DOCTORS' PAY AND THE MEDICAL SERVICES

HL Deb 22 January 1964 vol 254 cc943-1020

3.24 p.m.

LORD TAYLOR rose to call attention to the need for changes in the method of remuneration of general medical practitioners and for a ten-year plan for the development of general medical practice; and to move for Papers. The noble Lord said: My Lords, I beg to move the Motion standing in my name on the Order Paper. The subject to which I am directing your Lordships' attention this afternoon is, I am afraid, a little complicated, but I shall try to keep it as simple as I can. It is also a very important one indeed, since it concerns at least one-third of all the doctors in this country and at least 95 per cent. of all patients in this country—that is, of all citizens—since all of us, or almost all of us, when we start to make use of the National Health Service do so through our general practitioners. They are the portal of entry as it were, and on the skill and the speed with which they do their work depends the subsequent treatment that we get. Not only that, but very often they look after us when we come out of hospital, when the hospitals have done all they can; they look after many people in their terminal illnesses. So their importance to the nation cannot be exaggerated.

I wish to begin by making three short general points. The first is that the British National Health Service is a good institution. In fact it is very nearly a very good institution. It needs relatively few changes to make it the outstanding system of medical care in the world. But those few changes are needed, and one of the places where they are needed most is in respect of the general practitioner services. I think it is a tribute to the wisdom of the people who designed this Health Service, to Mr. Aneurin Bevan and his colleagues and the civil servants working under him, that it has required so few changes over the past fifteen years; and indeed I think it is in a way a backhanded tribute to the Government that they have in fact changed it so little during the course of the last twelve years, that they have left what was good alone.

The second general point I would make is that I put down this Motion before the medical profession had started to make approaches to Her Majesty's Government on the very subject of this Motion. They have not yet reached a stage of negotiation and I think it will probably help them—certainly it will help the public, and I hope it will help the Government—that we should have a debate now. In the Motion I have been very careful to link method of remuneration of the doctors with future development of the Service. I am not going to discuss amounts of remuneration. I think that is a proper subject for negotiation between the doctors and the review body which the Government have set up. But method determines quality of medical care and this concerns all of US.

The third general point I wish to make at the outset is that home medical care by general practitioners, provided it is of proper quality, is a far more economical way of looking after the sick and indeed of promoting health from the point of view of both the individual and the nation than hospital medical care. I would emphasise the words "of proper quality." Last year I had the privilege of visiting many general practitioners in the United States. There are, although you may not think it to hear American doctors talk, still 60,000 general practitioners in the United States, and many of the doctors the Americans call internists or pediatricians practise precisely as our general practitioners do. Yet there is an outstanding difference in their work from the work of the British doctor. They make on an average about two home visits per week, whereas our doctors think nothing of making fifteen or twenty home visits in the course of a day; that is quite a usual thing for a busy general practitioner.

The reason for the difference is this. In America the sick persons, even when they have a temperature and feel quite ill, are brought to the doctor's offices and are then admitted straight away to hospital. So a great deal more medical ill-health is admitted into hospital in the United States than in this country. The effect of this is, of course, that the cost of hospital medical care in the United States in terms of total cost to the nation is very much greater. That is one of the reasons why, if we provide good quality home medical care, the development of our general practitioner services is a good, sound national investment and one that we ought to do all we can to encourage simply from an economic point of view.

I turn now to the main theme to which I wish to draw your Lordships' attention. The general practitioners of Britain are now, I think, more disappointed than at any previous time in the last fifteen years. They feel that, despite continual assurances of their value and importance, the Government do not really care enough about them to ensure that the future of their service is properly looked after. I do not say they are right, but that is how they feel. To be sure, the present Minister has made some most encouraging remarks. But it is only fair to say that past Ministers have also made encouraging remarks where the general practitioners have been concerned, but alas! little has been done.

The three reasons why they are feeling so disappointed and fed up are these. First of all, there is no plan for the future of general practice. In 1962 we had a ten-year Hospital Plan. I must say that it was a good thing to have this Plan. Although one may criticise it in detail, the principle is an excellent one. In 1963 we had a ten-year Plan for local authority health and welfare services. But we have had no ten-year Plan for the general medical services which the general practitioners provide. It is true that we have had this document, the Annis Gillie Report—and quite good reading it is; it is full of admirable conclusions from which I do not think most of us would dissent. It is called The Field of Work of the Family Doctor. But although it says what ought to happen, it does not say how we are to get there, what route we are to follow to achieve these desirable ends. Indeed, the former Minister of Health, Mr. Enoch Powell, made that point in discussing this Report.

