§ 2.53 p.m.
§ LORD MORAN rose to draw attention to the Report of the Royal Commission on Doctors' and Dentists' Remuneration 1957–60 (Cmnd. 939); and to move for Papers. The noble Lord said: My Lords, a Member of your Lordships' House sitting on the Opposition Benches has claimed that the question before the House is a political question involving profound issues of social policy; and this on the ground that questions of relative pay breed class distinctions and social jealousies. I am sure your Lordships will forgive me if on this occasion I pitch my note a little lower and am content with rather more humdrum sentiments. Nor shall I attempt for a moment to follow the Royal Commission into their protracted comparison between the earnings of doctors and the earnings of those in supposedly comparable professions.
§ I myself once engaged in a rather ambitious exercise of this kind, with the help of actuaries and architects, and the results were very disappointing. It is very difficult to compare like with like, and I agree with Professor Jewkes, a member of the Royal Commission who said that comparisons of that kind are no more than "tentative probings amid uncertainties." Your Lordships will know that Her Majesty's Government have already accepted the Report of the Royal Commision as what is called, I believe, a "package deal." It is all or nothing, and therefore it would be a waste of your Lordships' time if I were to discuss the Report in detail. I shall be content to inquire how far economics play a part in the contentment of the medical profession and how far other factors come in.
§ I want, really, to ask two questions, and then try to find the answers to them. The first is: Why are the consultants, broadly speaking, content; and the second, why are the general practitioners, again broadly speaking, far from content? Dealing first with the consultants, they may perhaps not be content; and if they are not I am as much to blame as anybody, because I have been deeply involved in this matter from the beginning. But if "the 'contents' have it," as I believe most will agree, then I think 93 their contentment—and after all, it is contentment, in spite of the fact that they got no real equivalent of the £40 million given by the Danckwerts award to the general practitioners—is due to the fact that one principle has been faithfully followed. That principle is that exceptional good work should receive exceptional financial reward. That principle, if it is followed, will usually result in contentment.
§ I do not say for a second that we have been successful in following that from the very beginning. For me all this began after the First World War. There was a Royal Commission in 1913 which, after two years, decided that the denizens of what I may call the consultant quarter in London—Harley Street. Wimpole Street and the like—had been so busy in the pursuit of gain that they had rather forsaken the pursuit of knowledge; and the Royal Commission recommended as the only remedy that there should be an academic career in medicine open to those who wanted to devote their lives to teaching and research, and not to engage in private practice. In that way provision was made for a small minority to practise medicine at the highest level; but it was done at the expense of their material prospects. These professors of medicine and surgery, had they engaged in private practice, could have earned four or five times as much.
§ Now many years have passed, and I, at any rate, have learned a lesson—because it never seemed to me fair that if a man was anxious to practise medicine seriously he should be penalised financially. When 30 years had gone a very large Committee called the Evidence Committee, representing the whole profession, were engaged in drawing up some kind of scheme for the National Health Service Act. That Committee, when they came to consider consultants, decided that they had been engaged in a highly competitive profession and that those who had been successful had been richly rewarded. For example, the first Lord Moynihan's estate was declared at between £300,000 and £400,000. Another physician, Sir Thomas Barlow, left £250,000, and Lord Dawson of Penn left £149,000. And in 1948 it was found that more than 17 per cent. of all surgeons and gynæ- 94 cologists were earning incomes of more than £5,000.
§ I mention these sordid details, my Lords, because I think we must understand the position in which we found ourselves. The Committee saw that in a consulting service all this was going to vanish; and they saw quite clearly that if it did vanish there would be a real danger of a slackening of effort: the consultants might, like taxicabs, just tick over. The Committee passed this problem on to the Spens Committee; and the Spens Committee then set up what are known as the merit awards. There were three grades. It was proposed that the A award should add £2,500 to the basic salary; the B award £1,500; and the C award £500. That was a provocative proposal. It was likely to excite criticism; and it did. After all, my Lords, if I were to look round to those who are listening to me and try to pick a third of your Lordships as people of superior intelligence it might lead to misunderstanding. Yet that is precisely what we in the consulting world were asked to do.
§ The proposal, however, was passed. At one time I was quite certain that it would not be, because this time the opposition did not come from the consultants, as it did in the case of the economic award. The consultants were largely indifferent: they did not feel that there were any prospects at all of the award system coming in. The British Medical Association were against it; the Chancellor of the Exchequer at that time, Sir Stafford Cripps, was an almost fanatical opponent; and vice-chancellors of universities were also hostile, I suppose in the interests of other faculties. This state of affairs was such that I personally had made up my own mind that there was no prospect that the awards proposal would go through. At that juncture, Mr. Aneurin Bevan, who I may say was one of the most imaginative and able Ministers of the many I have been associated with, came to the rescue, and the awards were saved at the eleventh hour.
§ It is most interesting to see that after ten years that opposition has vanished. At the time the position was really formidable, not so much because of the opposition but because of the complete indifference of the consultants. In ten years' time that state of affairs has 95 altered. The Royal Colleges have always been behind these awards, but now we find the Council and Representative Meeting of the British Medical Association also unanimously in favour. The Treasury, who are not usually enamoured of a project of this kind, have said, There is nothing like this in the public service, but it seems to work, and we hope it will go on." Both the Majority Report and the Minority Report of the Royal Commission said, "These awards are the one imaginative feature in the whole of the Health Act." I think we may say that the almost universal opposition to these awards, when they came in, was converted into practically unanimous support.
§ There is no doubt that three things combined to change the climate of opinion. The first was that we recognised that these awards could not continue unless they enjoyed the confidence of the majority of the consultants, and that confidence could not be won if people were selected by a Committee sitting in Whitehall. It was absolutely necessary to decentralise the machinery; and that was done. Secondly, we did not attempt—either myself, the Chairman, or the Committee—to say which of two anæsthetists at Truro was the better: nor whether a psychiatrist at Carlisle was as efficient as another psychiatrist. We chose advisers to guide our steps. And, thirdly, in the last ten years, accompanied by Sir Horace Hamilton, representative of the Treasury, we held meetings all over the country, inviting criticism and explaining what we were trying to do.
§ One would think that if, as happened, the Royal Commission said they were unreservedly in support, not only of the principle but of the method of carrying out these awards, they would have shown that in their Report. But what did they do? They added £500 to the A award and £250 to the B award. That did not really make up for the change in the value of money over ten years. There was something else that was more serious. In the past the number of awards has increased in exact proportion to the number of consultants. If there were three new consultants appointed, there was one new award. Now, in the next three years at any rate, the number 96 is to be frozen and fixed. What does that mean? Nine years ago there were 6,356 consultants. In nine years that number became 7,684. That is an increase of 20.9 per cent. If that sort of increase goes on—and it is likely to—for the next nine years there will be 9,200 consultants. But of that 9,200, not 33 per cent., as now, will get awards, but only 28 per cent. To put it differently, while to-day one out of every three gets an award, in future only one out of every four will get one. It seems a curious form of logic first to bless a system and then to ensure that a diminished number will enjoy its benefits.
§ What of the future of the awards? Your Lordships will know that there are many things in this country that jog along very inefficiently but quite happily. The awards system, however, can never be one of them. After all, the majority, two out of three, have not got awards, and they will not for one moment tolerate a system if they do not think it is efficient. I say this rather feelingly, because I read in the Royal Commission's Report that, looking forward, not necessarily to my demise, but to the time when I cease to be Chairman, they think that my successor might not be so mobile. They say that the Central Committee may know the candidates for A and B awards, but not those for the C awards. Therefore, they say, Let these be given and selected in the region." On that point I would say: if the new Chairman—my successor, when he comes—cannot travel, he should not be the Chairman. For in no other way can he possibly hear criticism and the views of consultants; in no other way can he conceivably win their confidence. I have taken up a lot of your Lordships' time as regards incentive, perhaps because I feel that in the world we are going into an incentive will be necessary in far more fields than medicine. Mr. Khrushchev has said that you cannot build an industrial society without incentives. With that respectable lead I think I may leave that particular part of my subject.
§ Coming to the question of the general practitioners I have not the slightest doubt that when I say that the general practitioners are far from content somebody will get up in this debate and say 97 that I am unnecessarily gloomy. We have only to go round the schools at the present time to discover the really alarming condition with regard to the entry into medicine, which I shall touch on presently. Why are the general practitioners so discontented? I think the answer is that the principle I have extolled, that exceptional work should win an exceptional award, has been abandoned. If the general practitioner wishes to add to his income he must increase his patients more and more, until soon he has a number he cannot possibly look after.
§ There is almost unanimous agreement in the medical profession that no man can look after 3,500 patients, which is the permitted maximum under the present system. Why do I say that it is impossible? Well, a good doctor—this may surprise your Lordships—is independent of his instruments. If he asks the right questions of the patient, he will soon establish the diagnosis. But to do this he must let the patient talk, and that consumes time; and therefore if he has a large list, he simply does not do it. Moreover, if he gets discouraged, as he may well do, especially if he is not very conscientious, what happens? He bundles his patients into hospital, and so we find many people in hospital who are not there for medical reasons at all. At a recent investigation by the Nuffield Provincial Hospitals Trust into the North Lonsdale Hospital, Barrow-in-Furness, it was found that half the women patients and a quarter of the men patients were there for other than medical reasons. When we think of what this means in finance, there could be a tremendous saving; because they estimated in their previous surveys that if only people who needed medical treatment were in the hospitals, we should need, not 3.1 for every 1,000 of the inhabitants, but 2—a saving of one in three. There would be a tremendous saving of money, which could be used for other things.
§ I am not saying anything original. At Harvard, they make their medical students go through a three months' course of legal training in order that they might learn not to ask questions which suggest answers, to test the creditability of witnesses, to appraise evidence, and things of that kind. Your Lordships will hardly realise that, when you are 98 ill, your safety largely depends on how your doctor can take your history. It sounds simple, but it is one of the most difficult things in the world.
§ I have met a considerable number of general practitioners with very large lists—3,000 and upwards: men who have those lists simply on the strength of their personality and their skill—who would welcome a new condition of affairs in which they had a diminished number of patients, provided that their income did not fall. Many of these practitioners were looking to the Royal Commission to devise some means whereby a premium could be put on good work. If nothing else is carried to your Lordships in my speech except this, I do wish you to realise that the crying need in medicine at the present time is to put a premium on good work by the general practitioner. That is so important. He must be judged by the quality of his work, not by the quantity.
§ The Royal Commission have responded to this very great need by putting aside half a million pounds and saying to the practitioners: "You can have this if you can evolve a system". What is going to happen? The general practitioners are not at all in favour of awards—but nor were the consultants, when they started. The majority, I would point out to your Lordships, is not always right. After all, if we had listened to the clamour of the consultants, there would not have been an academic career in medicine at the present time—an incalculable loss. Further, if we had had a vote in 1948, there would have been no awards. Now we are faced with the vast and important problem of devising a scheme to keep the general practitioner on his toes. And what is going to happen? Are we going to be fobbed off with the suggestion that instead of merit awards there should be responsibility awards, so as to avoid all the unpleasantness of deciding who is meritorious and who is not?
§ My Lords, what does a responsibility award amount to? Responsibility is synonymous with seniority. Suppose you take medical superintendents. There are a vast number of medical superintendents, and if every one of them was given an award there would be no awards for anybody else: they all have the same responsibility, although they differ greatly 99 in merit. The British Medical Association have hammered out this question, and I devoted quite a long time with the Royal Commission to pointing out that responsibility was in effect the same as seniority. While those of us who are senior, as I am, would no doubt welcome a financial bonus as a solace to the handicaps of advancing years, it would not pay the community. Moreover, it would be utterly wrong. We must recognise perfectly clearly that we have a very unpopular thing to do if we are going to introduce these awards. We require somebody in the nature of a Sir John Anderson (or perhaps I should say a Lord Waverley) at his best, who can arrive at the answer to a question by first principles and then, having come to his conclusion, refuse to budge an inch, no matter what the opposition. That is what we really need. We do not want a Gallup Poll of the various sections of the profession to see what they are thinking at any moment. This is one man's job. It is a creative act; and, like all creative acts, it has got to happen in the brain of one man.
§ There is another reason why the general practitioners are not happy. Before the National Health Service Act came in they made modest excursions into specialist fields. One man would do his own surgery; another ophthalmic work; and another diseases of the ear, nose and throat. This added interest to their lives, and was one of the real causes of their efficiency. When the Act came in, all that was taken away. That was a demoralising experience: it took away much of the interest from their life. There is only one remedy, and that is to bring these men back into hospital. That is absolutely essential. Now, I need not tell your Lordships that if you dilute labour, there is bound to be a storm. Those in charge of hospitals would not like this at all, but I see no alternative.
§ There is another reason why it must be done. This is a little controversial, but I think it can be put quite simply. It is this. There is a "wind of change" (to borrow a phrase from another place) which is blowing over all the practitioners throughout the world. Many people feel that, with the enormous advances, especially the technical advances, in the past two decades in the practice of medicine, nobody but a specialist can possibly 100 master them. I think that is quite wrong. If you bring a good practitioner and associate him with a hospital, I think he can do it. However, we must look at it squarely, and must not dodge this issue.
§ Forty years ago, in Russia, they decided that a general practitioner was an anachronism, and they replaced him by specialists, generally of a rather low grade. In America, which is very specialist-minded, more and more hospitals are closing their doors to anybody who is not a specialist. In England, Dr. Fox, the very able editor of the Lancet, who is a devoted advocate of the family doctor, has recently been in America studying the future of general practice, and he has deliberately decided that the survival of the general practitioner in England—I repeat, his survival—depends upon his being associated with a hospital. And the Nuffield Provincial Hospitals Trust have come to the same conclusion. In other words, we have to bring these men into hospital, for two reasons: to make them contented, and to give them an opportunity to practise medicine at the highest level at which they are capable. It is not going to be easy to do that, but I will not stretch the point any more.
§ I will go on to say just a word about recruitment. There we have an absolutely alarming situation. A short while ago, if a boy at any of the schools thought of going in for science, his eye was probably on medicine. Now, it is about the last thing that it is on. Now, he wants to be an engineer, a physicist, or a chemist; to be associated with science and industry. If you go to any of these schools—and last year I went to a great number—you find that they have a Science Sixth; that the bright boys are studying physics, chemistry and mathematics, and that the less bright boys are studying physics, chemistry and biology. Science, in some form or other, takes the very pick of these people, and a very large number; and medicine is left with what remains. We have the sad paradox that the boom in science, which is doing so much good in industry, is having catastrophic results on the quality of the entry into medicine.
§ What is the remedy? At first sight, there does not seem to be one. The Royal Commission recommended that there should be 80 A Plus awards, which would mean that £4,000 was added to the 101 basic salary of £3,900. Now that is something. It provides for a significant minority the chance of a career and an income comparable to that in other professions. But I have talked this over with the masters of many schools, and I share the doubt of Professor Jewkes when he says he is doubtful whether the Majority Report would bring an entry into medicine of the quality that we all desire. If that is the right conclusion, it is a very alarming one.
§ Finally, let me say one word about the Review Body. Three years ago I was so distressed by the harm being done to the relations between medicine and the public by these repeated bickerings and disputes that I went to the Ministry of Health and asked them to set up a Committee which would be comparable to that set up in the Civil Service under the chairmanship of the noble Lord, Lord Coleraine. They said to me, "Nobody has suggested this gat all," and on February 18, 1957, I wrote a letter to The Times.
§ Why is such a Review Body so terribly necessary? I want your Lordships to realise that where medicine is concerned the Government are a monopoly employer. They control the demand, the supply and the pay of doctors—the demand because they control the size of the lists of practitioners and because they lay down the size of hospital establishments; the supply because we cannot get more doctors without increased facilities in medical schools, and that means more money, which comes from the Government. Therefore they have the whole thing completely in their hands. Is it any wonder that the profession is apprehensive of some arbitrary action on the part of the Government? And nothing that has happened in the last ten years has been very reassuring.
§ The Whitley Council B, which has dealt with disputes between consultants and the profession, can really go on to arbitration and do anything only if both sides agree, but if the Ministry of Health exercise their veto, then nothing happens. It is only fair to say that in many minor matters they do not exercise their veto, but so far as I know in all major issues in the last ten years, like Russia, they have exercised their veto. One of the results is that doctors have lost all faith in the Whitley machinery. Therefore, we require something absolutely new, and I 102 implore the Minister to set up deliberately something on the lines of the proposed Review Body. Here is a golden opportunity to win the confidence and faith of the profession. If that is done—and it is idle to pretend that such confidence exists at the present time—a new era will begin in the relations between the profession and the Government, of such a character that the services of the doctors to the community will be twice as fruitful as they have been in the past I beg to move for Papers.
§ 3.25 p.m.
§ LORD TAYLOR
had given Notice of a Motion to call attention to the remuneration and conditions of work of the medical profession; and to move for Papers. The noble Lord said: My Lords, at the time when the Labour Government were creating the National Health Service, my noble friend Lord Moran displayed, if one may say so, great skill and statecraft. In a sense, he is one of the Founding Fathers of the Service, for thanks to his advice and leadership the consultants of Britain accepted the plan, not as a bleak necessity but as a challenge and opportunity to give people better specialist care than ever before. The aim was to raise the standards everywhere to those achieved in a few selected spots, and this was done by seeing that conditions were such as to make good work possible throughout the whole of the country. My noble friend Lord Moran saw to it that the consultants were properly remunerated for their co-operation, and, as he says, my right honourable friend Mr. Aneurin Bevan recognised the point and accepted it.
I owe my noble friend a special personal debt which I shall mention later, which shows how he has often stood for progress and against prejudice. His speech to-day, as always, has been lucid and beautifully delivered. I remember that not very long ago he told me how, when he was going to give a lecture as a young man, he lost his notes in a fog and, as a result, has developed his wonderful capacity for speaking without notes, a capacity which we all envy him, because most of us have not got it and without our notes we feel a little naked.
