1115 the same, to stop all this talk of a strike and to accept the principle of arbitration, letting it be seen that that arbitration is manifestly fair to all interests concerned.
I would beg the noble Earl the Leader of the House to use his influence, as has been done several times, in my knowledge, so that where the terms of the remit are found inadequate to embrace the whole dispute they may be enlarged. That should not be done by letters but regularly, enlarging the terms of the remit and putting the whole matter before the arbitration tribunal. Her Majesty's Government are not bound to accept what the tribunal decide, any more than the doctors are bound to do so, though I sincerely hope they will. At any rate, we shall in that way get an impartial, quasi-judicial hearing of the whole matter, and there is every reason to hope that the two sides will then be bound by it. That would be setting an example on the part of both the doctors and Her Majesty's Government. If it is not too late, I beg the noble Earl the Leader of the House to use his influence to bring about that end.
§ 4.7 p.m.
§ LORD CONESFORD
My Lords, I had not intended to speak at all, and nearly everything I might have said has been said very much better by the noble Lord, Lord Moran, whose remarkable speech delighted the whole House. My excuse for speaking is similar to, though different from, that of the noble and learned Earl who has just addressed the House. At the time when the Statute was being carried through Parliament I was a member of the Opposition in another place, but I numbered among my constituents very many doctors because the great universities which I represented had great medical schools. In fact, only one Member had more members of the medical profession among his constituents than I had.
I know something about what doctors thought then and think now, and I very strongly support, in essence, the plea just made by the noble and learned Earl who spoke from the Opposition Benches. It seemed to me that he made one mistake in phraseology which in no way affected his argument. He talked about this Royal Commission as an arbitration tribunal, 1116 but of course it is nothing of the kind. Again and again the doctors have expressed their willingness that the matter of their claim should go to arbitration, but that request has been refused. I am not going to argue now whether or not it should have been refused, but I strongly agree with the view of the noble Lord, Lord Moran, that, if this Royal Commission is to serve any useful purpose, even from the point of view of Her Majesty's Government, it must not exclude from consideration the very question that the doctors are most anxious should be considered.
I know that the profession has taken a legal opinion on what their attitude to the Royal Commision should be—so I gather, from the representations that they have made to every Member of this House—but I cannot conceive of any lawyer advising the doctors that the terms of reference of this Royal Commission are satisfactory. How can they be satisfactory to the doctors, if the terms on which doctors entered the National Health Service are to be completely excluded from the consideration of the Royal Commission?
Before the terms of the Royal Commission had been settled I ventured to suggest to the House, by a question to my noble friend who then led the House, that there should be most careful consideration of what those terms should be. I regret that the medical profession was not consulted in any way, as I gather, about the terms. I cannot believe that this Royal Commission will serve any such useful purpose as I am sure that my noble friends in the Government desire, unless the terms of reference are amended. The noble and learned Earl, Lord Jowitt, who speaks with so much greater authority than I on these matters, has just said that, of course, you cannot satisfactorily alter, or indeed effectively alter, the terms of reference of a Royal Commission by an exchange of letters or anything of that kind. But, as Lord Moran has pointed out, there are precedents for varying the terms of reference of a Royal Commission, and I beg my noble friend who is about to reply not to close his mind against such amendment of the terms of reference of this Royal Commission as would enable it to conduct a much more useful inquiry than will be possible under the terms as they stand.
§ 4.12 p.m.
THE EARL OF MORLEY
My Lords, may I intervene for just a few seconds in this discussion? I speak as one who has twice owed his life to the medical profession. I feel certain that the present position arises from the lack of faith which members of that profession have had in various Governments. As Lord Moran has said, it is not so much a question of remuneration as of lack of faith and confidence, which has developed since the National Health Service was established. I am sure that the members of this profession are the most loyal people in the wide world. As the noble and learned Earl, Lord Jowitt, has said, they do not want any strikes. I am sure they do not want anything of that sort at all, for, as I have said, they are the most loyal people in the wide world. They want merely proper treatment by the Government. Satisfactory conditions have been promised to them not only by this Government but by preceding Governments. On the question of remuneration, it must be borne in mind that their costs are much heavier now than they were formerly. They want that matter reviewed. But there must be a proper arbitration. A Royal Commission does not provide a proper means of arbitration. It merely makes recommendations, and the Government are not bound to say whether they will accept them or not.
§ 4.14 p.m.
THE SECRETARY OF STATE FOR COMMONWEALTH RELATIONS AND LORD PRESIDENT OF THE COUNCIL (THE EARL OF HOME)
My Lords, may I, in the beginning, explain to my noble friend Lord Moran that if my arguments this afternoon may seem blurred or indistinct it is not because I am doubtful of the Government's case but because the whole medical profession has not yet found a remedy for the common cold.