Furthermore, it is almost identical—not quite, because it contains some new things—with the Report of the Cohen Committee on General Medical Practice which reported in 1954. That was a Committee presided over by my noble friend Lord Cohen of Birkenhead, of which, I may say, I had the privilege of being a member. The Committee reported in 1954, and its recommendations were not greatly different from the recommendations of the Annis Gillie Committee in 1963.

The second reason why the general practitioners are feeling frustrated is that they cannot see much hope for the future in their own personal practice of medicine. Better general practice depends on one factor above all others—the Gillie Report confirms this, and confirms, I think, what every principal in a medical practice who has been spoken to has said; it depends on the number of patients the doctor has to look after, the size of his list. Everyone with any practical experience of general medical practice knows that this has to be reduced. At the moment the permitted maximum is 3,500 patients. That is the number that a doctor is allowed to have on his list. The average in the National Health Service is 2,300. Quite frankly, a doctor cannot look after 3,500 patients properly; indeed, I do not think he can look after 2,300 properly. Most doctors would think that one cannot look after that number properly. I think it has to be a substantially lower figure if the work is to be done properly, if people are to be examined when they ought to be examined, and if one has not to rely on just guesses and hit-and-miss. Everybody who has thought about this question is agreed, I think, that we ought to reduce the maximum to 2,000, and the average number to about 1,500. This would mean many more doctors, and at least 1,000 more in general practice.

Yet what is the situation? In the year for which I have the last available figures, which is from October, 1961, to October, 1962, the number of general practitioners practising as principals went up by 137, but in the same period the number of general practitioner assistants who were helping these doctors but who were otherwise in full-time practice, went down by 149; so we get a net loss of about 10 doctors. That is perhaps not a serious matter. But during that same time the population went up by 503,000. So already the trend is going in the wrong direction. Thanks to unwisdom—I can describe it only as unwisdom—on the part of the Government, for this particular point really is a Governmental responsibility, there is no chance of more doctors for the next seven years.

At Table 125 of the Annual Abstract of Statistics we find the number of medical students in Great Britain in each year between 1951 and 1962. In each year, except one, the total number has gone down. From 1951 to 1952 the number of medical students was 13,910; in 1961 to 1962 it was 12,254. In ten years we have had a 14 per cent. drop in the number of medical students in the pipe-line, and in the same period the population of this country has gone up by 3 million, by 6 per cent. We can see why general practitioners do not see much relief, in the way of the hands that are so badly needed, coming along.

It is true that we have had a revision in the entries into medical schools. The cut which was made some little while ago has been done away with. But even when the replacement following the cut is allowed for, it still means that at best in seven years' time the provision of doctors will just about be keeping up with the population: that is the best we can hope for. Yet every year thousands of boys and girls who are qualified to enter medical school are being turned away. There are 30 male applicants, and something like 200 female applicants who are properly qualified with the appropriate number of "A" levels, for every place in our medical schools. These figures may vary a little from medical school to medical school. There is some overlap, but the demand for places certainly enormously outruns the available number of places. We have asked the Government for four more medical schools immediately. We asked them more than a year ago, and there are rumours that one may be coming along; but so far ahead as they can see there is no relief for these poor general practitioners.

We can see the position going wrong in another way, in the decline in the number of applicants for every vacancy in general practice. Again, according to the Gillie Report, in 1956 there were 43 applicants for every vacancy. That sounds quite a lot, but in fact the numbers were much higher in the South than in the North. However, in 1962 that number was down to 17 applicants, and now I believe the figure is even lower. So that is the second reason why the doctors are feeling fed up about it.

The third reason is that the doctors feel that they have been financially swindled or tricked. This is their feeling. Let me say at once that they are not entirely correct in feeling this. Strictly speaking, they are the victims of circumstances. They are man-made circumstances, and they are partly of their own making, or at least of the making of those doctors who negotiated on their behalf. In 1962, the Review Body which the Government set up awarded all the doctors in the National Health Service a 14 per cent. increase in income which was to last for three years. As a result, the general practitioners expected to get on average an extra £340 a year, less tax. The specialists and the consultants got their 14 per cent. added to their salaries and were duly grateful; but the general practitioners in fact received only 6 per cent, over their previous year's pay.

Why did this extraordinary anomaly arise? Why had a most hardworking section of the profession apparently been far less well-treated than their colleagues? The reason is a matter of history. In 1946 a Committee called the Spens Committee reported on how much a doctor in the National Health Service ought to earn, and in the case of G.P.s they set out a recommendation for income from all sources. This became known as the pool. The pool was the income of all the G.P.s from all sources. This pool was formalised following the award by Lord Justice Danckwerts. The principle of the pool was that the general practitioners were to be paid a capitation fee for each patient they looked after and for whom they provided general medical care; but the size of the fee was to vary. The total pool was to be calculated so as to give each average general practitioner an agreed income, but before the capitation fees were paid out all the other payments by the State to the G.P.s were to be deducted from the pool. General practitioners get paid extra for extra work, or, indeed, for special circumstances of practice—for example, practising in some remote rural area or some extremely unpleasant industrial area. But this extra comes out of the pool. Can your Lordships imagine anything more extraordinary?