I am afraid that we may differ from him on one or two points, points of substance and importance, but I must say 103 that they are fewer than I expected. My noble friend is always open to reasoned criticism, and he has not hesitated upon reasoned criticism of the Royal Commission's Report. I hope that he will listen to what we have to say and that in due course we may be able to present a united front. I do not think that a great deal separates his feelings and those which we shall be expressing.
My Lords, there are few more fascinating things than other people's money, always excepting one's own. Though not paid by the National Health Service, for five-elevenths of my time I am paid at National Health Service consultant rates, and if these go up, my salary goes up. Therefore, I must declare a private interest and partial affection in this debate. I have noticed that your Lordships are not over fond of statistics, but perhaps this dislike can be dissipated to some extent if one converts "the damned dots" into pounds, shillings and pence. I shall try to do that throughout, though I may occasionally have to lapse into percentages. I feel sure that your Lordships are much more in touch with financial reality than Radical Jack, the first Earl of Durham, who was nicknamed "King Jog" by Creevy, because he said that he supposed that £80,000 a year was the sort of income "a man could jog along on". When my noble friend talked about jogging, I thought of that.
It is widely believed that doctors are keen on cash. Chaucer's Doctor of Physic was a good fellow,Yet he was rather close as to expenses And kept the gold he won in pestilences. For gold in physic is a cordial. Therefore he loved gold in special.My noble friend Lord Moran referred to big medical incomes in the shape of money left after death. Probably the biggest fee ever received in medicine was that paid to Doctor Thomas Dimsdale, of Hertford, by Empress Catherine the Great of Russia and her son the Grand Duke Paul when he had to travel to Russia to inoculate them against the smallpox. He got a fee of £10,000, £2,000 for expenses, an annuity of £500 a year for life and a Barony of the Russian Empire. By contrast, I remember when my old chief, Sir Maurice Cassidy, was asked to see the senior executive of a famous London 104 newspaper. The chairman of that newspaper expected to get a bill for something like 100 guineas. In fact, he received a bill for three guineas. Sir Maurice Cassidy was a great doctor and a very ethical one, and I think that a great many—in fact, the enormous majority—of consultants would behave as he did.
About 70 years ago there died in London a skilled and popular physician, Sir William Gull, of Guy's Hospital. He left a sum of £344,000, which I suppose to-day would be worth £1 million. One estimates that he must have earned at least £40,000 a year. Yet, when he was a young man, advertisements like this were appearing in the Lancet:For disposal, a very snug practice—average receipts for the last five years, more than £200 a year. No other practice within 9 miles. Premium, house, furniture, drugs, the whole available for £800 cash.That was indeed a snug practice in those days, compared to what the parish doctor used to get. The parish doctor used to get £70 a year, and in the East End, in Bethnal Green, three parish doctors had to look after 75,000 patients. If we compare the lowest and the highest medical income in mid-Victorian days, we find that one was about 400 times the other. And it was not so different in 1906, when Bernard Shaw introduced us to Sir Ralph Bloomfield-Bonington and Cutler Walpole, at the one end, and the poor Dr. Blenkinsop, at the other. Thank goodness things are not what they used to be! To-day, thanks to the National Health Service, if the Royal Commission are to be believed, as I am sure they are, Sir Ralph Bloomfield-Bonington gets £5,300, while Dr. Blenkinsop gets £3,100.
Just before the war my noble friend Lord Simon of Wythenshawe calculated the spread of all salaries in three small democracies—namely Sweden, Denmark and Switzerland—and compared them with England. At the bottom he took a street sweeper and at the top a Judge of the Supreme High Court or a Cabinet Minister. In Sweden, Denmark and Switzerland the top people got six times as much as the bottom people; and in England the top people got 35 times as much as the bottom people—that is, of course, before the operation of tax. It is interesting, in view of what my noble friend Lord Moran said about Russia, to bear in mind that these three small 105 democracies are highly industrial and highly efficient States, and it does not appear to be an essential to have enormous cash incentives and enormous discrepancies between the top and bottom in order to get great achievements in industry and elsewhere.
Here we are at the very bedrock of politics. Do we believe that the spread of incomes should get narrower—by stabilisation at the top and increase at the bottom—or do we believe that a wider spread is inherently good and desirable? In considering this we should set aside the fact that the expenses we receive in your Lordships' House put us at the bottom of the scale—the work here is such fun that it is worth while for its own sake. In medicine, the coming of the National Health Service has immensely reduced the spread from the top to the bottom, and this has been for the benefit not only of the patients but of the profession as a whole.
When I was a student, the late Dr. J. L. Birley told us: "It is no good aiming at Harley Street unless you have £20,000 in the bank to see you through until you are 35." That, of course, was not absolutely true, but there was a good deal of truth in it. But to-day every bright student can earn his keep the whole way through to the top; and to-day, in spite of what my noble friend Lord Moran says, an increasing number of students are making general practice a career of choice, because it is so interesting and worth while, even though the rewards are only two-thirds of those of the average consultant. I think this in entirely good and that our policy for the future should be gradually to reduce the gap. I hope that my colleagues in the profession, and especially those represented in the negotiations will think the same. But if we accept the recommendations of the Royal Commission lock, stock and barrel, then the process will have been in some measure reversed, for it is the declared policy of the Commission to increase the spread and enlarge the gap.
I turn now to the Report of the Royal Commission itself. As I shall have to be rather critical of some aspects of their work, it is right, first, to give them due praise for the great deal which they have done well. First the Report itself is short: it is only 158 pages, though it has a valuable Appendix stuck on of an extra 100 pages. Secondly it is clearly 106 written, in marked contrast to other official documents which we have recently had to examine. Thirdly, the Commission have caused to be undertaken a piece of social research of immense importance not only to the medical profession but to the other great professions and to social science generally. Fourthly, in their recommendations they hold fast to much that is good about the way doctors are paid. In particular, they accept payment by salary for consultants and payment by capitation fee for general practitioners. Since they are accepted, there is no need to recapitulate the arguments, particularly in favour of the general principle of capitation fee. Fifthly, a large number of the recommendations the Commission make will command general acceptance in principle.
For example, the question of the Standing Review Committee, to which my noble friend Lord Moran referred, is something which I think we should all accept, in principle, and which is a very important decision in the whole question of wage relations and wage structure for the future: and not only for medicine. Secondly, we have higher pay for junior grades in hospital. I think everybody agrees about this, and one perhaps wishes that it could even be higher. Yet for those of us who are fairly senior, the picture has changed very much. When we were young the junior grades in hospital got nothing at all: we got our board and wages and nothing else. It was difficult going, and we could not think about marriage until we were getting on for 30. Now things have changed a great deal, but they should change a little more. A third typical example of something that is entirely good is that the employers' contributions for general practitioners' superannuation should come not out of the central pool of earnings for general practitioners but from the Government. That is what has been happening in the past, and I do not suppose that most general practitioners knew that they were themselves paying the employers' contribution to their superannuation scheme. The Royal Commission quite rightly would stop that. Finally-I only give these as examples, and there are many more recommendations which the Royal Commission make that are good—all their recommendations are clear cut so that 107 it is easy to say "Yes" or "No" to each.
Nevertheless, the Report suffers from a number of defects, and these seem to me to come from two main causes. First, there are the terms of reference. These were drawn up in a hurry, in the face of a political crisis. In consequence, they presented the Commission with a wellnigh impossible task. It is not surprising, therefore, that the Commission departed from them from time to time. What is surprising is that their departures were often haphazard and as often accompanied by disclaimers of any intention to do so. The second cause of the defects was that the members knew little about their subject when they started. To-day they have learned a great deal, and indeed they have taught us a great deal as they have gone along. But too many of the problems to which they sought answers had been studied in great detail by experts and validly answered in the course of the past ten years. Yet they quote none of these essential studies, and there is little evidence that they knew they existed.
To take one example. In 1950 the Central Health Service Council of the National Health Service set up a widely representative committee under my noble friend Lord Cohen of Birkenhead to study general practice. This Committee sat for three years and reported in great detail—and I hope that my noble friend Lord Cohen of Birkenhead will be saying something more about this later on—on the way general practitioners were paid. In particular, this Committee examined the whole problem of merit or distinction awards for general practitioners. After most careful study the Cohen Committee unanimously reported against such awards. Nevertheless, the Royal Commission recommended such awards, apparently in complete ignorance of the work of the Cohen Committee, to which I have been unable to find a single reference in the Report.
To take another example, most good general practitioners are in regular partnership in group practice; their incomes are determined by partnership agreements. Over the years it has been found in medicine that the happiest and most efficient partnerships are those where parity of income between partners 108 is achieved within seven years. This is well known and, indeed, recommended, I think, by the British Medical Association in its guide for young practitioners. Per contra, the unhappiest and least efficient partnerships are those where a senior partner does little of the work but pockets most of the takings. A good partnership agreement would, of course, largely nullify any individual merit or distinction award, since it would be shared among all the partners in the partnership. This fact the Commission never even noticed! There was available to them, from local executive councils and other sources, a great volume of evidence of partnership agreements. But they refused to see it. Instead, they argued by analogy from partnerships with which they were familiar; that is to say, among solicitors, accountants and others, where, for perfectly understandable and proper business reasons, seniors often get many times the income of junior partners. They were simply ignorant of the fact that in medicine every partner is forced, by the volume and the nature of work done, to take full responsibility from the start, and that junior partners actually do a greater volume of responsible work right from the beginning of their career.
One realises the difficulty which any Government faces in appointing a Royal Commission on pay for a particular section of the community. It may well be that no solicitors or barristers should sit on any body determining legal aid fees. But surely it would be wise to have a barrister or a solicitor sitting as an assessor or technical adviser on the technical aspects. This surely would have been the right answer for the Royal Commission on doctors' and dentists' pay. Had they had with them a consultant, a general practitioner and a National Health Service dentist, they would have avoided what appear to be certain elementary errors of fact. The lesson for the future is clear enough. When decisions about the future composition of the Review Committee are being made, doctors and dentists must sit either on it or with it to advise it, if palpable nonsense is to be avoided.
I return now to the terms of reference of the Royal Commission. A Royal Commission is really a research project. It so happened that there was only one 109 professional research worker on this Commission, Professor Jewkes, and he had to write a Minority Report. The success of any research project depends on getting the right terms of reference at the very start. The Royal Commission was asked to find out how the remuneration of doctors and dentists in the National Health Service compared with that of other professions; and, secondly, in the light of this, what their remuneration ought to be. The first part of the jab was difficult, but it was not impossible. It would have been easy, but for one circumstance. The information needed to make a comparison between the doctors' and dentists' incomes and that of other professions is all available in the archives of the Board of Inland Revenue. But the Board refused to give the information required for the different professions, on the ground that it would be a breach of confidence. In view of the terms of the Royal Warrant setting up the Royal Commission, I doubt whether they were entitled to do this. I think they were probably guilty of some frightful sin, because a Royal Commission is given power to call for papers from anybody. Strangely enough, the one place where the Government have decided already to reject the Royal Commission's Report is here; in other words, the Review Committee are not to have access to the information which the Board of Inland Revenue have about the earnings of doctors and dentists and about the earnings of other professions.
In medicine we are well aware of the need for professional secrecy in the individual case, but we do not believe in statistical secrecy of the group. Indeed, without the statistical studies of groups, freely published for all to read, medicine could not advance—and it is the same with the scientific study of remuneration and the science of wage and salary determination, of which this Royal Commission is perhaps the first great example. On this point, I think the Royal Commission was right and the Board of Inland Revenue and the Government were undoubtedly wrong. Fortunately, there was another way of finding out what had to be found out. Your Lordships may remember a Press "rumpus" in 1940–41 about an organisation called the Wartime Social Survey, christened by the Press "Cooper's Snoopers". I was in 110 charge of that organisation. We built it as well as we could, and it is now the Government Social Survey. It is an essential part of any Government machine. We built it because we knew that modern Government cannot function without finding out the true social facts of any situation on which it proposes to operate. Efficient social diagnosis must precede social treatment, and the Social Survey is the official instrument for much social diagnosis.
I said just now that I owed a personal debt to my noble friend Lord Moran. At the time when we were afraid that the then Prime Minister, Mr. Winston Churchill, might, in a short trenchant minute, dissolve the Social Survey, Lord Moran agreed to act as Chairman of our Advisory Committee. Under his wise guidance and powerful protection we survived. It was to the Social Survey that the Royal Commission turned for the information it could not get from the Board of Inland Revenue. The full story of how this job was done your Lordships will find in the 100-odd pages of Appendix A. But it was possible only as a result of the cooperation of 30,000 individuals, in eleven different professions and their professional organisations. The Review Committee which the Royal Commission proposes, and which the Government have accepted, will have to repeat this job every two to three years. Now for technical reasons this may prove impossible. Success depends on the willingness of a sufficiently large number of professional people to fill in very detailed questionnaires about their earnings, and a poor response would invalidate the whole process. The Royal Commission fears, and I fear, that the response to regular repetition will be very poor indeed, unless, of course, these other professions want the information for their own purpose. So if the Review Committee is to do its job, the Government may well have to overrule the objections of the Board of Inland Revenue to supplying the necessary statistical information.
The whole matter is well argued in the Royal Commission's Report, in paragraphs 441 to 450. The Royal Commission had been told to find out what were doctors' and dentists' earnings, and compare them with other professions; and with the help of the Social Survey they did this job. The result is 111 summarised in the form of a graph on page 31 of the Royal Commission's Report. Graphs are not perhaps the most exciting of things, but this is one of the most important ever prepared, for it shows the cash value which we in Britain place upon eleven great professions. I shall not digress into this fascinating subject, especially because I hope that my noble friend Lady Wootton of Abinger will be speaking more about it when she comes to wind up from this side of the House.
It is essential to treat separately the earnings of general practitioners and consultants. We find that a typical general practitioner starts at £1,710 a year at approximately the age of 32. His income then climbs up to a peak of £2,460, at the age of 50, and then it starts to fall. It falls until he is 60, when it reaches £2,160 a year. By contrast, the consultant climbs more or less steadily from the word "go" as soon as he is a consultant, when he starts at £2,100 a year and he climbs to £3,600 at the age of 60. At the start, the gap between the general practitioner and the consultant is £400 a year; at the end it is about £1,400 a year, and a large part of the increase is due to the fall in general practitioner earnings over 50. The dentist shows the same kind of curve as the "G.P.", only it is still more marked. He starts at £2,270 a year at 32; he reaches a peak of £2,540 at 42, and at this very early age his income starts to fall; and he is down to only £1,600 at the age of 60.
This strange shape of the earnings of the general practitioner and the dentist is an amazing discovery, and it is a scientific discovery of the greatest importance. The Royal Commission made this discovery but, so far as I can see, did not realise the importance of what they had done. They certainly never asked themselves why it happened. It is only fair to say that Professor Jewkes, in his Minority Report, asked himself this, and did consider the matter. So it is not surprising that the Royal Commission failed to suggest any remedy for this strange state of affairs. We in the medical profession know why it happens. General practitioners and dentists are paid, roughly, in the case of the "G.P.", or actually in the case of the dentist, for the amount of work they do. Consult- 112 ants, on the other hand, are on a salary scale or career ladder where there is no such disability.
General practice is one of the toughest jobs physically and emotionally that there is. The "G.P." is a constant car driver and car parker. When most of us are packing up and going home, at 5.30 or 6 o'clock, he has done a day's work and is starting his evening surgery, which may go on one, two or more hours; and after that there are one or two more visits to do. A quarter of all the patients seen in his surgery, and half of those seen on his rounds, are suffering from serious illness. The "G.P." looks after the majority of the slowly dying patients when the hospitals and specialists ihave failed. He is responsible for most births, although he will be present only if the midwife is in difficulty. He makes virtually every initial diagnosis, and to relieve hospital beds we are continually asking him to do more. Moreover, as the result of modern discoveries he does more treatment and more active prevention than ever before. Finally, the number of research papers which he is publishing is steadily increasing.
The toughness of general practice as an occupation is clearly demonstrated by the high mortality rate among general practitioners—the highest, I think, in any profession. All this information is available to anyone who cares to read it. But the Royal Commission does not quote the sources among the papers it has consulted. The reason general practitioner incomes fall in the last decade of their practice is simply that the practitioners are fagged out: they cannot carry on at the same pace. With dentists the situation is exactly the same. At the start of a dentist's career he works absurdly tong hours to make a very high income. But in a comparatively few years he has just got to cut. This is surely something we must accept as a fact. It has been demonstrated and proved by the Royal Commission. And surely the Royal Commission should have looked at its own findings and suggested the remedy.
I now turn to the second part of the terms of reference: to determine, in the light of a comparison between doctors and other professions, what the doctors' incomes ought to be. There were two possible ways of doing this. The first was to work out the different kinds of jobs 113 done by the different professions and to say if the doctors were in the right place on the table; and it would be necessary to do this in terms of the volume of work, the nature of the work and the difficulties and the rest—that is to say, a complete comparative job analysis. My general practitioner friends suggest that the easiest thing would have been to take the comparative mortality rates for the different professions and settle for that. The Royal Commission made no attempt at a comparative job analysis. The members of the Commission dismiss the whole matter in six short paragraphs. They claim in some mysterious way to have seen the whole picture and to have obtained sufficient information to enable them to exercise their judgment in making recommendations about the proper levels and spread of doctors and dentists' remuneration. Strangely enough, they pulled "out of the hat" a figure only 5 per cent. below that recommended by the British Medical Association, who had done the job much more carefully.
The alternative and much simpler way of going about it was to examine the trends of doctors' and dentists' pay, and to compare them with trends of pay in other professions over a period of years and to see whether the doctors were slipping back or getting too far ahead. This is precisely what Professor Jewkes did in his Minority Report. He found that between 1950 and 1959 the average person was 20 per cent. better off, while the average general practitioner was 20 per cent. worse off. Accordingly, he recommended an average annual net income for general practitioners of £2,550 a year, as compared with the Royal Commission's recommendation of £2,425 a year. Is it possible that the Government rushed to accept the Royal Commission's Report before the doctors realised that the proper figure might well be £125 a year higher than that which the Royal Commission had recommended? Of course it is not. I am sure the Government just had not studied it closely enough, and that they will now hasten to put right this manifest wrong. I do not pretend to know what the "G.P." ought to be paid. I do know that Professor Jewkes' approach was logical and reasonable, and that the Royal Commission advanced no serious arguments for its conclusions. My Party therefore accept Professor Jewkes' findings and 114 believe that the Government should change their mind and do the same.