If any section of the community or any profession has a claim on the attention and sympathy of the nation it is the doctors, and Lord Moran need make no apology to the House for raising these questions of their remuneration and their status to-day. I should like to join with others who have paid their tribute to the power and sincerity with which Lord Moran put the doctors' case. Your Lordships will wish that, within the limits of 1118 reason and possibility, justice should be done to the profession, and that justice should be seen to be done, because no body of men gives more indispensable service to the people, and none has a greater sense of responsibility. I know it is the wish of my right honourable friend who has lately become Minister of Health that justice should be done. I say "within the limits of reason and possibility" because there is a background to this case for the increased remuneration of doctors from which none of us can escape. The National Health Service is a comparatively novel experiment. The State has no inherent virtues as an employer; none of us on this side of the House have ever deceived ourselves on that score. It is the first time it has had to work out a relationship with one of the great skilled professions, and inevitably, I suggest, it must take time—and it would be reasonable to expect it to take time—before a satisfactory code of relationship and conditions of service can be finally established.
Again, these eight years of the National Health Service have run concurrently with a time of intensifying inflation, when the purchasing power of money has consistently declined and therefore the costs of all the professions have been raised. I might, in passing, just remind the noble Viscount, Lord Alexander of Hillsborough, that the professional costs of the general practitioner are met year by year out of the central pool as the costs rise. In such circumstances—that is, against a background of inflation—the doctors no doubt feel convinced that they have a case for increased remuneration, both actual and in relation to others. But the taxpayers also are bearing record levels of taxation, and they have an unanswerable case for relief. The Government are responsible not only to the doctors but to the taxpayers—a most unenviable position. And they have to be responsible to all and try to be fair to all.
I emphasise the complex inter-relation of these factors, because there is one proposition which runs through this dispute which seems to me to be false. Your Lordships will recall that the Spens Committees were set up to investigate the proper remuneration for doctors entering the National Health Service in 1948. But it has seemed to be argued since then that, because the Spens Committees based their 1119 recommendation for remuneration on 1939 prices, therefore subsequent settlements must always guarantee the doctors against the extra costs brought about by inflation. Like Lord Amulree and, I think, like Lord Moran, I do not believe that that is really a tenable proposition. So long as inflation persists, it is impossible to insulate one profession against the effects of it or to guarantee that all professions shall advance in their remuneration with proportional precision.
The remedy, clearly, if we can achieve it—and this is, of course, the Government's policy—is to stop inflation, and that itself requires the restraint of wage earners and salary earners. But, short of the happy day when we achieve a halt to inflation, the best we can do is to try to make as sure as we can that no section of wage earners or salary earners is put at a relative disadvantage with regard to any other section of comparable skill and attainment.
The Spens Committees' Reports were accepted by the Government of the day and were expected to provide a basis for the entry of doctors into the National Health Service. Mr. Bevan, when Minister of Health in the previous Government, said in 1950 that the Spens principle had served its original purpose and could not be regarded as the basis for remuneration for all time. I think that that is true, and what, in the Government's opinion, is needed now, after eight years of experience of the workings of the National Health Service, is to determine the proper place of the medical profession in relation to other skilled professions which make up our society and, when that is done, to fix the scale of remuneration, after authoritative and up-to-date findings by a Royal Commission. We believe that the Royal Commission can be the proper instrument. It can take into account all the circumstances that are relevant, and one of the factors which is clearly relevant is consideration of the Spens Reports.
In answer to the noble Lord, Lord Moran, I would say that if the doctors wish to put before the Royal Commission their interpretation of the Spens Reports, there is no reason why the Commission should not listen to and consider their views upon them. Clearly, the Royal Commission will take into account 1120 rewards for skill in other comparable professions and, equally, the special conditions of a doctor's life—the long and irregular hours; the load of responsibility, great in human terms, of which the noble Lord, Lord Moran, and others spoke; and the financial factors, which affect recruiting to a profession which is of such vital importance to the community.
§ EARL JOWITT
My Lords, the noble Earl has made these statements, but I am looking at the terms of reference, and may I tell him, with the greatest respect, that I do not think that he is right? Of course, that depends entirely on the construction of the terms of reference. Will the noble Earl at least do this? After the debate is over, will he make certain that he takes legal advice to find out whether he is right in what he says. I do not think that he would like to make these statements and then find out that he is wrong.
THE EARL OF HOME
My Lords, I have taken the advice of the Minister of Health on this matter before saying what I have said, and I am advised that what I have said falls within the terms of reference given to the Royal Commission.
Although the Royal Commission will act with every expedition, the Government thought that some recognition should be given to the difficulties which face the doctors meanwhile. A 10 per cent. increase has been given in respect of junior hospital staff, and the Prime Minister announced a short time ago that the Government are considering what should be done about a further interim adjustment for the senior hospital staff and general practitioners, both medical and dental, and he hopes to be able to make an announcement on that shortly. Against the background of the country's financial position, and taking into account the fact that the doctors' claim is of such a size that it would affect the incidence of taxation, I suggest that, both from the point of view of the doctors and from the point of view of the public, the interim assistance which I have just indicated, to be followed by a Royal Commission, is a fair way of dealing with this problem.