What happened in 1961–62? First, the birth rate went up. The doctors had to do a great deal more maternity work. They got paid extra for this, but this extra was deducted from their capitation fee, though, of course, there was no decline in their general medical work. Indeed, because of the great increase in the birth rate there was an increase in the amount of general medical work which they were doing; they were having to look after more patients. Secondly, there was a smallpox epidemic as a result of which hundreds of thousands of people demanded to be vaccinated. There was no harm in that, it was reasonable enough; but it was an enormous volume of extra work for the doctors. The doctors got paid extra for this, but it was deducted from the pool. So that once again the capitation fees for their general medical work went down. Third, the hospitals were running short of doctors and started offering paid part-time work to G.Ps. There was no less work to be done by the G.Ps. Some of them took part-time work in the hospitals; but again their payment was deducted from the pool—from the pay of all the doctors as a whole.

A number of doctors undertake work for the Treasury, examining civil servants; others work for the Ministry of Labour examining young workers in factories and workers in dangerous trades; yet others for the Ministry of Pensions. And for all these activities the doctors are paid. I think I am right in saying—and the noble Lord, Lord Newton, will correct me if I am wrong—that even those payments are deducted from the pool, and again the doctors get less for doing tile same amount of work. The most extraordinary deduction of all, I am pleased to say, was put right. It was put right by the Royal Commission on Doctors' and Dentists' Remuneration which discovered that the employers' contribution to the doctors' pension fund was coming out of the pool. The Royal Commission said that this was scandalous, and it was put right. But it would take an administrative genius of the highest order to devise a more unfair measure of remuneration.

The size of the pool is not determined by the number of patients who have to be treated but by the number of doctors in general practice so that they get a fair income. Let me say at once that this was done at the request of the doctors. It is quite all right so long as the number of doctors is growing in step with the size of the population, but at present the supply of extra general practitioners is beginning to dry up and at the same time the population is going ahead as never before. The result will be that if the population grows faster than the number of doctors, as seems almost inevitable, the pay of the doctor per patient cared for will steadily decline.

One might have thought that one had already reached the height of an Alice in Wonderland situation, but it is not so. The pool also includes an element for doctors' practice expenses. About 35 per cent. of the money in the pool—money paid out as capitation fees—is an allowance for the doctors' expenses. It is based as a whole on the doctors' own income tax returns, so that it really should represent the actual expenses. But, of course, it does not go out according to the individual doctor's expenses; it goes out on a sort of average basis. The doctor is not compelled to spend money on these expenses, and the result is that the less the doctor spends on his practice expenses—in other words, the worse the service he gives to his patient—the greater is his "take-home" pay. Conversely, the more the doctor spends on his practice services—that is to say, the better the service he gives to his patients the smaller are his actual earnings. So we have a built-in cash disincentive to good work. This was referred to by Mr. Enoch Powell as an "almost insoluble conundrum". I do not think that it is almost insoluble, but it requires a little thought to see how it ought to be straightened out: for straightened out it clearly must be.

But the story is not ended yet. Like everything else, the rents and prices of doctors' premises in towns and great cities have been going up steadily. A doctor who has a surgery in a working-class area may not own it, but may have it on a 21-year lease. The lease falls in, and he suddenly finds that he has to pay a greatly increased price for precisely the same premises. Yet these are precisely the places where practice conditions are already the worst. To improve practice conditions in these places the doctors must spend a great deal of money, cutting their incomes still further. A shopkeeper who improves his premises can hope for extra pay and thereby recoup himself for the money he has spent; but a doctor in Bermondsey or Lime-house or Shoreditch or Southwark already has a full list, and, anyhow, physically he could not do any more than he is already doing.

It is true there are group practice interest-free loans available for doctors who come together in groups and want to build new premises, and some 340 of these had been made by the end of 1962. But most of these doctors have gone into the suburbs, the new housing areas and the small country towns. Very few group practice loans have been made to doctors in the great cities. And the amount available on these interest-free loans is £3,000 per doctor—which is good enough if one is building in a country town or a suburb, but would hardly pay for the land needed to build a group practice premises in London. I see that the London County Council is now paying £57,000 an acre for housing land. How on earth can doctors hope to acquire land to build group practice premises at that sort of rate, particularly when one bears in mind that they have to provide parking space for their cars to be able to get in and out quickly, and sometimes even have to provide parking space for patients' cars on the site as well.