Assuming that either the Royal Commission or, as we think, Professor Jewkes is right, how should the money be spread among the "G.P.s?" Here again, the Royal Commission lost its way between an attempt to stick to its limited terms of reference, thus producing a spread of incomes similar to that in other professions, and a series of half-hearted glances at the broader issues. To attempt to mirror the spread of incomes in other professions is to assume that a general practitioner's work is like that of other professions. In fact, it is very different. However good the group to which the "G.P." belongs, most of his work must be done alone with his patients, in his consulting room or in their homes. Each day he has to see between 40 and 80 people, and at the end of each interview he has himself to reach a definitive and responsible decision. There is not the time, save in very exceptional cases, to call in a colleague or senior. He sees before him the whole gamut of sickness and health and human happiness and misery, and more than ever before in human history he is able, if he knows his job, to take positive steps to help those who need his help. Within this wide context we have to set the fact that his work does not change from the day he starts to the day he retires. Thus his work is utterly unlike that of an engineer or solicitor or architect or accountant. The only near analogy is that of a parish priest.
We believe, and we think most doctors believe, that the first consideration in the way a "G.P." is paid ought to be the encouragement of the best possible service to his patients, whether they are rich or poor, in country or in town, whether their ailments are severe or trivial, remediable or fatal. In the first ten years of the National Health Service it has been shown beyond all doubt that the way the doctor is paid helps to determine the service he can give. Yet to this fact the Royal Commission directed little or no attention.
It was a great disappointment to most of the medical profession to find that the Royal Commission adopted, without making any field investigations, recommendations which would tend to work against the public interest. Everyone 115 who studies the matter knows that the future success of general practice depends on the futher development of group practice which, as my noble friend Lord Moran said, may well be associated with extra hospital work and specialisation within groups. But, for obvious reasons, group practice is impossible in many rural areas—there are not enough people and the doctors therefore cannot form groups. To encourage group practice, the doctors and the Ministry have between them worked out an excellent cash incentive scheme to group practice. As a result, the number of doctors in partnership has increased, since it has been going, by about 25 per cent. Without giving any evidence or reasons, the Royal Commission describes these cash incentives to group practice as "somewhat excessive." Likewise, without field investigations or work studies, they criticise the extra cash rightly paid to rural practitioners as "somewhat overdone". On these matters the Royal Commission views are, I think, somewhat mistaken, and I hope that they will be altered.
We welcome the recommendation that the excellent interest-free group-practice loans fund, which enables doctors to build modern group-practice centres, should not come out of the doctors' earnings pool as it does at present, provided that the new capital made available continues to be interest-free. It is because the money is interest-free that it has been used so well that in five years something like 300 new group-practice premises have been built by the doctors themselves, thus enabling them to give better service to something like two million patients.
Perhaps the greatest disappointment of the Royal Commission Report to those of us who care about the quality of the Health Service—here, again, I agree completely with what my noble friend Lord Moran said—was the attitude of the Royal Commission to list size: that is, the number of patients that a general practitioner in the National Health Service may look after. Without any field studies whatsoever, without quoting the extensive literature, they concluded—here I quote:We doubt whether anyone is competent to set a fixed and universal limit to the number of patients a doctor should have.116 They seem here to have been caught by some strange irrational prejudice, and swept along by it regardless of the facts.
Here I really can claim to speak from a fairly wide experience. When I arrived in your Lordships' House I was delighted to find that there was already in the Library a book I wrote called Good General Practice. While I was working on this for the Nuffield Provincial Hospitals Trust, I remember seeing two doctors in a Northern industrial town. When the appointed day for the start of the National Health Service came and their patients had to register, they found that between them they had 17,500 patients. To get their lists down, they immediately took in two partners and an assistant. No doubt they would have claimed that they were giving a good service in the old days. They were not, and they could not. If a doctor takes no proper history—here again I entirely agree with what Lord Moran said—and seldom examines a patient, he can claim to look after a huge number of people. But this is a travesty of medicine.
The Royal Commission says that no one is competent to fix a top limit; yet the Ministry and the doctors between them have rightly fixed, first, a limit of 4,000, and then, when the Danckwerts Award came along, a limit of 3,500. I say categorically—and I think my noble friend Lord Moran agrees—that no man can go on looking after 3,500 patients over the years and continue to do his job properly. Remember, we are asking "G.P.'s" to do more and more to keep patients in their homes, to save hospital beds. Your Lordships will remember the Mental Health Act of the last Session. The essence of it was to keep patients with nervous and mental illness out of hospital. Yet those are the most time-consuming patients of all. All good general practitioners know that better doctoring for the patients will be possible only if lists are reduced still further.
We all hoped that the Royal Commission would help us to take the next stage forward. Since they have failed to do so, it is now up to the profession as a whole to tell the Government quite clearly what must be done. There will always be a few who will not agree— 117 for example, my friends in the Northern industrial town who thought they could look after over 8,000 patients each. But those are just the places where smaller lists are most needed in the patient's interests. We therefore advise, at the time that this award is introduced, an immediate reduction in the maximum permitted list size down to 3,000. To do this might require about 400 extra doctors in general practice, but they are coming, forward. Because the general practitioners' pool of payment is calculated not on the number of patients but on the number of doctors, it will not mean any reduction in the earnings of the average "G.P." Indeed, in the long run it might work the other way.
The third place where the Royal Commission have failed badly because of lack of knowledge is in their proposal for merit or distinction awards for general practitioners. They suggest that half a million pounds should be divided in lots of between £500 and £1,000 and given to 750 distinguished or meritorious general practitioners. Quite apart from the merits or demerits of the scheme, as a practical proposition it is just "out of this world." I spent two years studying in detail the work of 100 general practitioners. First, I would say that nothing short of a two-day visit, living and working with a "G.P.", will enable one to assess his real quality and merit. Real merit often bears little relation to the opinion held of a general practitioner by consultants, and even by his own colleagues who do not see him at work. Membership of Committees, published articles and good practice organisation are not certain criteria of excellence. There are 22,000 general practitioners from whom the fortunate 750 must be selected.
I am not surpised that some general practitioners have suggested that the best answer is an annual lottery with 750 prizes. Even if they could be visited as I visited them, it would be virtually impossible to pick out the top 5 per cent., which is what the Royal Commission want. One could pick out the worst 5 to 10 per cent. and perhaps even the best 25 per cent., but within that 25 per cent. who are all doing much the same work equally well, honest selection would not merely be invidious but be impossible. I am sure that however much the noble Lord, Lord Moran, may 118 want it, it just cannot be done, and I am sure also that the enormous majority of general practitioners and the great majority of good general practitioners will agree that selection for alleged merit, even if desirable, which it may not be, is just impracticable.
But, on the Royal Commission's own showing, there is need for a differential payments scheme for "G.P.'s", and the differential needed is for doctors' age. It is not a reward for merit; it is simply that if you look at the curve you find that what is happening is that the incomes of older doctors in general practice are going down because they cannot do the work. The Royal Commission says that general practitioners' and specialists' pay should be related roughly as they are at present. But, over 50, the "G.P.s" drop down while the specialists go up. To keep the curves running roughly parallel would mean stepping up the "G.P." over 50 by an extra £50 a year for each year between 51 and 60; so that at 60, a general practitioner would get an extra £450 a year. This might be linked with a minimum list of say 1,000. It might stay steady from 60 to 65, and then end at 65. I estimate that it would cost—this is an estimate for putting the two curves parallel and getting rid of the fall—just over £1 million a year, or twice the Royal Commission's figure of half a million pounds for the differential awards. But it would be fair and honest. It would put right a manifest wrong and would reward those who had borne the heat and the burden of the day and give them a chance to ease up a little when most of us ease up, without financial detriment to themselves and their junior partners. We therefore strongly commend this differential payments scheme both to the profession and to Her Majesty's Government.
The attempt to assess merit and reward it with cash is not new. It has been done on a world-wide scale by the Nobel Prize Committee since 1901. What is new is the size and number of the awards made to the consultants in the British National Health Service in the last twelve years and the secrecy with which this process has been surrounded. These awards are, of course, over and above the consultants' salaries which themselves go up to over £3,000 a year. The Royal Commission 119 have done a real service in making the first proper statistical analysis of the whole process and in recommending that such a similar analysis should be made every year. From this we can learn a great deal.
There are just over 300 consultants holding top merit awards of £2,500 a year and about 25 new replacement awards are made every year. The average age for such an award is 53, and it continues for twelve years and thereafter counts for pension. Its untaxed cash value over the full period is therefore about £50,000, assuming that the doctor is engaged whole time in the National Health Service. Actually, however, nine-tenths of the "A" merit award holders are part-time, so that the average value of the "A" merit award over the years is about £30,000. I can see no objection whatever to revealing the names of the recipients of these top merit awards. I am sure they are honestly and rightly awarded and we should be delighted to congratulate the recipients. They are our medical Nobel Prize men and as such should be publically acclaimed and acknowledged.
If we take the merit awards as a whole, we find that they are granted to 34 per cent. of our consultants, although, as my noble friend Lord Moran has said, that may alter a little if the Royal Commission's recommendations for "freezing" are implemented. When he starts, of course, a young consultant has not got a merit award. He has to show his merit. The average age for getting a first merit award is about 45; so whereas one in three of all consultants have merit awards, the proportion must steadily increase with age. Indeed, of the 147 consultants who retired last year 81 (or 55 per cent.) had merit awards. Any consultant, therefore, has a more than even chance of an award before he retires. Of course, everyone who gets a merit award is delighted, and I am sure they all deserve it; but what about the 45 per cent. who wait and wait and never achieve merit? The effect on them is appalling and wholly bad. Can we be sure that among them are not many who deserve as well of their patients and the nation as the fortunate 55 per cent.?
I believe that ultimately we shall all be driven to the view that the only honest 120 and right thing to do for the future is to amalgamate the "C" merit awards—that is the lowest one, the £500 a year—with the general consultants' salaries. The potentially fortunate ones would get a little less, but the invidious process of selecting at this comparatively low level of merit would end, in my view to the great benefit of general hospital morale.
The second level of merit awards—the B awards, of £1,500 a year—are given to about 800 consultants. Quite rightly, two-thirds of these awards are divided among the 2,000 teaching hospital consultants. Nobody criticises that: it is as it should be. Quite rightly, also, 85 per cent. of the top merit awards, the A awards, also go to these 2,000 consultants. It follows that nearly half of the teaching hospital consultants have A or B merit awards; and since most are given in the latter half of the men's careers, the Chances of a teaching hospital consultant getting a high award before he retires are very high. And, indeed, this is as it should be. But, again, what about the poor chaps who are left out? Is this elaborate business really justified and really morally right?
We have reached the conclusion that the proper course for the future is to amalgamate the B awards with the salaries of teaching hospital consultants and special Regional Hospital Board units. The effect will be much the same as at present, but the invidious process of choosing and excluding will go. The Royal Commission proposes to jack up the amounts of all merit awards by between £250 and £500 a year. This is fair enough, but the Commission also proposes 100 new A Plus merit awards of £4,000 a year, in addition to the 300 A awards of £3,000 a year. The new A merit award would bring the top consultant's whole-time peak salary to £6,900 per year, plus pension. Remember, however, that most of these men are part-time; and private practice at the top has, thanks to the business boom and the B.U.P.A. and other insurance schemes, been doing very well indeed. In the face of this, we feel that there is no real justification for the A Plus awards—that is, the extra £1,000 over sand above the £3.000, which itself is on top of £3,900—and that it would be much better to increase the number of A awards to, say, 450. We hope very much that the 121 consultants will feel as we do and that Her Majesty's Government, on consideration, will also agree with this.
To sum up our proposals for consultants, they would cost the nation no more than the Royal Commission's proposals. The Committee of the noble Lord, Lord Moran, will have to pick out only the top 450 men and women from the profession, instead of 2,800, as at present. Those who are appointed to special posts will automatically get special recognition. But the secret division of staffs within hospitals into better-paid sheep and worse-paid goats will cease.
My Lords, we have come a long way since the great Lord Moran said that the thing he liked about the Garter was "that there was no damned merit in it". "Merit", said Lord Palmerston, "is the opinion one man entertains of another"—
§ LORD MORAN
My Lords, if I may interrupt the noble Lord, he is crediting me with a remark I certainly never made. That is a well known thing.
§ LORD TAYLOR
My Lords, I am sorry; I thought I said "Lord Melbourne". As I was about to say, my noble friend Lord Moran and his Committee have performed an impossible task very well, and our proposals would convert the task from an impossible one to a possible one; but they have to remember that the most meritorious prophets are not always popular. I doubt whether in 1938, eleven years after the discovery of penicillin. Alexander Fleming would have got an A Plus or even an A merit award. The same might be said of the first doctor to sit in your Lordships' House, Lord Lister. When he came South from Edinburgh in his fiftieth year he was greeted in London with jeers and sneers. His patients, however, knew the truth, and this is what one of them, W. E. Henley, said:If envy scout, if ignorance deny,His faultless patience, his unyielding will,Beautiful gentleness and splendid skill,Innumerable gratitudes reply.His wise, rare smile is sweet with certainties,And seems in all his patients to compelSuch love and faith as failure cannot quell.We hold him for another HeraklesBattling with custom, prejudice, disease,As once the son of Zeus with Death and Hell.122 Envy and ignorance, custom and prejudice, are still our enemies.
Compare this great man with a humble general practitioner. In a house off Fleet street lived a grumpy old widower who supported, out of charity, four strange familiars—blind Mrs. Williams; the Negro, Frank; the cat, Hodge, and poor Levett. Poor Levett saw his patients on foot, and when offered payment in a glass of spirits he did not want he drank it so as not to offend. Yet, thanks to that grumpy old widower, he too has achieved immortality:Well try'd through many a varying yearSee Levett to the grave descend;Officious, innocent, sincere,Of every friendless name the friend.Yet still he fills affection's eye,Obscurely wise, and coarsely kind;Nor, letter'd arrogance denyThy praise to merit unrefined.When fainting Nature called for aid,And hovering death prepared the blow,His vigorous remedy display'dThe power of art without the show.No summons mock'd by chill delay,No petty gains disdained by pride,The modest wants of every dayThe toil of every day supply'd.His virtues walked their narrow round,Nor made a pause, nor left a void,And sure the Eternal Master foundHis single talent well employed.My Lords, this "power of art without the show," this "merit unrefined," would have gained no merit award in general practice. The Royal Commission have worked hard and done well, but if they had known their Johnson I think they would have written a better Report.
§ 4.23 p.m.
§ THE MINISTER WITHOUT PORTFOLIO (THE EARL OF DUNDEE)
My Lord's, my noble friend Lord Hailsham, who would otherwise have been in charge of this debate, is at present abroad, and I must ask your Lordships' indulgence in making a few very brief observations upon a subject on which I know a great deal less than any of your Lordships who are taking part in this debate. Burt I am lucky enough to have the help of my noble friend Lord St. Oswald, whose normal duty it is to speak for the Ministry of Health and who will be winding up. I should like to begin by thanking and congratulating the two noble Lords, Lord Moran and Lord Taylor, for the most informative and authoritative speeches with which they have opened the debate, including the 123 fine poetic termination to which we have just listened.
This is the first time on which there has been a Parliamentary debate on this subject in either House since the publication of this Royal Commission's Report on Doctors' and Dentists' Remuneration. There are two general observations which I have to make about the Report. The first is that it is a long and carefully reasoned document which bears witness all the way through to the care which has been devoted by the Chairman and members of the Commission to every aspect of professional remuneration, and the Government are greatly indebted to the Chairman, Sir Harry Pilkington, and to the other members of the Commission for their unremitting labours over a period of nearly three years.
The other thing I have to say, is that the Government have carefully considered the recommendations which have been made and, as has already been announced, the two Health Ministers, my right honourable friends the Secretary of State for Scotland and the Minister of Health, have informed the profession that the Government are prepared to accept the Commission's recommendations as a whole as they stand, provided that the doctors and dentists respectively, for their part, are ready to accept them on the same basis. That is to say, the Government are prepared to accept the Commission's recommendations for both hospital doctors and general medical practitioners together, if the medical profession does so also; and the recommendations for both hospital dentists and general dental practitioners together, if the dental profession accepts them in the same way. My two right honourable friends the two Health Ministers have drawn attention in making this offer to various matters which are an integral part of full acceptance of these recommendations, including the establishment of a standing body to keep medical and dental pay under review on the lines proposed by the Commission.
The preliminary discussions which these Ministers have had with representatives of the professions have been helpful, and my right honourable friends have offered, as the next step, to arrange for the proposals to be worked out in detail jointly by officers of the Health Departments with representatives of the 124 professions in order that as clear and comprehensive a picture as possible of their practical effect may be put before their members. We understand that before that can be done this will have to be put to the professions through the appropriate channels and the Government hope that the professions will reach their decisions and enable discussions to begin as soon as possible. Your Lordships may have noticed that the Council of the British Medical Association are recommending their representative body, which meets next month, to accept the Minister's offer and to authorise participation in these discussions.
I think it would be better if the extremely interesting and detailed proposals and criticisms of the noble Lord, Lord Taylor, were to be replied to at the end of the debate, because your Lordships are all looking forward to hearing the speeches of a number of noble Lords and one noble Lady, all of whose advice on this subject is of special interest to the country, and I do not think it would be right that the Government spokesman at this stage in the debate should take up too much time. I am particularly anxious not to do anything to delay or impede the desire of the noble Lord, Lord Taylor, to form a united front with Lord Moran. A great many of the criticisms of the noble Lord, Lord Taylor, though not all of them, were concerned with matters which have not yet been finally decided but will fall to be discussed in the negotiations which we hope will take place between the Ministry of Health and the professions, and I have no doubt that the noble Lord's views will be duly noted and considered at those discussions.