There have been certain other criticisms of the terms of reference of the Royal Commission. It is right that they should be examined critically. I do not 1121 think that we can give the Royal Commission vague terms of reference. Probably the noble and learned Earl, Lord Jowitt, will remember that in 1910 there was a Departmental Committee on Royal Commissions. One passage in their Report says:One of the chief securities of deriving full advantage from an inquiry by Royal Commission and one of the essential requirements of obtaining definite results…is that very great care should be taken to ensure that the subject of inquiry which it is intended to submit to the Government should be set out in unambiguous terms.That my right honourable friend the Minister of Health has attempted to do, and in such a way that the terms are not so broad as to lead to an endless inquiry, with vague recommendations, yet not so narrow as to exclude anything which is relevant to the doctors' needs.
One of the points raised on the terms of reference was the question of delay. I have dealt with that. The Royal Commission have already held a number of sittings and the chairman has every intention that the Commission shall act with speed. There has been a criticism, not made to-day in your Lordships' House but outside, that there are no doctors or dentists on the Royal Commission. My right honourable friend took the view that, on the whole, they would be more valuable as witnesses, and so long as the Royal Commission had competent and able people on it, it was a good body, which would be seen to be impartial. It has also been asked why, if the terms of reference propose comparison with the remuneration of other professional classes, they did not also include a direction to take into account remuneration in commerce and industry. My right honourable friend thought that, had there been a direction to that effect, it would have meant an immensely long inquiry, and there is a great field in industry and commerce in which conditions are not comparable at all. In any case, the matter remains for the Royal Commission to decide, and there is no reason to think that they will not put a realistic interpretation upon their terms of reference, nor any doubt that they will listen to any evidence put before them which is relevant.
Then there is the question of merit awards, a matter which was raised by the noble Lord, Lord Moran. I understand 1122 that the Royal Commission will normally be concerned with the levels of medical and denial remuneration and not with the methods, as such. Whether they will find it necessary to look at the question of merit awards in order fully to discharge their term of reference will be for them to decide.
So, my Lords, it is the hope of my right honourable friend that the interim help which has been given to the profession, followed by a Royal Commission, armed, as he believes, with fair terms of reference, which will enable them to take into account all those matters which are relevant to the doctors' future, is the right and fair way of dealing with this. It is the Government's hope, as it was the hope of the noble and learned Earl, that we should be able to move away from the atmosphere of distrust, of accusations of bad faith, of trials of strength and non-co-operation with the Royal Commission and with the Health Service, because that seems to all of us to be quite out of character in a profession recognised everywhere for its sense of responsibility.
But if that is true, it is equally true that the community, who are the new employers, should not trade on the tradition of patience and good will of the doctors. As the noble and learned Earl said, there must be give and take; there must be understanding and sympathy on both sides. It is the Government's desire that there should be a settlement, rapid, fair and comprehensive, and we believe that the Royal Commission is the method which will most surely reach these results. The Commission have been appointed. They are already pursuing their task, and we hope that after they have finished and have reported, we shall be able to arrive at a permanent settlement which will end for the doctors this rather unhappy chapter in their affairs.
§ 4.30 p.m.
§ LORD MORAN
My Lords, whilst I am grateful to the noble Earl for his reply, I must acknowledge at once that I am profoundly disappointed in its substance. I gave him notice of two questions, neither of which he has really answered in any way satisfactorily to the doctors. On the minor question of awards, he simply says that that is for the Royal Commission to settle. In other words, this question of remuneration of consultants may be torn up by the roots, 1123 and much that has been done in the last seven years may be thrown away.
But the more important question that I asked was whether, in fact, the Royal Commission would be entitled to look into the terms of the Spens Committee. The answer of the noble Earl, at first, seemed to be satisfactory: that there was no reason why the Royal Commission should not listen to and consider the doctors' evidence on it. That would be satisfactory. But I understand that a Royal Commission are strictly bound by their terms of reference. It is not the Minister of Health who will advise what those terms are; he has not the power. It is for the Chairman of the Royal Commission. If the Royal Commission decide that this is outside their ambit, nothing will happen. In other words, I go away by the same door by which I came in, with no surety about the awards, and nothing whatever on this matter of the Spens terms.
What we want now is straightforward dealing with the doctors. They primarily want to know whether or not the undertakings given to them at the time of the Spens Committee will be taken into account by the Royal Commission. The noble Earl gave us no reassurance on that point. Therefore, while, as I said before, I am grateful to the noble Earl, I go away profoundly apprehensive about the future. What the doctors are concerned with is that they should be allowed to put before the Royal Commission everything that they think relevant, and should not be prevented from doing so. I beg to withdraw the motion for Papers.
§ Motion for Papers, by leave, withdrawn.1124
§ BARCLAYS BANK D.C.O. BILL
§ Brought from the Commons; read 1a, and referred to the Examiners.