I am afraid that the simple truth is that the Government have not indulged in any real, constructive thinking about the future of general practice and what we must do to try to improve it. They have thought quite a bit about the hospitals, and during the past fifteen years the number of consultants in the hospitals has gone up by 50 per cent.—and quite rightly. The administrative and clerical staff in hospitals have gone up by about 40 per cent.—probably rightly, though one may think that perhaps there is a little too much administration. The money spent on drugs prescribed by general practitioners has gone leaping up by about 180 per cent., though strangely enough the number of prescriptions that the doctors have prescribed has gone down over the past fifteen years from 202 million to 197 million, although they are dealing with several million more patients. The number of general practitioners in England and Wales in the past fifteen years has gone up by only 15 per cent. which is just a little more than the population; and indeed all the evidence is that there will be a swing the other way.

What must be done about it? I want to put it quite simply and quite shortly. First, I am quite sure we must think about a ten-year plan for general practice, with clear-cut objectives, as we have for the hospital services and the local authority services. The target for 1974 should be to have enough general practitioners to bring maximum permitted lists down to 2,000. This means four to five new medical schools absolutely straight away. We cannot wait, because the throughput time is at least seven years. We must have them straight away, and it really would not be very difficult to start first-year medical departments straight away. Two or three at least must be in the great conurbations or towns of the North of England, where the shortage of general practitioners is greatest. It is a strange fact that the general practitioners who graduate from Provincial medical schools tend to practise mainly around the school where they were trained—and a very good thing, too. That is why it is extremely important that the bulk of the next new medical schools should be in the North of England, where the shortage of general practitioners is most severe.

Secondly, we must aim, within ten years, to have the great majority of general practitioners working in groups in properly equipped group practice centres. In achieving this, the first priority must be given to the poorer parts of our great cities, but there is no reason why—because the premises that are needed for good group practice are not big; they are only of the order of about 2,000 or 3,000 square feet—we should not move forward everywhere. But if there has to be a priority, it must be where things are worst, which is in the great cities.

How are we to do it? We must spend money in order to get group practice going in great cities, but this does not mean vast sums of money such as the amount required for building a hospital. The present maximum group practice loan which a doctor is allowed is £3,000, or 80 per cent. of the cost of his building. I think there is no reason why the loan should not cover the full cost of his building, provided it is approved, or why the ceiling should not be greatly raised, because he is going to pay it back anyway. He is not taking the money away. I think we must have outright capital grants for all projects where the land costs are above the national average, because there is no hope of getting doctors established in group practice in new buildings in our great cities unless we can get the land for them.

There must be recognition of the fact that in areas of physical decay new premises may have a limited life only; that the area may be pulled down in ten or twenty years. Yet that is no reason why the people living there should have to keep going to a doctor practising in some dirty, dilapidated, tumbledown place. There is no reason why the doctor should not have a "prefab" consulting room, a "prefab" group practice unit with a limited life. In cases of that sort I think a grant of up to half the cost ought to be made, and I cannot see why interest-free loans should not be given for all practice improvements. It would be nice to say that local authorities must supply the premises that are needed, but in fact we have tried that and it has not worked. The local authorities have had the power to provide group practice centres, to provide health centres, under the National Health Service Act, but it has been to very little avail indeed. They have been very slow off the mark and, where they have got off the mark, they have had great difficulties because the doctors did not want to practise in local authority buildings—partly for historic reasons, and I do not think anybody is to be blamed for that. I think the doctors are probably right in their decision. But that is the situation which has to be faced, and I do not think we can leave it to the local authorities and hope that anything will be done, on the scale that needs to be done, within ten years.

Therefore I think we ought to look at some other sort of machinery to do the job. A Practice Premises Trust is one of the suggestions that has been made: that we should create a new Government agency to build and own these buildings and rent them to the doctors at reasonable rents, which in some cases would have to be below the economic rents, particularly where the land costs were high.

Thirdly, in group practice centres there should be accommodation not only for the doctors and their ancillary helpers, for the nurses who may be helping them and for the patients waiting, but also for district nurses, health visitors and midwives who are provided by the local health authority; and there is no reason at all why this accommodation should not be rented by the doctors to the local health authority. That is a reversal of the old health centre idea. It is essential and, thank goodness!, it is now recognised in both these Reports, and particularly in the Annis Gillie Report—that general practitioners must play an active part in all the local health authority work: that is, in the ante and post-natal care of the mothers which the midwives do; in the home delivery, where the midwives work under the supervision of the general practitioners; in child welfare work, which is a local authority responsibility; and in the care of well babies, which is something which can be done by general practitioners who are specially trained and for which they can be specially paid. I may say that in our new town of Harlow we have some six group practice centres of this kind; we have had them for a number of years now. The doctors are doing all these things, and the system works perfectly satisfactorily and is a great success.