§ LORD TAYLOR
My Lords, may I interrupt the noble Earl for one moment? That is a very important statement and, so far as we are concerned, a most satisfactory one, because I do not think anyone quite knows what the term "accepting the Report as a whole" means. One had hoped that there would be room for discussion of the large numbers of detailed matters.
§ THE EARL OF DUNDEE
My Lords, I am most interested to hear the noble Lord say that, and I think I shall try to confine my own observations, very 125 briefly, to the few things which ought to be said on behalf of the Government about the principal recommendations of this Report. In doing so, I hope I shall be able to go some way towards enabling the noble Lord to see which parts of these proposals are to be accepted as part of the package deal, and what aspects of them are still open to discussion.
First of all, there is the Review Body, which is proposed in paragraph 438 of the Report. We hope that this is a recommendation which may lead towards future harmony between the Government and the professions. I think it is more likely to have that effect, it is more likely to lead to harmony, if questions of remuneration are settled not by the difficult processes of negotiation which have hitherto prevailed but on the recommendation of a Review Body. In their Report the Commission considered with great care possible alternatives for ensuring that medical and dental remuneration is fairly based, and they proposed that this standing Review Body should consist of a chairman and six other lay members, all of whom should be persons of eminence and authority, to be appointed after consultation with the medical and dental professions. This Body should advise the Government, and concern itself only with major matters. It should itself take the initiative in considering changes, though it would also give advice if it were asked to do so by the Government.
There are one or two questions which have been raised about certain aspects of this proposal for a Review Body, and I should like to make the points which have been raised quite clear. In the first place, it has been asked how the Government would interpret the recommendation that the members of this Body should be appointed after "consultation" with the professions. I think that is quite easy to clear up. On the one hand, of course, it would not be constitutionally proper that the medical professions should have a formal right of veto of any member to be appointed: but, on the other hand, the Government recognise that this Review Body would be no use if its members were not acceptable to the professions. Therefore, if the Report is accepted, the comments of the professions will be invited on a provisional list of members, and their 126 views will be fully taken into account. We shall do our best to see that the medical professions will be satisfied with the membership of the Review Body.
Then, the Commission point out in their Report that, since the function or this Review Body is to advise the Government, only the Government ought to have the right formally to approach it. That may be so, technically; but we are ready to give an undertaking that any representations which the professions wish to make to the Review Body will be passed on to it by the Government, including any suggestions that for some particular reason a review earlier than the normal minimum period of three years may be desirable. With regard to the procedure of the Review Body, subject, of course, to the particular recommendation of the Commission that it should meet in private, which I think is obviously desirable, I do not think we ought to lay down any rules of procedure for a body of this kind, which is going to consist of persons of eminence and authority. We must leave it to them to decide their own rules and their own procedure. But the Government recognise that the medical professions do attach special importance to being able to present their arguments to this Review Body orally, and are therefore prepared to make a recommendation to the body that the professions should be given that opportunity if they wish to have it.
My Lords, as the noble Lord, Lord Moran, has said, we think this Report must be accepted, if it is accepted at all, as a whole. The noble Lord used the more modern phrase of "a package deal". However, I ought to mention one small exception to that, which I had thought was only of incidental importance but which I was a little disturbed to find the noble Lord, Lord Taylor, evidently thinks is of some importance, because he devoted a good deal of his speech to it. That is the recommendation in paragraph 449:… that arrangements should be made for the Board of Inland Revenue to make available to the Review Body such information about professional earnings as that Body may require, and for the information to be published to the extent that the Body may determine.For reasons which I hope your Lordships will understand, including the objections to making available for other 127 purposes confidential information obtained solely for taxation purposes, we do not think it would be possible, as the Royal Commission had in mind, for the Inland Revenue to supply the Review Body with information about the profession's earnings. But the Government are confident that the Review Body should be able to obtain the necessary information by other means, such as sample inquiries, and will be ready to give the Review Body any help to this end which lies within their power.
The noble Lord, Lord Moran, pointed out that the recommendations are, of course, different in relation to hospital doctors on the one hand and to general medical practitioners on the other. So far as the hospital service is concerned, the Royal Commission has recommended new and much improved scales, and have paid particular attention to the need for improvement in the salary of young doctors. I think one of the most interesting features of the Report is the increase in pay which is recommended for the junior hospital staff. Whereas the general increase for doctors as a whole is something like 22 per cent. above that of 1956, the increase to house officers is over 50 per cent., and the result has been a very considerable scaling-up in the rates of pay which a recently qualified young doctor can expect. This represents a very striking difference as compared with the pattern of earnings of hospital doctors before the Health Service came in. For example, for a house officer the rate of pay recommended for the very first post held is £675 a year. The Royal Commission's recommendation would certainly afford to the junior resident recognition of the fact that he is a responsible doctor still learning his job, but none the less worthy of an economic salary. The changes in the rates of pay of registrars and senior registrars are less striking, but the same trend is visible.
In paragraph 293, on page 101, the Commission has suggested that, as an aid to recruitment, hospitals outside the towns and cities containing teaching hospitals should be allowed to pay up to an extra £100 a year in order to recruit suitable staff in The grades of registrar, junior hospital medical officer, senior house officer and house officer. This proposal is designed to help hos- 128 pitals in peripheral areas which have difficulty in getting staff, and the Government certainly hope to work out, in consultation with the profession, a scheme for putting this into effect.
I rather hesitate to say anything about the distinction awards, because that seems to be the main obstacle in the formation of this united front between Lord Taylor and Lord Moran. As the noble Lord, Lord Moran, told us, the distinction awards system for consultants was introduced into the National Health Service on the recommendation of the Spens Committee in 1948. The Royal Commission has strongly endorsed the principle of this system, and has recommended increases in the value of existing awards to the figures of £750 for C, £1,750 for B, and £3,000 for A awards, respectively, and the introduction of the new proposed A-plus award of £4,000.
I think we can well understand Lord Moran's observations about the difficulty with which he copes so well as Chairman of his Committee in deciding on these awards, and I think we all recognise that there are bound to be criticisms of it. There is sometimes a certain amount of feeling that under the present system more than an average number of awards may be held in some particular specialty, or at certain hospitals. The reason is that there are differentiations between specialties in age distribution, in their attraction of the best men, in research activities, and sometimes in length of training. The number of people who go into one special branch of medicine often changes from one generation to another, and that is the reason why we may have at one time a larger number of these awards in one specialty which has been filled up some time ago. But that does not mean that in future there will not be an equally large, or even larger, number of awards in a new specialty which has not yet filled up, which has not reached the larger age groups to any great extent.
§ LORD TAYLOR
My Lords, the noble Earl will acquit us of making any criticism of this. We do not criticise the differential award at all.
§ THE EARL OF DUNDEE
My Lords, the noble Lord, Lord Moran, spoke of a feeling which inevitably arises from the method of distributing these awards, which your Lordships can well under- 129 stand. I think that the present award system does allow new situations to be met as they arise, without any change in the rule. It is the same as between hospitals. It is only to be expected that competition for posts between teaching hospitals should be more intense in their specialties, and it may mean that these hospitals may have a higher proportion of talented graduates. Awards are given purely on merit, without any attention to the particular branch of medicine in which the recipients are engaged.
The noble Lord, Lord Moran, reminded us that at present awards are granted to one out of every three consultants, and he suggested that as time went on the proportion might be reduced to one in four. As the noble Lord will see in paragraph 231 and 232 of the Report, when the Commission gave their reasons for proposing this change they pointed out that it will be one of the functions of the proposed new Review Body after the first three years to suggest any alteration in the number or awards which they think is required. The present fixed number is about one-third of the total number of consultants and it would be possible for this number to be raised and at the end of the three-year period reach more than that proportion.
In regard to the general medical practitioners the Commission endorse the system of paying their remuneration through a central pool. They remark that though this method is unusual, it has a number of practical advantages. They have recommended a change, which your Lordships will find in paragraph 339, in order to simplify it, and which I think will make it more easily understood by the general practitioner. The result of the new method is that the average general practitioner should receive a net average remuneration of £2,425 annually, which is about £260 per annum more than he is receiving at present. The Commission leave the question of detailed distribution of the pool to negotiation between the profession and the Government. They only make the suggestion that certain factors should be given due weight in the course of negotiation.
One of these suggestions, which I think the noble Lord, Lord Taylor, would not find easy to accept, is that there should be some reduction in the special benefits 130 to be given to rural doctors at the expense of other practitioners and, in order to mitigate the preponderant influence of list size in determining their earnings, that greater weight should be given to other items than capitation. So far as country doctors are concerned, many of your Lordships will sympathise with the kind of work they have to do, but this and many other matters are among those which require detailed discussion in the joint negotiations which the Government and the profession will soon agree to start.
The same applies to the differential payments proposal which drew a great deal of criticism from the noble Lord. The Royal Commission thought it important that, if possible, some system acceptable to the profession, should be devised whereby some general practitioners might earn a good deal more than the average. They recommended in paragraph 348 that over and above the finance needed to meet other recommendations a special fund of £500,000 per annum should be provided to recognise distinguished general practice in accordance with a scheme to be agreed (it has not been agreed yet, and I understand that it will still be possible to consider the noble Lord's alternative of a lottery!) between the profession and the Government, but that this money should not be provided unless and until the scheme has been agreed. The Royal Commission recognised that many general practitioners might have strong views against any sort of merit award scheme in general practice, but they consider that there should be some arrangement whereby in the field of medicine, as elsewhere, the most distinguished practitioners may secure a larger income.
I think that I had better say a word about arrears. The Commission do not as a matter of principle recommend retrospective payments (paragraph 348). In fact their proposal for a Review Body is designed to eliminate the need for such payments. On the present occasion, having regard to the conclusions that arise about the levels of medical earnings in 1955–56, they recommend that from January 1, 1960, and the fact that in 1957 they were asked to recommend the "current" levels of remuneration, they consider that some payment in respect of past years for doctors and hospital dentists is called for. They recommend (in, paragraphs 395 to 398) that £9 131 million for hospital doctors and hospital dentists and £11 million for general practitioners should be distributed in accordance with schemes to be agreed between the Government and the medical profession.
The noble Lord, Lord Moran said that he thought that general practitioners on the whole were not contented with the proposals in the Report.
§ LORD MORAN
My Lords, I am afraid the noble Earl misunderstood me. I meant that general practitioners were discontented with the life they led. It had nothing to do with the Report. I have not the slightest notion of what they think of the Report.
§ THE EARL OF DUNDEE
My Lords, I am glad to hear that I have misunderstood the noble Lord. The people who may have some reason to be dissatisfied with this Report are the general dental practitioners. The Commission have recommended that in general terms hospital dentists should follow the recommendations made for hospital doctors, but that does not apply to general dental practitioners as compared with general medical practitioners. The Commission concluded that in 1956 both doctors and dentists were underpaid and that bath ought to have a roughly similar increase. Interim increases were given in March, 1957, and in January, 1959, both to doctors and dentists, but these increases at no time raised doctors' or hospital dentists' earnings to a level which this Commission thought appropriate. Therefore the Commission have recommended for doctors and hospital dentists an increase of rates from January 1 of this year, plus a lump sum for back pay.
So far as general dental practitioners are concerned, the information which the Commission had about their gross earnings subsequent to 1956 indicated that these earnings had risen substantially and progressively, and it was against this background that the Commission recommended no immediate change in the increased rates of remuneration and no back pay for the general dental service. The Commission have recommended for the future that the average general dental practitioner should earn £2,500 net per annum from the General Dental Service, 132 this recommended level being related to the present number of hours worked by the average dentist, and they propose the early appointment of a Dental Rates Study Group whose function it would be to obtain factual information upon which the level of fees can be realistically assessed to secure the desired result. The Government feel that, with good will and co-operation, this Dental Rates Study Group could be welded into a most effective machine for safeguarding the level of dental remuneration in the years to come.
Although this Report has not yet been accepted by the professions, and it may be that there is still a lot of ground to cover before it is finally agreed to, the Government very much hope that it may open the way to a new and happier relationship between the Government and the doctors and dentists. Past differences over the important matter of remuneration, whatever the merits or demerits of those differences may have been, are extremely regrettable. As all your Lordships know, there is no profession in the world which is more unselfish and more devoted to humanity than the medical profession, and we have heard to-day something about how they are trained. I have always thought that if a man has to spend most of his life listening to the ailments of 1,000, or even several hundred, people every week, he must either become an extremely wise man or else go mad.
We have heard something from the noble Lord, Lord Moran, about the initial training in which doctors, as most of them do, learn to become wise men, and I am sure that none of us who is not a doctor could ever contemplate the task of looking after more than a few dozen people in that way. I am sure that the noble Lord, Lord Moran, may be right in saying that 3,500 patients is too many for any one doctor, but it is amazing how many people doctors do learn to look after and to how many people they are able to give the right advice quickly. I heard of one doctor the other day who was rung up by a mother who said: "My little daughter has just swallowed my fountain pen." The doctor was a very busy man, but he said, "I am sorry to hear that. I will do my best to get round, and I will be 133 there in about three-quarters of an hour." The mother said: "Three-quarters of an hour? What am I to do in the meantime?"; and the doctor said, "Could you not try using a pencil?". I am sure it is one of the wisest professions in the world.
We know undoubtedly that the real object which both the Government and the medical profession have at heart is to ensure that the Health Service is developed and improved in an atmosphere of mutual confidence and respect, to the maximum benefit of patients for whose needs it is provided and also of the public who have to pay for it.
§ 4.53 p.m.
§ LORD AMULREE
My Lords, I am sure that the members of my profession will be pleased when they read what the noble Earl. Lord Dundee, has just said about our profession in reply to my noble friends Lord Moran and Lord Taylor. We do appreciate very much the kind words he has said about the work that we do. One of the great advantages in not, taking part in the opening stages of this debate is that a great deal of what I might have said has already been covered so much better by my noble friends Lord Moran and Lord Taylor. Therefore, it does not leave a great deal for me to say, other than to cover one or two matters on which I feel a further word should be said.
In the first place, I am pleased that the Government are going to accept the Report more or less in toto. I feel that one could have no objection to the Pilkington Report, which is generally sound and good. One thing I would mention, as was mentioned by my noble friends Lord Moran and Lord Taylor, is what a good thing it is that there will be some permanent body to review rates of pay in the future; that we shall not have to go through all the trouble there has been in the past, but that it will be done more or less automatically and in a far simpler way. This will make a great deal of difference. I am sure, too, from the point of view of the consultants—and here I speak as a part-time consultant with a contract with one of the London teaching hospitals—that I have got nothing but praise for the Report and no serious criticism of that part of it. Personally, I have always found that the scheme of merit awards for consul- 134 tants has worked well. So far as one can judge, it has been fairly administered and, for my part, I do like the idea of secrecy. The now nation put forward by the noble Lord, Lord Taylor, is most interesting, but at the moment I think the profession would do well to consider whether the merit award system has outlived its usefulness or should continue. What I am worried about is that the Royal Commission suggest that there should be a period when merit awards are, as it were, frozen. That, I think, would be a pity, and I wonder if the point could be looked into again with a view to the system carrying on regularly as it has done up to the present time.
One branch of people I should like to say a few words about before I sit down are the whole-time consultants, who seem to me to labour under certain disadvantages when compared with their part-time colleagues like myself. For example, they get little or no allowance for travelling expenses. They have difficulty in getting expenses paid if they visit conferences, meetings and such things in different parts of the country. They do not get money allowed for taking professional journals. These particular things apply to all people paid whole-time by the Service, both consultants and some of the younger members of the profession. Surely it is necessary that these younger members should visit conferences and meetings, if indeed conferences and meetings have any value, which we are always told they have. Whether that would be a matter for the Inland Revenue or the Minister to decide, I am not sure. Certainly it was not until the Budget of 1958 that it was possible for whole-time consultants to get some tax relief for the fees they pay to be a member of professional associations. Whether the other thing would apply to that, I do not know.
A further point is, that certain younger people who are not resident in hospital but have whole-time appointments are not required to have a telephone, but it is a great advantage for all concerned if they have one in their house. One would have thought that some part of that cost might be taken as a professional expense. The last thing, which I have always thought to be a peculiar anomaly, is that one of the jobs consultants are called upon to do sometimes is what are called domiciliary visits, for which they are paid a fee of four guineas. If a part-time con- 135 sultant like myself is called out, I get my visits paid for regularly. But supposing I was a whole-time consultant I should need to do eight of these ancillary visits before I was paid anything. I cannot see what the magic of the word "eight" is. I cannot see why some get paid for the same work and others do not. I think that is an anomaly which might be looked into when the Government are considering a certain reconstruction in the payment of the medical profession.
We all share the noble Earl's pleasure that the younger members of the profession, house physicians and the like, are being paid a more substantial salary than they were. But I trust it will not occur now, as it has done in the past, that the cost of their keep was put up by the boards of governors so that they did not get any great increase in salary. Most of it went into the increased charge made for their board and lodging. I trust that it will be possible for the Minister to see that that sort of thing does not occur again, because it seems to me they will be getting nowhere at all. It is merely putting money into their pockets with one hand and taking it away with the other. Those are the things which occur to me when thinking about the full time employees of the Health Service.
I should like to say a word about general practitioners. Anything that can be done to improve their standing and conditions I think should be done, because they are one of the most important props of the service; and if there were not a good general practitioner service the Health Service as we know it could not possibly work. I was worried when I heard the noble Lord, Lord Moran quoting from Dr. Fox when he said that he thought unless the practitioners got back into hospitals, general practice in this country would not collapse but certainly undergo a great change. I think everything should be done to encourage them to go into the hospitals. At the same time something must be done to reduce the size of the general practitioners' lists.
Every noble Lord who has spoken is in agreement that it is impossible to look after 3,500 patients properly, efficiently and well. It may be done if the practitioner is very young, very 136 active and very energetic, but I am sure that when they are getting to middle age they cannot look after a large number of people. I was attracted to the scheme suggested by the noble Lord, Lord Taylor, that there should be some payment made each year to the practitioner. From the age of 50 he should receive a bigger sum each year, and yet at the same time should be able to cut down the large number of people on his list, so that his total income would not fall although the amount of work he had to do would not be quite so great as it was.