Fourthly, all medical school students in the future should learn about general practice. There are only two medical schools at the moment where anything substantial is done in this way, though a number are beginning. But at Edinburgh there is now a professor of general practice, and at Manchester there is an excellent general practice teaching unit. Every medical student should learn about general practice, what goes on and how to do it better. Incidentally—it may be that he should learn this partly before and partly after he qualifies—I think every specialist should also learn about general practice as well.

Fifthly, general practitioners should be encouraged to do some work in industrial medicine in the factories. The reason for this is that we have a great many factories where medical care is needed, and there is no other chance of getting any medical help for them at all. May I say that this can be done perfectly easily—and, again, that we do it in our New Town of Harlow, even though the doctors have very full lists? By good organisation and by full use of ancillary help, we get them to do some, and it is of great benefit to their patients and to them in appreciating the environment in which their patients work.

Sixthly, I think the general practitioners can do more to relieve the hospital services of unnecessary work by doing, for example, certain kinds of minor surgery. They used to do this, but they have given up doing it now because they are not paid for it and it is easier to send the person up to hospital. But the person who arrives at hospital will then be attended by some junior who himself, probably, in later life will become a general practitioner. If general practitioners are properly trained to do minor surgery and are experienced at it—I do not mean to treat fractures, but to do small portions of surgery which they can properly do—then I think they should be encouraged to relieve hospitals from doing work which hospitals do not need to do.

The seventh and last thing we have to do, and the most important of all, is to carry out a massive revision of the way we pay our general practitioners. That must be undertaken, and I think it will be undertaken straightaway, because unless that is put right nothing else can be got right. Now 1 would say once again that I am not concerned with the amount of remuneration; that is a proper subject for the Review Body. But reform is bound (at least, it is almost bound) to involve some increase, even without any purposeful exercise in that way, simply because, when one sorts the matter out, it will be found to be so unfair that the getting rid of these anomalies alone will be bound to lead to some increase.

The first thing we must do—and I think most doctors will agree with this—is to abolish the pool system, once and for all. I am sorry to say that some of those who are negotiating on behalf of the profession think they can keep the pool going in part and gain from doing this. I believe that it is a mistake to do this. Hopes that it may be possible to gain some "spin-off" benefit from being clever about this matter, saying, "If we keep the pool it is just possible the number of doctors may increase at a higher ratio than the number of patients, and therefore we shall gain," are bound in my view, to be frustrated. And, more important still, I think they are bound to lead to grave discontent on the part of the profession with the negotiators who do these things in the hope that they are doing something smart on the doctors' behalf. So we want to see the pool system go once and for all.

This does not mean that we should not go on with the capitation fee system. In my view, it has proved its worth, although some people believe (and I think more doctors now than in the past believe) that there is a great deal to be said for getting rid of it and having a simple salary. But, speaking personally, I like capitation fees, because they make it possible for patients to reward their doctors, in a way, by selecting the doctors of their choice. But capitation fees ought to be reasonably fixed, and they ought to be redetermined every three years by the Review Body, having regard, first, to the volume of work done for each patient at risk; secondly, to the number of patients the doctors are allowed to have on their lists; and, thirdly, to the actual average list size. As a result, the remuneration of general practitioners from capitation fees alone should steadily move forward as the gross national product permits, and should more approximately meet, or come nearer to, the salary of consultants.

At present, these capitation fees are weighted in a number of ways; there are a number of allowances for special practice areas, and so on. For all these there are excellent reasons, and all these weightings ought to be retained. But there is urgent need for one new variation in this, and that is a weighting, an addition to the capitation fee, according to the age of the doctor. The situation is that at the moment there are two main professions where as you get more senior you get poorer. They are general medical practice—not consultant practice, but general practice—and general dental practice. In both these professions the earnings of practitioners go down after the age of about 50 simply because they cannot keep up the pace. They have to take in partners or assistants, and they cannot increase their earnings by getting more patients. They have, in fact, to give up patients, and so they receive less. The only honest and decent thing to do is to increase the capitation fee for a man or woman who has worn himself or herself out in the service of the community over the years.

The third feature of a decent pay structure should be extra pay—genuine extra pay—for extra work done. One would have thought that this was common sense, and it was only as I gradually realised and understood the way that all these extra payments were deducted from the pool that I myself began to feel that, for whatever reason, the doctors had not had a square deal in the past. So there should be genuine extra pay for maternity work, for child welfare work, for vaccination and inoculation, for hospital work, for school medical work and for all the jobs that doctors do over and above general medical care. There is no reason why they should not get extra pay for doing extra work.

The final feature of a decent pay system is that doctors' expenses should be completely separated from their payment for the work they do. This, again, one would have thought, was common sense: yet it has not happened. Doctors should be reimbursed their reasonable and proper expenses—doing, as they are, entirely, or almost entirely, work for the National Health Service, for the community as a whole, paid for out of taxation. It does not require any very great ingenuity to work out a system whereby they can be reimbursed for their expenses, because their expenses fall into certain groups. There are, first of all, the expenses which all doctors have—the capital cost and the "write-off" cost of their car, for example. We do not expect them to be given expenses for an expensive car; just an ordinary, average, decent car. If they buy something more expensive, that is their affair. But the need is something which is common to all.

Likewise, they should have secretarial and receptionist help if they are to do their job properly—and that, again, is something for which one can work out a proper rate. In fact, the rate of payment should be the same as the rate of payment of a receptionist in the hospital service, which is a negotiated rate. The doctors should be reimbursed for the actual number of hours they pay a proper receptionist. I would suggest that if doctors employ their wives in this respect—there are a few who do so, but I think it is an undesirable practice—they might be slightly penalised; but if they employ a proper receptionist, that receptionist should have the proper rate for the job and the doctor should get back that proper rate for the job.

Lighting, heating, telephones, and so on, are also all items for which national rates can be worked out. The only two difficult items are the actual mileage which a doctor does—and here one must have variations as between rural, semi-rural and urban practices—and the cost of his premises. In the case of the premises, costs are bound to vary accord- ing to whether the doctor improves his premises, and according to whether or not he practises in a built-up urban area. Again, one can work out a formula based on the square footage, which must be related to the average value of the area; or, indeed, one can work on what he actually has to pay and reimburse him accordingly.

My Lords, that is the lot. It is a little complicated, but it is not an insoluble conundrum. Those are the steps which must be taken now if we are to get general practice back to running on the right lines again. I have given the broad framework; I have not filled in the details and I have not touched on a great many things which are very important, such as postgraduate refresher courses, the actual nature of the general practitioner's work in hospitals, and so on; and I have suggested minimum changes only. One could have suggested far more radical ones; but I do not think these are essential. If we made these minimal changes matters would go right. It is a great pleasure to see so many of my distinguished colleagues taking part in this debate. I am delighted that they should have decided to do so, and I am sure that the general practitioners of Britain will be as delighted.

I would give my good wishes to those who will soon be negotiating on behalf of the profession. I think they have come, over the years, to recognise that their interests and the interests of their patients are identical with the views which we hold and which we have expressed for many years on this side of the House. That is, to me at any rate, very encouraging. I hope that the wisdom they now show may be met by equal wisdom on the Government side in the discussions ahead. May I say that we do not expect too much of the noble Lord, Lord Newton, to-day. It would not be fair to expect him to say too much, because of the fact that there are going to be negotiations in the period ahead; but we can assure doctors that if there is a change of Government in the next nine months there is no problem in our marching forward together towards the kind of goal that they have in mind, because it is precisely the kind of goal that we on this side of the House have had in mind for a long time. We realise that general practice is not only a vital part of the Health Service; it is a most valuable form of human activity, and we want to see it properly, rightly and fairly rewarded for the future, so that it can flower as it should. My Lords, I beg to move for Papers.

4.12 p.m.

LORD BRAIN

My Lords, I am very grateful to the noble Lord, Lord Taylor, for having put down this Motion. I had intended to put down a similar one myself, but he anticipated me. I find myself almost entirely in agreement with everything he said. A short while ago, when addressing your Lordships' House on the subject of the Robbins Report, I drew attention to the great need for more doctors and for educational facilities for them, and one of the reasons I gave was, as the noble Lord, Lord Taylor, has said, that if the general practitioners are to have smaller lists and give more time to individual patients there must be more doctors. In medicine, diagnosis precedes treatment; and, so far as the financial problems of general practice are concerned, I think that the diagnosis, as the noble Lord, Lord Taylor, has shown, is fairly clear and complete. But finance, important though it is, is not the only cause of dissatisfaction among the general practitioners. If we are to have, as the noble Lord has suggested, a ten-year plan, I think we need as complete a diagnosis as possible.

To get this, my Lords, we need to look at our present deficiencies against the background of what has been achieved. During the last twenty years we in this country have carried out a reorganisation of the medical service which, in scope and complexity, is without parallel. The resulting task of organisation and administration has been enormous and it has produced great advances in human welfare. But that is not the whole story. This great change in social organisation has been taking place at a time when medicine itself has been advancing and changing more rapidly than ever before. Dramatic new techniques and achievements in the hospital field, based on costly and complicated apparatus and highly organised team work, have quite rightly captured the public imagination and necessitated a great and rapid expansion of our hospital service, not only to meet the needs of patients but, equally, to enable us to keep up with the achievements of other countries in this field. I will say something later about the effect of this upon general practice.