One of the things we do not want to go back to is the custom of having so-called "good practices", where people charged substantial fees in better-class districts and did not have to work very hard, and second-class practices, where a club doctor, a shilling doctor or a half-crown doctor got very little money and had to cope with an enormous practice. I think the National Health Service has done a great deal of good work in breaking down this kind of thing. But I think it must go one degree further and see that the general practitioner does not get his back broken by too much work and that he should be allowed a certain amount of leisure when he grows older. I am sure that any steps the Government can take to do that will be welcome—even the system of merit awards, which I think will be difficult to work out and which I should have thought (although I know this was said about the consultants as well), will lead to ill-feeling between individuals. Therefore I think the scheme which the noble Lord, Lord Taylor, has put forward and which would cost a little more is a more equitable scheme and would be more acceptable to the profession.
§ 5.5 p.m.
§ LORD COHEN OF BIRKENHEAD
My Lords, we have once again been indebted to the noble Lord, Lord Moran, for a comprehensive, cogently argued and, to me, in most respects compelling speech. His views are born, as we who know him best acknowledge, of a vast, unrivalled experience in medical fields, and we should expect that they would bear the imprint of such authority as he rightly wields. I should also express, with the noble Lord, Lord Taylor, our gratitude to him for having overcome many of the birth pangs of the National 137 Health Service and for having helped it through its earlier years, perhaps the more difficult years of infancy. I am also grateful to him personally for having supported the plea which I made in the last debate in this House on Hospital Services, that general practitioners should be more closely associated with hospitals and that there should be less use of hospital beds for purely hotel purposes. I think his figures were not exactly those of the Barrow Report, but certainly the R.H.B. (48) I Memorandum, which sought to determine the numbers of hospital beds necessary, gave as 5 per 1,000 the appropriate number of acute general hospital beds. Although there have now been three surveys, the Barrow Survey shows the highest required number, and that is under three.
We are also indebted to the noble Lord, Lord Taylor, for his wide and wise survey on most of the controversial issues of the Royal Commission's Report. We were wittily titillated, those of us who have been in practice, by his recital of the type of fee which was paid in the past. But I would warn him that the amount of the bill is not necessarily all earned in practice. Gull, Jenner and others might well have been among the fortunate Victorians who invested their money wisely. Indeed, I know of an ophthalmologist in my own city who left well over £500,000, but he owed that wealth not to the fact that he had earned it in the field of ophthalmology but because of the lucky circumstance of having a father who held some of the founder shares in a tobacco manufacturing firm which was later taken over by the Imperial Tobacco Company. In giving his views on dentists' remuneration, he neglected to pay a tribute to this remarkable discovery of the drop in income after the age of 42 to our mutual noble friend Lord McNair in his Report on Dentists.
I am sure we must be grateful to the noble Earl, Lord Dundee, who has clarified many of the more obscure inferences from the Royal Commission's Report and the Government's attitude towards them. I share the gratitude of the noble lord, Lord Amulree, to him for the panegyric which he has uttered on our profession. He suggested that we are perfect. But I would remind him of the perils which await perfection. There was a distinguished Roman, 138 Mucius Scaevola, of whom it was said that he was not only the most brilliant of administrators, the most learned of jurists, the most distinguished of orators and the most persuasive of logicians, but that he was also a paragon of all virtues, both public and private. Well, my Lords, he was murdered on the altar of Vesta—which is tragic but hardly surprising.
Three years ago, following the appointment of the Royal Commission, there was a debate in this House in which powerful voices were raised, first because they feared that much of the information which was available and many of the documents which had played an important part in determining the doctors' remuneration would not be eligible for discussion by the Commission—such Reports as the Spens Report and the Danckwerts Award. Others were anxious lest the Commission should completely upset, for example, the merit awards. Others were not a little disturbed by the fact that the Minister of the day appeared to have suggested that if the Royal Commission's Report was not favourable to the Government, then the Ministry might not recommend the Government to implement it.
Since then hundreds of pages of evidence given before the Royal Commission have been published, not free from the occasional inflammatory utterance and not infrequently recording highly dramatic incidents. Three years after the Commission was appointed its Report was published. I share with all who have spoken to-day admiration for the Chairman of the Commission and the Commission itself and its Secretary in publishing a Report which is a monument to their industry and, despite some criticism which must clearly be levelled at the Report, to their sagacity. To my mind (and I think I should say this) much of the statistical evidence is irrelevant to the main issue; and secondly, much of the task which the Commission undertook may well have been determined a priori because the problem that was set them was resistant to a strictly rational solution. I will not enlarge on that because I have a suspicion that the noble Baroness, Lady Wootton of Abinger, in view of the article which she wrote in the Spectator a few weeks ago, will dilate in much greater detail on that particular aspect 139 of the problem. But I share her anxiety and I, certainly without her wisdom on economic and social problems, share some of her fears because of the potential fallacies in the observations of the Commission.
Yet I am glad that its recommendations have been generally acclaimed and accepted by the Press and by my own profession as offering an equitable settlement of many outstanding problems. The British Medical Association and I believe the Royal Colleges all approve in principle the Report. They regard it on the whole as favourable to the profession and they accept it, as I say, in principle, if not in every detail. Many who regard Royal Commissions as a device for shelving Governmental responsibilities may be surprised that the Government themselves within a very few weeks were able to announce that they, too, accepted the principles in general of the Royal Commission's recommendations. I believe that, with goodwill on both sides, the stage is now set for a much brighter relationship and a much happier future between the Government and the profession. There are many matters of detail which, had there been time, I should have liked to discuss—the question of the weighting of part-time consultant session, the method of calculating the notional half days of a part-time consultant and how the retrospective remuneration is to be distributed, and the like. But it seems to me that these are primarily matters which should be discussed by the profession with the Government representatives.
There are, however, two major matters of principle which have engaged our attention almost to the exclusion of all others this afternoon. They are merit awards, which in the case of general practitioners are referred to as "differential payments", and the Review Body. The consultant merit or distinction awards, whatever doubts were expressed about them at first, whatever anxieties might have been felt at their inception, have been resolved since the machinery has been clearly defined and since we have experienced its working for nearly ten years; and they have been resolved very largely because of the judicial approach to many of the problems to which merit awards gave rise by the noble Lord, Lord Moran, as Chairman of the Awards 140 Committee. No one doubts that the theory of merit awards is unique and that it is wholly illogical in theory, but it works. I believe that if we are to retain differentials—and, after all, one does retain them in every aspect of academic and professional life—it is better to retain the differentials as they are at the moment than merge the "B" and "C" awards, in the manner which the noble Lord, Lord Taylor, suggested, into the normal remuneration of teaching and non-teaching hospital consultants.
Difficulties have in the past arisen because it has been thought that merit awards reflect solely the service which the consultant gives to a patient. It has been made abundantly clear that they are awards for distinction and not simply for the quality of service which is given to the patient. There are other fields, indirect as well as direct, in which the quality of service to a patient and the quality of service to medicine in general can be recognised. The noble Lord, Lord Moran, explained quite clearly that although the "A" merit awards were on a national basis, the lower awards were fundamentally determined regionally by regional bodies, which, although having no statutory authority (which was vested in the Awards Committee) yet advised the Awards Committee so that it was almost impossible for the Awards Committee to deviate from firm recommendations if they were widely held. Obviously, it is inevitable in the case of the consultant awards that there should be regional and specialist advice on the merits of any consultant. You cannot compare the merits of an orthopedic surgeon at Ormskirk with an ophthalmic surgeon at Oswaldtwistle, but you can determine in general what type of service, what quality of service, what merit of service is being given by consultants.
There are, however, one or two anomalies and certainly one abuse to which I should like to refer, and I am sure that if the noble Lord, Lord Moran, knows of them he will rapidly rectify them. The first is that there are anomalous situations in which most distinguished professors of subjects which are eligible for merit awards, solely because of the local set-up are prevented from receiving them. I do not want to specify names because this is not a matter, I am sure, of which the noble Lord is unaware. Secondly, I have 141 come across examples of an abuse of the award system, where a university has endeavoured to attract a distinguished professor from a university where he is getting only a part-time award at an "A" level, to the other university where he is promised a full merit award. I think that that is a most serious matter.
§ LORD TAYLOR
My Lords, may I ask my noble friend, first of all, how the first university knows about this award? These awards are secret. If this gentleman is getting an award at another university and that fact is known, does it not mean that the secrecy is unreal?
§ LORD COHEN OF BIRKENHEAD
The noble Lord must surely know that there are varying degrees of secrecy. There are secrets as between the noble Lord and his noble Lady; there are secrets as between the noble Lord and his children; there are secrets as between the noble Lord and members of his own Party, if I may say so; and it is not difficult on these occasions, as I am sure anyone familiar with university matters will agree, to know that a certain professor receiving a merit award. Indeed, when he is interviewed for a post or applies for it, it may well be that one of the conditions of his accepting it is that he will receive a similar "quantity" of award because the same award in quality remains.
There is another point which I think worthy of mention: namely, that in this country, medically qualified pre-clinical staff—anatomists, physiologists and bioahemists—are not eligible for merit awards. I have met this situation in Northern Ireland where, in November, 1955, I was invited by the Government of Northern Ireland, the Hospital Authority and the University to recommend a method of determining which pre-clinical teachers should receive merit awards. I learned several facts which were then new to me but which I am sure are of profound importance—namely, that before merit awards were instituted for pre-clinical professors before they became consultant members of the staff hospital, the surgeons, for example, hesitated to consult them over, say, an anatomical or physiological problem because they felt that their pre-clinical colleagues were not members of the hospital staff. Now that these are members of the hospital staff and are 142 receiving merit awards, they have no hesitation in consulting them over their problems, and there is a much closer and happier clinical and pre-clinical relationship than in many other universities.
I have said that the vast majority of the profession now agree that the merit award system for consultants is an admirable one and works fairly. The cynic might say that one-third of them receive these merit awards, another sixth will receive them, and perhaps those who fear that any vocal protests might jeopardise their chances of an award are not anxious to make their views known. But I do not believe that at all. I have to mix with a number of consultants in different teaching hospitals in different regions, and I am convinced that, particularly within the last few years, there has been virtually a complete acceptance of the objective and judicial determination of these awards and that it would be difficult to find many who would wish to upset that. Now, of course, the Royal Commission agree with that view, and with the arguments put forward for augmentation of the awards.
But I find the Royal Commission's paragraphs on differential payments for general practitioners among the least persuasive of this document. I think that they contrast with the clear and cogent advocacy of the rest of the document. If you look at paragraph 345 they say:We are of course aware that the nature of general medical practice is less favourable to extremes of income than that of most other professions or the other branch of the medical profession.But their own figures show that there is just as much difference between the lower quartile and the upper quartile of the remuneration of general practitioners as of the consultants; and, indeed, there is on the general practitioner's side rather a balance in his favour. But if we take the average they are approximately the same—between the lower quartile and the upper quartile there is approximately a 50 per cent difference.
Then comes the statement, in paragraph 347:Unless one believes, as a matter of principle, in equal incomes for all, one must surely wish to see the higher incomes associated with some desirable quality, and among professional men the obvious quality is professional distinction.… There has probably never been an organisation in which some of the promotions have not been criticised, and those who are responsible for making decisions 143 on promotion of staff know it to be a difficult task in which mistakes must inevitably sometimes be made.But there is a method of differentiation—it may not be a very satisfactory one—in which the capitation fee method of payment does differentiate between the practitioner who has 3,000 patients and the practitioner who has 2,000 patients. It is true that it is not an arithmetically progressive change, because there are loading payments for 501 to 1,500 patients, yet it is there. That is one of the points which not only my own Committee but others have thought justified a capitation system. But againthere has never been an organisation in which some promotions have not been criticised.That is true. But these promotions in other organisations, and, as far as I know, in every other profession, are made by superiors who are well aware of what the man who is employed is doing. This would not be the case with general practitioners. We must face it that only one in 23, or perhaps one in 17, depending upon the amount of money which is given for each of these awards—let us say, only one in 20—practitioners would receive an award.
The noble Lord, Lord Taylor, has spoken of his Good General Practice, with which I am privileged to feel I have some association. But in my years of practice I met, not hundreds, but thousands of general practitioners all over the country, and I should have thought it extremely difficult to pick out those few practitioners who I thought merited an award. Of course, there are one or two who are quite outstanding and there are many who are at the opposite pole; but there are great difficulties, and I should have thought that if the Royal Commission had felt that this was extremely important they would have themselves produced an appropriate scheme. I confess I am sceptical when someone says to me, "It is not beyond the wit of man to devise such and such a scheme", because I know that it has defied his wit. I suspect that this defied the wit of the Royal Commission and so they did not put forward any scheme; and I am not surprised!
There are two factors to be considered here. One is whether general practitioner differential payments are 144 desirable—and I would agree wholeheartedly that they are desirable. The other question is: are they practicable? I believe the evidence, at any rate so far as we have yet heard, is that they are not practicable. The noble Lord, Lord Taylor, mentioned that I had been chairman of a Committee which had discussed this very problem among all the other problems of general practice which had then confronted the National Health Service. That was a Government appointed Committee, appointed by the Ministry of Health through their Central Health Service Council. As the noble Lord has said, that Report is completely ignored by the Royal Commission. No reference to it is made. But I am not speaking out of any embarrassment or bitterness; it is just that I feel that they might have learned a thing or two had they read the Report.
What did the Committee say about special rewards for efficiency and experience in general practice? Very briefly, they said this:Whatever may be the advantages of merit awards for consultants and specialists"—and, so far as I know, no one on my Committee then doubted that they had advantages—in the field of general practice the suggestion was dismissed on purely practical grounds. Two types of criteria in particular have been suggested which might govern such payments. On the one hand, there are the objective criteria, such as age and length of experience of the practitioner, the possession of higher qualifications or the number of refresher courses he has attended. But none of these can give any guarantee of quality and at best a reward on this basis could only be made in the hope of some correlation between the objective factors and good service. On the other band, there is the subjective assessment of merit, and this, in the Committee's view, is open to even more serious objection if for no other reason than the very large number of practitioners whose work would have to be assessed and the consequent difficulty of securing any sort of uniformity of judgment.Then there is the point made by the noble Lord, Lord Taylor:The process of assessment might do very serious harm to the good relationships which at present exist between general practitioners in the Service and indeed it might undermine the very basis of group practice.I might remind your Lordships that in order to stimulate group practice it was this Committee who, at the request of the Ministry of Health, drew up certain criteria of desirable group practice. It 145 was not only the Cohen Committee but also much of the evidence given before the Commission which doubted the practicability of merit awards or differential payments for general practitioners. How were we to assess talent, industry, enterprise, quality of service, originality and so forth?
Within the last few weeks there has appeared in the journals of this country a large number of suggestions as to how merit in a general practitioner may be gauged. It is suggested by many that a points system would be appropriate for this; that for each of the qualities which a general practitioner possesses he should be given a certain number of points, and that if he reaches the appropriate level he will then obtain a merit award. Among these qualities are age, length of service, hospital experience, qualifications—and hence the more diplomas one has the more points one receives. The danger would be that doctors would pursue qualifications not for the sake of improving their skill or knowledge but from a desire to obtain additional criteria which secured merit awards.
Then, war service. I understand that a martial spirit may be desirable in dealing with a horde of patients in a surgery at eight o'clock in the evening, but it is surely no criterion of quality in general practice. I am not suggesting that some of these proposals are put forward very seriously, but they have been made. Having attended a refresher course, it is suggested, should add to the merit, as if one could make a horse drink if one took him to the water. Low prescribing costs is another of the criterion—equivalent to blackmailing the doctor into prescribing the least expensive drugs, even when the more expensive would improve the patient's condition more certainly and more rapidly.
A number of other, and I think quite meritorious, criteria have been suggested, such as having appropriate secretarial and nursing staff; having proper instruments in the surgery (provided the doctor uses them and does not merely display them); having an appointments system, and so on. There are some suggestions that I really cannot take seriously: belonging to committees of the British Medical Association, the Church Council or the St. John Ambulance Brigade, being in local poli- 146 tics of on the Magistrates' Bench. One of my friends has suggested, I suspect quite cynically and light-heartedly, that there ought to be a series of polls—that the local pharmacists might be polled for the legibilty and accuracy of prescription writing; local consultants for the frequency of hospital referring and accuracy in presenting diagnoses; executive councils, local authorities, and the Ministry of Health, for speed in replying to official correspondence; with a Gallup Poll of patients for the doctor's popularity and a similar poll of general practitioners for the popularity of each general practitioner with his colleagues. A withering, scornful letter from Josephine Lee on this topic, which most of your Lordships will have read, has appeared in The Times.
Let me say this. Despite the unlikelihood of arriving at a widely acceptable scheme based on any criteria other than age and length of experience, I believe that this proposal should be re-examined, but with a much larger amount in mind, so that it affects not one in 23 but perhaps one in four or five. That might make the problem much simpler. Mind you, my Lords, if the principle of the problem is not wholly valid then no amount of money will justify it, but there might be a point in investigating and exploring the possibility. I believe sincerely that the least worthy reason for accepting this money would be that it is just another handful of silver to be put into the kitty. It would be a tragedy if discord and frustration, whether real or imagined, were to disturb the unity of general practice. Wordsworth, over 100 years ago (and I am tempted by my noble friend Lord Taylor's poetic quotations to quote Wordsworth) observing the advance of science, said:True it is That Nature hides her secrets less and less,Man now presides in power where once he trembled in his weakness,Science advances with gigantic strides,But are we all enriched in love or meekness?Unless we can learn how to answer the last question, then we cannot know the criteria for general practitioner diffential payments. I should hope, however, that if for the Royal Commission's suggestion no satisfactory valid scheme can be found by which to distribute the £500,000 on the basis of differential payments, it might be used for other reasons.