The point I now wish to make is that at the very time when medicine itself was advancing most rapidly, and sometimes in unforeseen ways, administratively we were concerned with stabilising the organisation and, as always happens in any State-run concern, enforcing the rules; and this task alone has more than fully occupied the administrators at all levels. Our medical educational system, although about the time the National Health Service was introduced it began to recognise the need for change, has on the whole changed very little in response to the large new problems which medical progress has created. So if the National Health Service now finds itself in some difficulties, as it does, I would ask your Lordships to look at these difficulties as, to a considerable extent, the product of changes in medicine itself, which have added to the extremely difficult task of initiating the service. If this diagnosis is right, it is clear that much more than a financial settlement is needed.

I think it is fair to say that for various reasons, some of which I have already mentioned, general practice has been the Cinderella of the Health Service. Compared with the hospital service comparatively little money has been provided by the State for the development of general practice; and, here again, money is no t the only factor. I get the impression on the whole that, in spite of the valuable work of several Committees, notably the one of which the Chairman was the noble Lord, Lord Cohen of Birkenhead, and Dr. Annis Gillie's recent Committee, less thought has been devoted by the profession as a whole, including the administrators, to the needs of general practice, both present and future, than has been the case in the hospital service or in medical research.

I do not think I need to say a great deal about the economic aspects of general practice with which the noble Lord, Lord Taylor, has dealt. The complexities of the pool system, as your Lordships have heard, are quite extra ordinary. It is as though a trade unionist were asked to work overtime on condition that, as a result, he and all his fellow workmen receive less in their basic wage packets every week in return for what they earn by overtime work. The noble Lord said that this was the economics of Alice in Wonderland. In fact, it is in Alice in Wonderland alone that I have been able to find a parallel. Those of your Lordships who were brought up to read the right books will recall that Alice, when she found the cake, said If I eat one of these cakes it's sure to make some change in my size; and as it can't possibly make me larger, it must make me smaller, I suppose". This is precisely the effect of the general practitioner's extra work beyond his routine examination of patients. Much the same applies with the expenses system of general practice. If the general practitioner spends more than the average in the way of expenses in the service of his patients, it comes out of his own pocket; if he spends less than the average he makes a profit on it. That, my Lords, is the economics of Alice Through the Looking Glass. Such a system is really indefensible, and I am surprised that general practitioners have put up with it so long.

It is worth while noting that to some extent it is one of the by-products of national planning, because all the consequences of planning on the national scale cannot be seen in advance. If practices had remained the property of general practitioners there would have been economic inducements for them to improve their premises and their ancillary services, because it would have improved the capital value of their practices. The present system offers no such inducement and may even act as a deterrent; and, as the State has not taken the initiative in the matter, we have fallen between the two stools of individual enterprise and national planning.

There is another economic anomaly, to which again the noble Lord has drawn attention—that is, that as doctors grow older in general practice, they tend to earn less. General practice, as we know, is a strenuous life, and it is not unnatural that the older man and woman should feel that they have done a fair share of the more arduous part of it. But a reduction in their lists must mean a reduction in their earnings, which is contrary to the established practice in many other walks of life, and it is surely quite paradoxical to penalise in this way seniority and experience. I do not propose to discuss in detail all the possible ways of dealing with it, but I am sure that it ought to be dealt with.

I hope that my general practitioner colleagues have not finally ruled out the possibility of some system of distinction awards. In the consultant field, this system, after a number of years' experience, was endorsed by the Royal Colleges and the Joint Consultants' Committee before the Pilkington Royal Commission and accepted by the Royal Commission. Though the system, as it is applied to consultants, would need to be modified, if the principle were accepted for general practice and—this is important—if an adequate amount of their remuneration was set aside for the purpose, I believe that it could be made to work and that it could be the system in general practice by which special merit, possibly combined with seniority, could be recognised. The award system in consultant practice has been strongly supported on the ground that it adds to the financial attractions of this branch of medicine, and it is important that we should not lose sight of the need to make general practice attractive financially.

The noble Lord mentioned the need for change in medical education to cope with changes in medicine, and I believe that it is very important for the future of general practice that medical educationalists should recognise that this is a specialty in its own right. This is now only beginning to be recognised. Our medical education is still fundamentally based on the idea that, when a doctor is registered, he is equipped to go into general practice, but needs several years' more training if he wants to become a specialist.

When it is fully recognised that a medical graduate needs at least two years' post-registration training to fit into general practice, not only will it be a great advantage to those entering general practice, but it will enable us to devote under-graduate medical training to a basic education, upon which training for any of the specialties, including general practice, can be built after qualification. Nothing, I believe, would do more for general practice than to give a longer training to those going into it. Such doctors would find their work more interesting and it would make general practice more attractive. But this presupposes two things. At present, general practice appeals to young doctors because it is the field in which they can become more quickly established. If they are to spend more time in their training, and especially if part of that time were spent in hospitals, every hospital would need adequate married quarters for residents. Secondly, longer training is of little use unless the doctor's working conditions enable him to do his best work.