147 There are many gaps in our present remuneration of service. There are gaps, for example, in relation to the doctor working in an industrial city, whose life might well be shortened for years by the fact that he works in that centre, and who in the pre-National Health Service days might have changed his venue and practised in a more healthy atmosphere. Some scheme might be devised which might help him so to do. I think that general practitioners working single-handed should have some incentive, for their own sakes and for the sake of the patient, to take holidays; for at present, if they take them, they must pay for them themselves by providing cover although—and I think this is right—the consultant has six weeks holiday with pay each year. I think, also, that if the general practitioner becomes disabled during the course of his service in the National Health Service there should be some source to which he might turn for some help. These are a few, a very few, of the many possibilities. But I am most anxious to support the proposition that if the £500,000 cannot be used for one purpose, because it cannot be judicially distributed, it should be used for other appropriate purposes.
Finally, may I say just a word or two about the Review Body? This is another of the imaginative ideas for which, as the noble Lord, Lord Moran, reminded us, we are indebted to him. It was, as he said, the Royal Commission on the Civil Service from which emerged a Committee under Lord Coleraine—which is responsible for a similar review. I believe firmly that this is the best instrument for its purpose if the members carry the confidence of the profession, which the explanation of the noble Earl, Lord Dundee, now makes certain: first, that the membership will have the approval of the medical profession; that they will be consulted and shown a provisional list to comment on the proposed membership of the Review Body; and secondly, that they shall have direct access to the Review Body so that they can present their arguments to them. It has been suggested that this is an entirely novel approach, but as a matter of fact it has been used before. The Association of University Teachers have direct access to the University Grants Committee. Mr. Butler ensured that that would be so.
148 My Lords, I fear that I have spoken at too great length, but I hope that the professions will agree and not press for any substantial alteration except on very minor details, and that they will discuss the recommendations of the Report in a co-operative spirit. May I conclude by expressing the earnest hope that this Royal Commission will have been the beginning—and that the Review Body will be the continuation—of a machinery which will prevent the disputes, the manifestos and ultimatums which have from time to time been displayed in public; that there will be an end to these, and that the brilliant history of the first dozen years of the National Health Service will not be scarred in the future, as it has been in the past, by these unseemly wrangles.
§ 5.45 p.m.
§ LORD TEVIOT
My Lords, I find myself aligned with some very great men who are all professionals, and I am the first layman to take part in this debate. My excuse for doing so is that for two and a half years I was the chairman of the Inter-Departmental Committee which sat on the question of teeth and dentistry, and there is in existence a Report which I believe is referred to at times as the Teviot Report. I will not touch on the very learned discussion that has taken place and which has been contributed to by various noble Lords on the subject of remuneration. I will leave that side of the dental profession to the Dental Council, to fight out their own battles. But there are many things which I will deal with, quite shortly, because the noble Baroness and another noble Lord wish to speak and I will give them every opportunity to do so. After all, it is not six o'clock and it is not really so late that one cannot get up and say a few words.
It seems to me that one trouble has been demonstrated in this debate: that not enough importance is attached to the teeth and dentistry. In the two and a half years in which I sat as Chairman of the Committee something like 300 or 400 witnesses told their experiences in regard to the various aspects of the dental profession; and I am afraid that there is no doubt at all that there is a very great shortage of dentists if we are to have a comprehensive dental service throughout the whole country. I am sorry 149 that the noble Lord, Lord Moran, is not here at the moment, but he said something at the beginning of his speech about there being a political aspect with regard to this question.
I can see no evidence of that in the debate, and I do not think it is political. It is a national matter of great importance. I feel that there is a good deal that has been said by the noble Lords, Lord Taylor and Lord Moran, and also by Lord Cohen of Birkenhead, with regard to the lives of the general practitioners and the medical profession which could be applied, and I believe very satisfactorily applied, to the dental profession. The Dental Council before my Committee sat was practically nonexistent, but is now a body of importance, and they take a great interest in everything that is necessary.
I want to read a very short piece of a letter that I have received. Naturally, I had any number of letters on this subject, and here is one from a Mrs. Roland. She apparently took a serious view about her children's teeth and saw that they were clean. One child, a daughter, went to school at 5½, and took with her, her mug, her toothbrush and toothpaste. The child proceeded, after the first school meal she had, to clean her teeth. The teacher said, "What on earth are you doing?" The child said, "I am just doing what I do at home. I am cleaning my teeth. After every meal I always do so if possible. That is what we do." To that the teacher said, "Put those things away. Nobody cleans their teeth in this school." That is the sort of thing that is going on, and I want to see something done about it: I think a great deal can be done, to the great benefit of the health of children. As noble Lords know, many children get earache, sore throats, and that sort of thing, which often are due to a tooth being wrong. I should like to see something done about that. I hope that this debate will be carefully read by those at the Ministry of Health, and that some of these ideas, which even a layman like myself has, might be adopted.
I asked a Question the other day which was answered by my noble friend Lord St. Oswald, who is going to reply to this debate, I am glad to say. He answered me. I am afraid, not very satisfactorily, so far as I was concerned, but I should 150 like to read a few words of what he said [OFFICIAL REPORT, Vol. 222, (No. 59), col. 246]:… children's teeth are getting steadily worse and already have a higher incidence of decay than before the war.Let us get at it at once. Noble Lords who are in the medical profession know perfectly well how important it is that the teeth of children should be carefully studied and taken care of. And it is not only the children: those of us who are farmers sometimes find that the teeth of our cows go wrong and that we must get them put right. It is the same, I understand, with racehorses. Their teeth are taken great care of, for if their teeth are wrong they do not win prizes and they do not win races.
My Lords, there is one other matter I should like to raise. I asked whether the situation still existed, because I found during the discussions we had that there was a practically unanimous feeling that, where you have children at school, and a child has developed, either on the way to school or during school hours, toothache, face-ache or whatever it is, you are not allowed, even if the dentist is available, to bring in that dentist to treat that child before you have the consent of the parents. That seems to be the sort of thing which, with a little propaganda, parents would see was an unwise provision; and I think that they would probably agree to do away with a regulation of that sort.
In the course of my two and a half years' work on this subject, immense interest and a great deal of information came from all sorts of people and from all parts of the country with regard to diet; and there is no doubt that diet is of great importance, as the noble Lord will at once admit, with regard to health generally, and in particular with regard to the teeth. My Lords, as it is now admitted that the condition of the teeth of the children of this country is very bad, let us try to do something about it, and not just say, "The toothbrush and mug, and that sort of thing, is not what we think might improve it." During the last war I was in China, and there it was amazing to see the wonderful teeth which the people had. In every school that I went to, where I could walk around and have a look, all the children had a mug and a toothbrush, and they all had the most 151 beautiful teeth. In China they attach enormous importance to their teeth.
Then, just a word about dentists themselves. If you think of it, a dentist, when he sees a patient, has a very difficult task. One has often heard someone say, "I have to go to the dentist tomorrow. I would almost sooner face a lion. I am terrified of him", and so on. It is something of which we are frightened. We get a certain amount of pain from the treatment. The dentist needs to have a very Charming, sympathetic mind in order to deal with some of the nervous patients—and nearly all of us are a bit nervous when we are sitting in that chair with our mouths wide open. He has hard work to do: it is physically rather a difficult job, and is very tiring; his position is generally bending: and he has to be absolutely steady with his hands and the way he uses his instruments. There is every evidence that a great physical strain is put on a dentist during a day of dealing with people's teeth. Then, of course, it goes without saying that enormous importance is attached to the hygiene of their instruments, and of the other material used. As I have said, it is not only the teeth: very important parts of one's body can easily, and do, go wrong due to bad teeth.
I hear of merit awards that doctors get, but I have never heard of an award of merit for dentists; and I am wondering whether they should come into the picture as regards merit awards. I hope that that matter will be considered. My Lords, that is all I am going to say. It is only the result of the experience I gained during two and a half years' work on this subject which made me feel that I had to say a few words.
§ 5.58 p.m.
§ LORD AUCKLAND
My Lords, I represent the last batsman, so to speak, on this side of the House, before my noble friend Lord St. Oswald winds up; and I feel sure that we are all waiting with great interest to hear what the noble Baroness, Lady Wootton of Abinger, has to say, so I shall be brief. I think we all enjoyed the speech of my noble friend Lord Teviot, who has just addressed us. He and I share one thing in common, and that is that, unlike the majority of noble Lords who have taken 152 part in this debate, we are not practitioners. But I would add this to what he has said from his great knowledge of the dental profession: the importance of urging children to see dentists early in their lives, and to get used to the dentist's Chair. The lot of the dentist would be made a great deal easier, and children would be far less nervous, if they were introduced to the dentist, particularly, a lot sooner than many of them are. It is a great fascination for a child to be introduced to a dentist's chair. I remember my own experience. In these days, when both dentists and doctors are considerably overworked, it is action like this which would ease their lot.
I do not intend to deal with the financial side of this Report. The Motion deals with both remuneration and conditions of work, end I Shall confine my remarks to the latter aspect. First, a word about the National Health Service. I am not one of those who subscribe to the view that the National Health Service has been a failure; indeed, I think that very few people do. Of course, it has its faults. Its administration is cumbersome in some respects. But, being in the insurance business, I have had experience of dealing with claims by people who fall sick with poliomyelitis and other illnesses when in the United States, and I see the enormous expense with which they are confronted. Admittedly there is the Blue Star system, which perhaps is the equivalent of our National Health Service. But I think that before we criticise our own Service too much we should give a little consideration to the difficulties with which people are faced if they should fall ill when in a country like the United States. I have an acquaintance, a nurse, who has just returned from America, where she has been doing two years' nursing, and she has emphasised the cost of medical treatment there. I do not say that the standard of doctoring and nursing in America is any better or worse than our own—I have not had the experience of visiting that country, so it would be improper for me to comment—but, by and large, both doctors and patients under the National Health Service are playing their part fairly and wisely.
Of course, there are abuses, and I hope I shall not weary your Lordships if I quote just one. Recently my own doctor 153 was confronted with this situation. A car pulled up outside his house at one o'clock in the morning. Out came two people, who knocked the doctor up. They pretended to be very shaken up, but when he examined them he found nothing wrong with them. It transpired that their car had broken down and they expected to have an ambulance laid on so that they could get to Mitcham, ten miles from where the doctor lived. Needless to say, the refused their request, and rightly so. One gets this type of abuse. One gets patients who are unco-operative, and on occasions may perhaps get a doctor Who falls down on his job; but, as in every profession, we hear all too much of the persons who fall down on their jobs and too little about those who do well. I believe that the doctors and dentists in this country are doing a really good job.
The limitation-of-patients rule has been mentioned during the debate. I do not claim to be any kind of authority on this matter, but it seems to me, from what information I have gleaned, that the rule is a little rigid. Surely a doctor who has a practice in a residential area is better fitted to cope with more patients than a doctor who lives in an industrial area. For example, a doctor in Sutton can probably cope with more patients than a doctor in Stoke-on-Trent.
§ LORD TAYLOR
My Lords, I think the experience is generally the other way round, because patients in Sutton tend to talk twice as long as patients in Stoke-on-Trent.
§ LORD AUCKLAND
I am grateful to the noble Lord. The point I was trying to make was that in Stoke-on-Trent people tend to have larger families than people in Sutton. Whether that is true or not I cannot say, but in industrial areas families do tend to be larger than in residential areas and this would make a doctor's lot harder, particularly if an epidemic of infectious illness occurred. Perhaps the noble Lord, Lord St. Oswald, may have some comment to make on the limitation rule.
The noble Lord was kind enough to see me yesterday and I mentioned to him the problems of the locum and the partner. I am not sure of the exact situation here, but there seem to be certain difficulties with this scheme in 154 some areas, and I think that a little more uniformity might be arranged. Similarly, the compensation paid to general practitioners who fall sick seems to be a little unfair compared with that of doctors in hospital practice. Here, again, I do not presume to be in possession of the facts and figures, but we know that a general practitioner has to work all hours of the day and perhaps night. He has to go out in all weathers and see all types of patients. I am not saying that a hospital doctor has an easy job—far from it—but the general practitioner not only combines a steady hand and careful eye, he has also to drive to his job sometimes in grim climatic conditions, and I feel that the compensation for general practitioners who fall sick and may be confronted with other expenses could be looked at. Again, perhaps the noble Lord who is to speak for the Government may have something to say, either now or in writing at a later date.
The debate has covered the medical profession in general, but so far mention has not been made of nursing staffs. After all, hospital doctors have to rely on matrons, sisters and nurses for much of the treatment which is prescribed. I do not think that this is an occasion for a debate on nursing conditions, but there are a number of improvements which could be made in the lot of nurses, both in general nursing and in mental nursing, particularly in regard to accommodation. Pay is often one of the greatest grievances, and I think that both in the doctoring and the nursing professions it is inadequate. But that is another matter. The conditions of service and good nurses' homes—and I am pleased to see that along with the new hospitals that are being built, nurses' homes are being improved—might well help in the recruitment of nurses. After all, if the recommendations of this Report are to be successful, the recruitment of nurses must be sufficient to go hand in hand with them.
The general public and the doctors must, of course, co-operate with one another, and I believe that as the Health Service progresses that is being done. After all, general practitioners, surgeons, consultants and dentists are all human beings, and they can work only to a certain capacity. If a patient dies, or if complications occur, it is all too 155 common a practice to blame the doctor, and we see reports of a doctor who has been struck off the register for incompetence or negligence. But set against that the outstanding work which is being done in all branches of the medical profession which often does not get sufficient recognition. I think that both the noble Lord, Lord Moran, who has had such a distinguished medical career, and the noble Lord, Lord Taylor, have done a great service by initiating this debate today.
§ 6.13 p.m.
§ BARONESS WOOTTON OF ABINGER
My Lords, the late Earl Lloyd-George, then Mr. David Lloyd George, is said to have remarked, when he was piloting the first National Insurance Act through Parliament, that in his dealings with doctors, which were numerous and extensive, he found the medical profession to be both unruly and unreasonable. No one who has listened to-day to the speeches made by the noble Lords, Lord Moran, Lord Taylor and Lord Cohen of Birkenhead, could detect the slightest trace either of unruliness or of unreasonableness; and the whole of the discussion which has ranged around the question of doctors' remuneration since the appointment of the Royal Commission has, one might say, been conducted in a spirit of sweet reasonableness.
I should like to associate myself with all that has been said this afternoon in support of the work which has been done by the Royal Commission, and, I would add, in support of the most valuable evidence which was produced before the Commission by the representatives of the medical profession. I should like also to associate myself with the noble Earl, Lord Dundee, in welcoming what he called the new and happier relationship which this perhaps portends as between the medical profession and the Government, and in particular the Ministry of Health. I welcome, too, the elasticity which was apparent in the speech of the noble Earl, Lord Dundee, where he made it perfectly plain that, although the Government are accepting the Report in one sense as a package deal, the package is clearly not very tightly tied, and that there will be opportunity for modifying the contents, 156 and perhaps even for abstracting some of the objects contained in the parcel and surreptitiously substituting others. Nevertheless, sweet reasonableness is not exactly the same thing as reason, and I hope that I may be allowed to make a few comments upon the proposals of the Royal Commission, more particularly from the angle of their rationality.
The work of the Royal Commission may be viewed from two angles: on the one hand, from within the profession; and, on the other, from outside in terms of the general professional and wage and salary structure of the country as a whole. From within the profession the effect of the recommendations will be, as was pointed out by my noble friend Lord Taylor, to widen the spread of incomes. It will be not to make the spread as wide as it was in the golden age described by the noble Lord, Lord Cohen of Birkenhead, but to make it appreciably wider than it has been in recent years. That we deprecate. We have welcomed in recent years that one of the main contributions to the National Health Service, so far as the medical profession is concerned, has been to narrow the spread of medical incomes. We welcome this, partly because, in the view of those who sit on these Benches, it is good in itself, and partly because it has particular merit perhaps in relation to the medical profession.
To us it is good in itself because it is a factor which has changed the face of England and made us a much more united and less socially separate community, and because it is one of the outstandingly valuable trends of the last half century. The narrowing of the great gap between the largest and the smallest incomes has been one of the things which has made this, though not yet an equalitarian community, at least one in which we are not separated by unbridgeable gulfs; and we regret new trends which are likely to widen those gulfs again. Those whose minds are indeed set on the things of this world can, of course, take a hint from the speech of the noble Lord, Lord Cohen of Birkenhead, and convert their attention rather to wise investment than to the practice of medicine; and I think it is common observation that opportunities for wise investment have not been deficient in recent years. Also, from the angle of the 157 profession, the noble Lord, Lord Moran, spoke with great eloquence about incentives, and he quoted, somewhat surprisingly, as an authority—not that he needed authority to support his views—the observations of Mr. Khrushchev.
Incentives are obscure motivations, and I have during this afternoon been wondering more than once what can be the incentive which, for instance, has caused me to expose myself at much shorter range than usual to the shafts of which I already have experience to be directed at me by the noble Lord, Lord St. Oswald. I do, however, take courage in facing these shafts that are to come (which remind me of one of the lions of the noble Lord, Lord Teviot) by seeing that this afternoon's occasion is unusual in more ways than one, and that I have support such as I could not have anticipated in the really exceptional constitution of the Official Box. This has been, may I say, a great consolation to me in my very exposed position.
It is rot for me to say much about incentives in the medical profession. After listening to the speech of the noble Lord, Lord Moran, and after reading with great care the evidence that he gave before the Royal Commission, I can only say that I, like others, have been enormously impressed by the Dare and skill with which he and his colleagues have discharged their almost impossible task, in assessing, not merit, nor responsibility, as the noble Lord, Lord Cohen of Birkenhead, has reminded us, but distinction. I find myself wondering whether, even in the distinguished medical profession, we could rely through the ages upon a full supply of Lord Morans who would be equal to a task so arduous.
As I listened to this description and read his evidence, I could not but feel that there was much to be said for the view which the noble Lord, Lord Taylor, put forward; that, after all, in all occupations there are grades. We are accustomed to promotions—the Royal Commission itself recognised this—and that perhaps even among consultants there might be some form of differential which did not involve these extraordinarily elaborate inquiries and this, as I must now say, "façade" of secrecy. Study of the mechanism by which distinction awards are now arrived at certainly encourages the view that the right solu- 158 tion would be to amalgamate these—at any rate at the lower levels, the B and C awards—into the salaries of the appropriate consultant grades. That view is, I think, strengthened by the discovery, as the noble Lord, Lord Cohen of Birkenhead, remarked, that there are, after all, degrees of secrecy.
I think, too, that the spread of incomes which the Royal Commission encourage is to be deprecated particularly from the point of view of the profession, in so far as it does to some extent favour the view, which I have heard expressed by medical students, that general practice is something of a "second order" section of the profession. That seems to me to be most strongly to be deprecated, and anything that makes the young medical student feel that general practice is the mark of the man who has not succeeded in the best sense in his profession is surely a disaster for medical practice. Surely general practice should rate at least as high in public esteem—and that is closely associated with money—as the more specialised branches of medicine.
On the subject of incentives in general practice, I need hardly add to the delightful picture drawn by the noble Lord, Lord Cohen of Birkenhead. It can be summed up by saying that differential payments, as he pointed out, already occur, possibly in the wrong way, but certainly in some way, as the statistics show. To make them happen in a more rational way might be desirable, but appears to be plainly impossible. May I remind your Lordships of the qualities which the British Medical Association told the Royal Commission must be found in the general practitioner? Not only must he have high educational standards, but he must also be able to act as a guide, philosopher and friend to his patients. He must be a good mixer; he must be equally at home—an unusual gift—with all classes of society, and he must have the full confidence of his patients. He must also be a profound student of human nature and possess immense reserves of mental and physical stamina.
All that, my Lords, is only too true. But words fail to describe the qualities of the man who would be able to differentiate the degree in which different general practitioners possess this astonishing and laudable collection of admirable qualities. Surely, if we are going 159 to differentiate, the evidence that appears in the Royal Commission's Report indicates where differentiation is called for. As the noble Lord, Lord Taylor, pointed out, it is the old doctor, the elderly dentist and the young doctor whose needs are, clearly, most inadequately met. Above all, the need emerges to cut down the lists of doctors who are trying, for reasons of their own financial situation, to cope with far more work than they themselves feel they can adequately discharge.
So much for within the profession. I should like now to turn for a few moments to the wider aspects of this Commission's Report. First, may I say how grateful we are for the evidence which the Commission have produced for the first time about relative professional earnings in this country? This we may study with continual profit, and there are many lessons to be drawn from it. Some of us may sigh that at a younger age we did not think of taking up the profession of actuary, which seems to occupy a uniquely valuable position in the professional hierarchy in this country. All of us will draw the conclusion (which I am sure would distress those who sit upon the now vacant Episcopal Benches) that the service of Mammon in this world is a great deal more rewarding than the service of God. We shall note such incidental facts as that the top-line consultant, with the top distinction award, normally earns about two and half times as much as the head of a large grammar school. We can draw many other similar comparisons, comparisons which remind me of some studies that I myself made some years ago, and which are perhaps no less illuminating. Some years ago, when investigating comparative incomes in this country, it came to my attention that the salary which I was then earning as a university teacher happened to be exactly the same as the income which was earned by the larger elephant in Whipsnade by giving rides to children.
Much of the material which the Royal Commission have produced—material about professional incomes—appears to me to have about as much, or as little, rational justification as that particular personal comparison. But we learn with great distress that this informaton, which has been laboriously gotten, is not to be 160 made more readily available in future and in a more comprehensive form. We cannot but ask ourselves: Why this secrecy? Why this immense diffidence? In my experience, and, I think, in the experience of most of us, there is only one other subject upon which a comparable secrecy prevails to that which invests the discussion of income.
In regard to that other subject, since the publications of Dr. Freud there has been a considerable relaxation of the secrecy, and topics are now discussed with a degree of frankness which would have astonished our parents, still more our grandparents, if not ourselves in our younger days. But no similar progress seems to be made in the matter of income, and on this occasion it is surely wrapping the pall of secrecy rather tightly if we are not to be allowed to hear not of individual incomes but even information about aggregated incomes; so that hereafter when the Review Body (about which I wish to speak in a moment) comes to discharge its functions, it will have to discharge them, like the Royal Commission, with only such information as it can itself, perhaps rather hastily gather together. If we may take an analogy from that other sphere, the psychiatrists will tell us, I think, that our reluctance to discuss certain subjects is nearly always associated with a conscious, or more probably unconscious, sense of guilt. Is it because we are guilty that we have too much money or is it because of shame that we have too little money that we are so reluctant to let it be known what in fact we have?
We thank the Royal Commission for collecting so laboriously this new and fascinating evidence, but as we turned their pages we waited breathlessly to read their discussion of its significance; and, astonishingly, no discussion followed. The evidence was set out, the figures were paraded in tables, and we anticipated that the Commission would point out the laborious and dangerous nature of the actuaries' duties which would explain their relatively high position in the table, and the easy routine character of the schoolmaster's duty which would explain his relatively humble position—not in the table but hidden away in the Appendix. No such discussion followed. The Royal Commission told us that they had considered all the factors which differentiate 161 these various professions but that they were unable to share with us their meditations on this subject. They then turned the page and came out with the ex cathedra statement, with which we do not disagree, that doctors' earnings are too low.
This seems to me to be the central significance of this Report: the central fact about it is that it is operating in a complete vacuum, and there it is not alone. It expresses a trend which you will find pervades a great deal of the negotiations and determinations of wages and salaries to-day. As the noble Lord, Lord Cohen of Birkenhead, said, the Royal Commission did not argue their case, for the reason that the problem which they were set was, in fact, insoluble. There is one possible solution, and that was the solution which Professor Jewkes adopted in his Minority Report. It is the solution of the straight-forward economist, that when you are asked to determine what is the proper remuneration of any calling you ask yourself what is necessary in order to attract suitable persons into that cdling—the good old rule of demand and supply.
The Royal Commission rejected this out of hand. They satisfied themselves that in the light of the Willinck Committee's investigations there was, at any rate for the near future, an adequate supply of doctors coming forward for training. A harsh and ruthless economist would have drawn the conclusion that the pay of doctors must therefore also be adequate. But the Royal Commission, discarding thereby the whole of economic learning, blandly took the view that this meant that there was no relevance in the conditions of supply, and they dismissed it out of hand. Nor did they substitute any alternative criterion. A possible alternative criterion might have been a careful job analysis of the conditions of work of occupations that might compare with that of a doctor. Probably it was prudent that they should not do so because, as has been said this afternoon, it might well be argued that the work of clergymen, or I might perhaps add probation officers, is very likely the nearest thing we have to the work of the doctors. Perhaps wisely the Royal 162 Commission did not collect evidence about salaries of probation officers and therefore did not quote the fact that the maximum salary of a probation officer is something considerably less than half the average earnings of the underpaid general practitioner. They did, however, collect some information about the earnings of ministers of religion of various denominations; but that they quietly put in the Appendix where it would not attract perhaps so much attention as the tables in their text.
Having abandoned economics and having abandoned work comparability, the Royal Commission were left, as I say, in a vacuum. So what we have to recognise is that the hierarchy of the profession as it stands is really an expression of social conventions and an expression also of the values which are recognised and esteemed in our society. Even the choice of occupations which are described as professions is itself a purely conventional choice. The dentist who takes teeth out of heads has professional status. The hairdresser who puts curls on to heads does not. So one could continue. It is a conventional list of occupations, and the grading within this list undoubtedly expresses the attitude of mind of the community. I think there is little doubt that in this community as a whole if the fear of death were less lively and the expectation of immortality more confident, there would be some disturbance of the relative positions of the clergyman and the doctor. But let that pass.
We have these conventions, but we make no discussion of them. And the result is that we are gradually committing ourselves to an astonishing rigidity in the pattern of remuneration in this country. So long as we have abandoned the criterion of demand and supply, so long as we do not face the discussion of any alternative social measurement or grading, there is nothing to fall back on but that we should maintain the relative positions of everybody as far as possible; that is to say that we should set the stamp of eternity on the particular pattern of remuneration which happens to prevail to-day, and that this should acquire a rigid permanence surpassing even that which apparently pertains to the policy of Her Majesty's Government in the matter of pictorial 163 stamps. Here we have the supreme example of conservatism in our time.
There is one point in the Royal Commission's Report—one rather ominous remark—in which the Commissioners express their awareness that their Report may have repercussions upon other professions: but that, they say, with justification, is none of their business. Certainly it was none of their business. But the medical profession having pulled itself up in this table, other persons will, by definition, relatively fall down, and surely it is somebody's business to sort out whether the old relativities must immediately be restored: whether we are going to commit ourselves, first, to extreme rigidity and, secondly, to a kind of situation of competitive inflation which we have known very well from the past. So I would ask that if we are going, as apparently we are, moving from profession to profession, to set up Review Bodies of wise men, we should give those bodies some kind of guidance.
The Royal Commission suggested that the Review Body would, in general terms, have regard to recruitment, that it would have regard to changes in the cost of living and that it would have regard to earnings in other professions. It did not say what kind of regard—just "have regard". It did not indicate, or attempt to evaluate, the factors which the Review Body would need to take into account. In fact, we are contemplating that the Review Body, which we are very glad to welcome as a step forward, is itself to work like the Royal Commission, in a complete vacuum, unless Her Majesty's Government are prepared to give some thought to the shape of remuneration as a whole, and some guidance as to the modifications in the present pattern which they would wish to see.
The Review Body was ostensibly modelled on the Coleraine Committee which followed upon the Royal Commission on the Civil Service, but I think that here there has been some confusion. I had the honour to be a member of the Royal Commission on the Civil Service, and perhaps I may claim some small part in devising the machinery which now governs changes in Civil Service wages and salaries. The Coleraine Committee is concerned not with the salaries of civil servants but 164 with the salaries of a small group of higher civil servants—namely, those who under the old procedure would have been outside the range of the arbitration procedure. The reasons for making this special provision were primarily that there might be something undignified in civil servants who have to advise their Ministers also, so to speak, taking their Ministers to arbitration on salary questions, and that equally it would be embarrassing to advise the Minister about one's own salary, particularly if that salary compared rather favourably with the salary that the Minister himself enjoyed. Therefore these delicate duties were devolved upon the body of wise men who sit under the wise guidance of the noble Lord, Lord Coleraine. But the Royal Commission suggested this select body to operate only at the top of the Civil Service.
May I remind your Lordships that for civil servants as a whole the Royal Commission made another proposal which has also been carried into effect—namely, that some steps should be taken to make objective comparisons between the work of a civil servant and work in comparable fields outside, and that in determining the scales of wage and salary an exhaustive analysis both of the content of work and of rates of pay should be undertaken. In fact that has been done with surprisingly good results. But no such guidance is given to the Review Body for the medical profession. It has not been charged with the duty of making any comparison between the work of various kinds of doctors and the work of other persons, either in auxiliary medical callings, like the nurses, for whom the noble Lord, Lord Auckland, put in so kind a word, or in other fields. As I say, the Review Body is left like the Royal Commission, in a vacuum, unless and until Her Majesty's Government are prepared boldly to step into that vacuum and to fill it.
In that position one can only suppose that they will feel very much as the doctor pictured by the noble Earl, Lord Dundee. Faced with the problem of dealing with many hundreds, indeed thousands, of patients, the noble Earl, Lord Dundee, suggested that anyone less gifted than our doctors would be inclined either to go mad or to acquire supernatural wisdom. Those were the alternatives that faced him. Those, too, will be the alternatives 165 that face the Review Body, as far as we can see; and, faced with these alternatives, it looks as if they might fall back on one third possibility, namely, that of extreme conservatism, which means running as fast as we possibly can in order that we may all stay in the same relative places.
§ 6.47 p.m.
LORD ST. OSWALD
My Lords, my first and entirely delightful duty is to congratulate my noble friend—as, indeed, I hope she is in everything but the narrowest political sense—Lady Wootton of Abinger, on being the first noble Lady to decorate either Dispatch Box in your Lordships' House; and not merely for doing so, but for the manner in which she has done it, and it gives me an opportunity to say in this House, without fear of any contradiction, that we in this House have become very proud of our noble Ladies—in fact we would back them in brains and charm against the ladies of any other place.
My Lords, the Royal Commission began their general observations upon their work with these words:We were appointed nearly three years ago to carry out a task which was then expected to be simple, and short. It has turned out to be neither.After spending the Easter Recess in a laborious study of that task, once performed, it defeats me entirely how anybody could ever have expected it to be simple or short. The noble Lord, Lord Taylor, upon whose Motion we are now debating this Report, had the kindness to write to me in Scotland to say that he hoped that I was enjoying a splendid holiday. From anyone else's benevolence I might have taken this to be a cruel piece of irony, because if he has any measure of my conscientiousness he must have known how my days, indeed into the late evenings, were being spent.
But that is in no sense a reflection upon the style or content of the Report. In common with the noble Lord, Lord Taylor and other noble Lords, I found the style to be clear and readable throughout. The amount of detail incorporated in its 450 paragraphs, 11 chapters, 8 appendices and 57 tables, is enough to cause a permanent headache to anyone not intimately familiar with medical and dental practice. It was of no comfort to me, I am afraid, on my 166 return to your Lordships' House yesterday morning, that the first person I saw in the entrance was the noble Lord, Lord Taylor, clear-eyed and jaunty, evidently having taken this massive document in his stride; and I am afraid that it is no good his telling me this afternoon how much he is enjoying this work in this House.
However, it is now my task to "argue the toss" with the noble Lord in respect of certain of his comments and conclusions on, the Report. This is never a simple engagement, partly due to the noble Lord's modus operandi in debate. His chosen methods are either to ask me questions in order to provide his own answers, sometimes noticeably inaccurate, which he always prefers to my accurate answers; or to invite my agreement to proposals which he knows I am bound to resist—all this done with such consummate charm and apparent innocence that at the end I am partly mesmerised into wondering whether it is not I who have been unfair to him—a flagrant impossibility.
My noble friend Lord Dundee hag explained, in his speech, that Her Majesty's Government have accepted the recommendations in the Report of the Royal Commission as they stand, provided that the doctors and dentists respectively, for their part, will accept them on the same basis. If at this point some Member of the Government should fall victim to the persuasive arguments of the noble Lord, Lord Taylor, and join in criticism of the Report, which I am sure I am in no sense desirous of doing, that would obviously prejudice the matter in its next stage—its discussion, and we hope acceptance, by the two professions.
Within the main edifice of the recommendations there are spaces where there is room to swing an interpretation and others where discussion still has to take place; and since both the noble Lord, Lord Taylor, and the noble Baroness, Lady Wootton of Abinger, asked for examples of these latter, I can give one or two. In the hospital service the arrangements for allowing extra payments to junior staff at peripheral hospitals, described in paragraph 293, have already been mentioned by my noble friend Lord Dundee. The fixed charges for board and lodging, mentioned in 167 paragraph 292 have been referred to by the noble Lord, Lord Amulree, and, in the general medical service, the detailed arrangements for distributing the total amount of money which the Royal Commission recommend should be provided, as the Commission recognise, have always been settled direct and will continue to be so settled.
The Royal Commission themselves refer to various factors which they feel might be taken into account, but as my noble friend has said, there are many factors apart from these which will require to be studied jointly. For instance, complex questions arise in settling the relative weight to be given to capitation and other detailed fees within the overall total, and in both the general medical and the hospital services the detailed arrangements for distributing the back pay recommended by the Royal Commission, dealt with in paragraph 397, are also a matter for detailed consideration. For the rest, I am committed, I fear, to "argue the toss" and attempt to persuade the noble Lord that he is again wrong. My noble friend Lord Dundee has already referred to some of his proposals, and I will elaborate only on the very important matter of the Review Body. If the professions accept the offer made by Her Majesty's Government, and the Review Body is set up, the Government have undertaken—and this I must emphasise—to ensure that the professions are fully consulted upon that body's membership. They will also give a firm undertaking to pass on any recommendation made by the professions and to stress to the Review Body the importance attached by the professions to being able to present their case orally.
I am aware that doctors and dentists would prefer to be able, so to speak, to "press the button" themselves to set this machinery in action, but some doctors are not happy that any "monopoly employer" as the noble Lord, Lord Moran, has called it, should be within reach of the button. But that was not among the recommendations of the Royal Commission, and it is not favoured by the Government as a unique privilege for the medical profession. The recommendations, as accepted, contain acceptance of the exclusion of doctors and dentists in the composition of this body; and 168 as those who have read the Report will know, the Commission gave most careful thought to the composition and functions of the body, which they visualise as being eminent and authoritative and, as such, being outside any implication of bias, either for or against the medical and dental professions. I could quote the views of the Commission on this point, stated in paragraph 430 of the Report, but I feel that at this hour it is better not to take up your Lordships' time.
I have spoken to doctors on the subject, and I may say that they were more vehement than I could have thought possible, and certainly more vehement than I am prepared to be in contradicting the views of the noble Lord, Lord Taylor. The burden of their argument was that the position of these professional delegates on the Review Body would be quite intolerable; that they would be blamed by their colleagues for every failure to act as a body as a whole or to act as the bulk of the profession—
§ LORD TAYLOR
My Lords, I am perfectly happy to accept that, provided that some technical advice is available to the Review Committee. It seems to me that the place where the Royal Commission fell down was in the lack of available technical advice; and because they did not know the facts they sometimes went off the rails. That is really the situation. Equally, one hopes that what is sauce for the goose will be sauce for the gander, and that when legal aid fees come to be determined that will not be done by the legal profession.
LORD ST. OSWALD
My Lords, the noble Lord has made his point keenly and I have no doubt it will be taken into account. With regard to the provision of financial data to the Review Body, with which my noble friend Lord Dundee has dealt, Her Majesty's Government are satisfied that it would not be practicable for the Inland Revenue to provide the Review Body with the information they require. We are satisfied that that Body should be able to obtain the information they need by other means; and, as my noble friend has said, they will be given all possible help in this pursuit.
It must be very fortifying for Professor Jewkes, as it would be for anyone, to know that he is now joined in his isolation by the noble Lord, Lord Taylor, and 169 that they now stand shoulder to shoulder on the same grounds of criticism; but I still think, in all fairness, that the noble Lord is suggesting, loyally, that his ally is alone in arguing the case properly in desiring a reasonable figure for general practitioner remuneration. But the fact is that Professor Jewkes's approach to this problem is different from that of the rest of the Commission. Professor Jewkes is in favour of giving general practitioners an increase related to changes in living standards since their pay was last fixed. This is what might be called "back to Sports" line. The Commission point out that a great variety of factors are relevant in considering changes in pay, and here again I could quote paragraph 425, but I feel I should spare your Lordships any further quotations from the Report, with which you will be familiar. It is hard to describe the conclusions in the Report as being "out of the hat". The difference between the Report of the Commission and the Jewkes memorandum of dissent is a measure of the difference in view on the weight to be attached to the relevant considerations.
The noble Lords, Lord Taylor and Lord Moran, are together in wishing to see, concurrent with the implementation of the Report, an immediate reduction of local practitioners' lists to a maximum of 3,000, and, frankly, I should find it extremely hard and less enjoyable than usual to argue upon this point. But in fact it is not an argument which enters into this debate, and the Commission themselves, after some thought, considered it to be a question outside their competence. The truth of that can be seen from the terms of reference which are described at the top of page 1, at the start of the Report. The arguments and their recommendations are in a form which would allow for such a change. They have put in nothing in the way of a change beyond advice that if the maximum were reduced the spread of income should be affected as little as possible, that earnings of established practitioners should not be substantially reduced and that care should be taken not to prejudice the payment of adequate salaries to assistants. The question of list size, therefore, would become a matter for discussion in detail, as part of the consideration of the distribution of the pool, supposing—as we 170 hope—that the recommendations of the Royal Commission were accepted by the professions.
§ LORD TAYLOR
My Lords, the noble Lord is making an important statement and saying, in fact, that the list size will be one of things which is and should be discussable.
LORD ST. OSWALD
My Lords, it is a matter which is discussable, and for that reason it would not be wise for me to say anything more upon it at this point, as the noble Lord will appreciate.
The noble Lord, Lord Amulree, who has explained that he cannot be present, has urged that travelling expenses for full-time consultants should be as advantageous as those for part-time consultants. He has, as one would expect, made a clear and powerful case for this, and I shall naturally pass it on to my right honourable friend. I was not aware (though I am sure he is right) that they did not receive travelling expenses for conferences. The question is dealt with, in fact, in paragraph 210 of the Report, and as the noble Lord will have seen, the recommendation at the moment is to reduce the advantage of part-time specialists in the matter of travelling expenses, so I cannot promise what will happen to the noble Lord's suggestion that those full-time consultants travelling from their home to their normal place of work should be compensated for doing so. It would give them, it seems to me, a rare privilege among professional men. The recommendation about part-timers will become another matter for detailed discussion with the profession if they accept the Government's offer.
The noble Lord, Lord Amulree, also mentioned domiciliary visits, and the present position there is that in the case of whole-time officers no consultation fee is paid for the first eight domiciliary visits in any quarter of the year. The concession that whole-time officers should be paid for any visits was made by agreement on Committee B of the Whitley Council in 1955. In paragraph 211 the Royal Commission recommend that no change should be made in the current arrangements or in the level of fees paid. I am afraid that this is one of the things which would have to be accepted as part of the package deal. 171 My noble friend Lord Auckland mentioned the situation of locums, and here I am afraid I cannot give him very much happiness. The Royal Commission recommended locum rates in detail; the changes are in Table 42 on page 100, and he will find there has been an increase. This is a recommendation going to make up the Report which the Government have accepted as a whole.
We come to the vexed problem of distinction awards. A great deal of what the noble Lord, Lord Taylor, had to say was dealt with by my noble friend. But I am bound to say from my own investigations in the past fortnight that there is—and I think this is a matter for some criticism—no wide understanding among doctors of the way Lord Moran's Committee in fact operates. It took the noble Lord, Lord Moran, I noticed, a considerable time—most of the day—to explain it to the Royal Commission, as is seen from the Minutes of Evidence; and I am not sure that I was able to grasp it in the course of those Minutes, or even from his very succinct description to-day. It is a matter of immense complication, but I am happy to hear from all sides of the House the admiration which has been expressed for the way he has carried out that difficult work.
But this concerns the matter of career prospects, and in this matter I found in my study of the Report that time after time I was stepping out of the territory of Pilkington and into the territory of Platt. I do not know whether other noble Lords had a similar experience. The Platt Committee, whose work we are not discussing and cannot discuss in detail to-day, is concerned with staffing problems. But it was put to me by more than one young doctor to whom I spoke that Pilkington is buying time while Platt will go to the core. Although I believe this not to be true, it seems to me that the work of these two bodies is closely interrelated. We cannot hope for a healthy medical profession unless young doctors are keenly interested in, and are hopeful about, their career prospects. The Royal Commission were not set the task of coping with over-crowding at the top or of providing posts. But it would be small comfort, I should think, to a senior 172 registrar to know that a consultant's job was to be better paid than ever before yet would remain as inaccessible as ever.
In this connection I have had described to me the three separate streams within the National Health Service: the hospital service, general practice and public health service; and I was told, as an outsider, that it is extremely difficult to cross from one stream to another, or at least to join it at anything like the same point of advancement. But what I have also learnt is that in certain regions there are plans for an interchange of registrars with assistants in general practice, so that each can have an opportunity of experience in the field of the other. This seems to me an entirely good thing, and one can hope, I think, that arrangements of this sort will prosper and multiply. Until that happens, I should think, for instance, that if a registrar were to find when he was ready to become a consultant that the number of applicants so far outnumbered the number of posts available that he had little hope, he would undoubtedly feel frustrated and discouraged if there were no means of entering general practice except as an assistant earning little more than half the existing salary. I learn that this is a true picture. The noble Lord, Lord Taylor, is in a far better position to know; but if he confirms it and if this encouragement from this Bench from one, however unimportant, connected with the Minister of Health is something to encourage such doctors, I am glad to give him that small comfort.
Concern has also been expressed in the matter of secrecy in these awards. In the course of a notional week not long ago, the noble Lord, Lord Taylor, sought diligently to break my security by a series of Parliamentary Questions. I am happy to say that he was less successful than the noble Lord, Lord Cohen of Birkenhead, appears to have been. Lord Cohen of Birkenhead did not get his information from me.
§ LORD TAYLOR
My Lords, I was not seeking to break the noble Lord's security. I did not want to know who has any merit awards. I was trying to get some ordinary statistics out of him.
LORD ST. OSWALD
My Lords, it seemed to me as if the carefully placed 173 Questions of the noble Lord were designed to focus on a certain type of consultant, and from certain Answers the noble Lord, with his brilliant mind, could have found the answer to the question which he was not openly, I agree, asking.
I am by no means deaf towards arguments against secrecy, but on the whole I think I yield to the arguments in favour. I should have thought it was bound to be invidious for most of the 66 per cent. remaining without an award, and in general practice it would certainly cause some bitterness of feeling. I am not going into the question of general practice; I mentioned it as an aside. Perhaps I may be permitted to illustrate this with a brief analogy which some noble Lords might find fanciful and others tantalising. Let us suppose that the noble and learned Viscount who normally sits on the Woolsack, or his deputies, had the same powers as the noble Lord, Lord Moran, and his Committee have of awarding at the end of a Session distinction awards for the best speeches of that Session. Without any question whatever, the noble Lord, Lord Taylor, would be in receipt of an A-plus and nobody would resent that. However, some noble Lords, with greater pretensions to the stature of the noble Lord, finding themselves in the outer 66 per cent., might well feel that they were hard done by. When it is brought home I myself feel that more doctors would be resentful and hurt and ashamed than would be pleased by a change in this system.
§ LORD TAYLOR
My Lords, I think that the noble Lord is treading on dangerous ground. We might all be against merit awards in those circumstances—I know I should. The suggestion is that secrecy should be done away with only for the top awards, the small group of people whose merit I think everybody would agree with and which should be very properly and reasonably publicly acclaimed.
LORD ST. OSWALD
My Lords, the noble Lord may be right. As I say, he knows infinitely more about the medical profession than I do. But it is not noticeable that jealousy decreases at the top of a profession; and I should not think myself, looking in from outside, that that was entirely inevitable.
174 I said that I would not mention merit awards to general practitioners, but I will mention them to the extent of reminding noble Lords that implementation of the Report does not depend upon the acceptance of this recommendation. Although I sympathise with the idea of the extra payment to doctors over 50, put forward by the noble Lord, and supported by other noble Lords, I must point out that the whole idea of merit which was emphasised by Lord Cohen of Birkenhead would have to be abandoned. I cannot see how, under the present provisions, the half million pounds could be diverted to a completely different purpose.
My noble friend Lord Teviot spoke of dentists, and I took it from my knowledge of him that he was going to attack the Report on the way it treated dentists over their remuneration. He did not do so; and therefore my speech, aimed at attempting to persuade him, is somewhat vainly composed. However, for the benefit of the Record, I will say that although at first sight it appears that dentists have had a raw deal—indeed, my noble friend Lord Auckland seemed to think so—in fact there is no real question of members of the Royal Commission and of the Government getting some of their own back at one "swipe" for those hours of openmouthed agony in the dentist's chair. There is one other thing on which I can satisfy my noble friend, Lord Teviot: that is, that dental consultants in hospitals are in receipt of merit awards; and in fact there is a sub-committee of Lord Moran's Committee which deals with their cases.
My Lords, I should like to give a brief outline of the situation of dentists since the Commission began to sit, in explanation of their treatment in the Report. The Spens Committee estimated that dentists could work properly 1,500 hours in a year at the chairside—that is to say, excluding the time spent on book-keeping, case notes, and other professional activities. Their remuneration is therefore reckoned on that assumption, built up from items of service and from the time each item of service might take. For example, one small filling, in times of minutes, was, I believe, 25 minutes. The Royal Commission discovered that, instead of 1,500 hours per annum, the average dentist is working 2,050 to 2,200 hours per annum. Moreover, into this 2,200 hours he is getting more items of 175 service than was thought possible by the Spens Committee, even had they based their estimate on 2,200 hours. This is due to modern machinery, especially the high-speed drill, which enables a dentist to work faster; and the result has been that, even though dentists are entitled to a rise in theory, they have in point of fact caught up with that rise in practice, and might even gain a longer lead as still more modern instruments are introduced. These facts emerge from the Report, and the advantage in pay to the young dentist over the young doctor is emphasised on page 130.
My Lords, I now come to the speech of the noble Baroness, Lady Wootton of Abingor; and here, as once before, I am in a difficulty. As I informed her then, I would far rather march under her banner than watch it go by without me; and to shy bricks at it, even if they are intended to miss, would be unthinkable. But to-day I am an admitted onlooker, and a minor critic. I may have read more into her words than I should have done, but it seemed to me that the noble Baroness considers that the system of wage and salary fixing is untidy. Both in theory and by desire I am tidy myself, although incurably and, I am afraid, noticeably untidy in practice: but democracy itself is an untidy system compared to dictatorship, and I am sure that both the noble Baroness and I would prefer untidiness in those terms.
§ BARONESS WOOTTON OF ABINGER
My Lords, if the noble Lord would forgive me, I think he is putting the word "untidy" into my mouth. I am not aware of having used it.
LORD ST. OSWALD
No. I am not attempting to quote the noble Baroness: I am paraphrasing her, albeit badly.
§ BARONESS WOOTTON OF ABINGER
If the noble Lord will allow me to say so, what I intended to convey was that I thought it was socially undesirable, which is rather different.
LORD ST. OSWALD
Then I paraphrased her wrongly, and I am sorry. I am happy to learn, incidentally, that she does not disapprove of untidiness. However, the noble Baroness seemed to me (I may be wrong here, though, again, I am not attempting to quote her, but am paraphrasing) to be posing the question: 176 how, in this complicated world, can we decide how much should be paid to whom for what? Her contention appears to me to be that wages and salaries are settled industry by industry, job by job, and that nobody attempts to look at the picture as a whole or to bring the whole thing into focus.
I have also read her words in a most impressive and reasoned article in which she questionedthe extreme sanctity which now attaches to collective bargainingand also questioned the credo that it is unwise to interfere with any collective bargain that anybody chooses to make. Under a dictatorship, an employer can be told what he will pay and an employee can be told what he will work for, though that may not be what the employer is prepared to pay or what the employee is willing to work for, which is what we aim at in collective bargaining. Under the political system in which we live, I should have thought that there surely had to be some overwhelming reason of public policy to justify any intervention from outside, or any introduction of a fixed theory. It would certainly be very difficult to justify such an intervention on a theory that some authority of infinite eminence knew what people ought to be paid for their work.
§ BARONESS WOOTTON OF ABINGER
My Lords, will the noble Lord forgive me for interrupting once more? I should not like to have the inference drawn that some regulation of the pattern of remuneration necessarily involves dictatorship. If the noble Lord would devote his attention to what has happened in Sweden and Holland, I think he would find that in those very undictatorial countries some such overall control is exercised.
LORD ST. OSWALD
I was not drawing the inference that the noble Baroness has suggested; I was merely saying that in a dictatorship some regulation would be easy to introduce, whereas in our system it would be very hard to introduce—and, I think, pretty unpopular. I think there does not seem to be much wrong in the theory that the parties themselves know best what the employers will pay and what the employees will be content to work for. Is the noble Baroness affirming that there ought to be at least a single set of criteria by which 177 the validity of any pay claim could be judged? I personally cannot imagine that any modern Solomon could obtain agreement to the various fractions or degrees of x, one against the other, which would add up to this touchstone: for example, exposure to danger, skill, experience, scarcity—all in turn measured for wage purposes against the economic capacity of an industry, or of industry as a whole. In the debate on economic affairs last night my noble friend Lord Mills mentioned in three or four instances the importance of price stability to the whole economy of a country such as ours, and that would have to be counted in as well.
I should have thought that one thing on which employers and employees would always agree is that no single standard of absolute value of job A as compared with job B exists or is obtainable. The facts affecting it are not limited to what the noble Baroness called "the good old rule of supply and demand." Custom, expectation, and even human prejudice, all enter into the conception of fairness; and I, for one, am driven back upon the conclusion that it is, quite simply, the essence of what people, for one reason or another, will agree to accept without being ordered to from outside. A definition or yardstick of fairness imposed from outside would, I think, be far more likely to start a whole series of disputes, than to end the present one, as a definition so often does.
This has been a most interesting and deeply informed debate. It has fallen to me to wind up, from a knowledge of the subject deepened by that of the majority of noble Lords who have taken part. At least, I can say that I am among those who are wiser than when the debate began. To assist my education in the subject, I took out of the Library some days ago this book. Its condition reveals either that it has been read by a great many people or that those who took it out treated it with some violence. I trust that it may be the former, because it has certainly helped me a great deal. As it has become fashionable in the course of this debate to end on a quotation, I propose to end by quoting from this book, this time in prose:The doctor's day has much in common with a military operation. It can peter out 178 in a series of inconclusive actions and minor defeats; it can be carried through with exemplary efficiency, yet the purpose behind each activity may be missed, so that victory is never fully exploited; or it can march to completion with a full sense of satisfaction for both patient and doctor.I hope that the recommendations of this Report and the Government's acceptance of them may encourage doctors to begin and later leave behind them the sort of life described in the concluding words of this passage.
§ 7.20 p.m.
§ LORD MORAN
My Lords, in asking your Lordships' leave to withdraw this Motion, may I say a few words? The noble Lord, Lord Taylor, was speaking for the abolition of the A plus, B and C awards. The Evidence Committee, 50 in number and representing the whole profession; the Spens Committee; the British Medical Association, both the Council and the Representative Meeting; the Royal Commission, both Majority and Minority Reports; the three Royal Colleges and the Treasury—perhaps with the exception of the Treasury; I do not know what they have done—accept this scheme, and I think that a practical man would say that perhaps there is something in it.
My noble friend Lord Cohen of Birkenhead has generously said that his doubts are resolved and that he completely accepts it. I think that is very generous, for I know that for some time he doubted whether it was a practical scheme. I have been very much impressed, in going round a large number of schools, by what the masters have said about the difficulty of medicine competing in entry with engineering and science, and therefore I am not in a very receptive mood when the noble Lord, Lord Taylor, asks, "Are enormous incentives necessary?" and when the noble Baroness, Lady Wootton of Abinger, asks, "Should we not narrow the gap between large and small incomes?" Naturally, coming straight from this question to these political matters, I am not disposed to discuss whether the profit motive is going to go this year or next.
Again, when the noble Baroness says that the general practitioner should earn as much as the specialist, what strikes the practical mind is that the specialist must be kept on at medical school for 179 ten or fifteen years, at a relatively low salary, while the general practitioner is making much more in practice. There is no Dean who does not realise that this is the case, and that it is necessary to make it financially possible, if the specialist is not to "do his family down". Again, when pleading that it might be possible—I am not asking any more than that—that general practitioners should have awards, I was pleading for a premium to be placed on good work. And suddenly, out of the blue, comes the suggestion that this money should be given in a subsidy of old age—a totally irrelevant remark. It is a good thing to subsidise old age, but that is not the question here.
My noble friend Lord Cohen of Birkenhead spoke interestingly on the giving of general practitioner awards. I am not certain that it can be done, but if it is practicable, it is enormously important that it should be done. I am not at all convinced that it cannot be, and I think that his suggestion that it might be narrowed from one in 23 to one in 4 or 5 might make it much more easy. At this late hour, I am sure your Lordships do not want to hear more. I should like to say how grateful I am for the nice remarks that noble Lords have made about the awards. For five or six years we have had nothing but abuse, so that the other kind of reception is welcome. I thank your Lordships and beg leave to withdraw my Motion.
§ Motion for Papers, by leave, withdrawn.
§ LORD TAYLOR
My Lords, I do not intend to move the Motion standing in 180 my name, but I should like to thank the noble Lord, Lord Moran, for initiating this interesting debate and the noble Lord, Lord St. Oswald, for the charming way in which he has wound it up.