But we now realise that for all doctors, consultants and general practitioners alike, education is a continuing process, which should go on throughout professional life, and this is vital for the welfare of general practice. A beginning has been made in organising such continuing education in the regions, but we have barely scratched the surface of this field of work. We are still far from knowing what should be done and who should do it. But it is not enough, I am sure, to say that general practice is a form of specialty. We must go on to ask what the work of the future general practitioner ought to be. It is significant that some responsible critics say that he has no future and that hospitals and polyclinics attached to them should provide all the medical service that people need, as is the case in some other countries. It is said, moreover, that on the whole people would be satisfied with this. This is a challenge which I think the general practitioners need to take seriously.

The real challenge to general practice is whether we should maintain the principle that it is a good thing that every person should have a personal doctor, who is primarily responsible for all aspects of his medical welfare and remains so whatever specialised help he needs to call in. In spite of some plausible arguments to the contrary, I believe that that is right, and that it is a good thing not only for the patient, but I would say also for the hospitals and clinics, that there should be a doctor with a personal and continuing responsibility for the patient. But I believe that, in one way or another, the general practitioner in future will have to have a much closer relationship with the hospital, in particular with his local hospital, than he has had in the past in most cases. For, as medicine becomes more scientific and medical treatment more complex, he inevitably has to take a bigger share in continuing treatment begun in hospital after the patient returns home.

However, to accept the principle that every individual should have his own personal doctor does not by any means imply that the present pattern of general practice is the best possible one. I believe that a considerable number of general practitioners, especially among the younger ones, believe that there is a good deal to be said for some form of salaried service based on health centres closely linked with hospitals. I am not advocating this, but I mention it to show that we ought to take nothing for granted when looking at the future of general practice. I hope, therefore, that while the urgent needs of general practice, financial and otherwise, are being urgently attended to, we shall not then assume that all will be well for the next ten years, and I hope that Her Majesty's Government will be prepared to set up a small committee of inquiry to look at the way in which medicine is moving and to consider, and through their Report give not only the medical profession but the whole country an opportunity of considering, the alternatives that lie before us.

4.27 p.m.

LORD AMULREE

My Lords, I do not want to follow my noble colleagues, Lord Taylor and Lord Brain, in talking about the financial side of this Motion. Both have expressed themselves firmly and clearly about that, and all I would say is that there is not one thing they said with which I do not entirely agree. Therefore I do not think that I need go into that aspect any further at the moment. I should like to confine the few remarks I am going to make to the Ten-Year Plan that the noble Lord, Lord Taylor, has put down in the Motion now before us. I quite agree that a Ten-Year Plan for general practice is much more difficult than a Ten-Year Plan for the hospitals or welfare services, because these last two consist a great deal in planning what premises are going to be built, whereas in general practice we are dealing with people and not with buildings.

I agree with both noble Lords that there is a need for more doctors at the present time, because we have a population which is growing in number. At the same time there is a large and growing number of elderly people in the population and, as your Lordships will realise, they require a good deal more care from their doctors than younger people do. One matter I find rather difficult to understand about the number of doctors and medical students is this. Although I have seen reports that there has been a slight increase in the number of medical students accepted each year for training, when we take the total number of medical students in training this total appears to have fallen. I do not know what happens to all those accepted, and I think that this is a point that requires inquiring into.

LORD TAYLOR

My Lords, I think that I explained the reason. It is because the intake into medical schools was cut for five or six years and therefore the total number going through would not increase just because the amount of the intake is raised.

LORD AMULREE

I thank the noble Lord for that clear explanation of what has gone wrong. One of the points upon which most people are agreed is that the lists of general practitioners are now far too large. The average list is, I think, about 2,500, but the maximum can be 1,000 more. I do not think it is possible for doctors to do satisfactory work if they have such a large number of people to take care of. There I agree with the noble Lord, Lord Taylor, that lists should be cut down to 2,000 rather than be at a higher figure than that. One is told many tales of the way doctors get work and the manner in which they are almost forced—I do not mean to neglect their patients, but they cannot take so much interest in them as they should because they have not the time.

A report was published the other day by the Nuffield Provincial Hospital Trust in which they refer to what they call the submerged iceberg of disease in general practice, which means that a great many people are suffering from diagnosable and treatable diseases who do not go to their doctors. If they did go to their doctors, we should require more doctors to cope with the extra work that these extra people would bring along. There is nothing particularly new in this idea. People suffer from remediable complaints which should be put right. That was shown by the work of the Pioneer Health Centre at Peckham some years before the war; but this has since closed down. The point is that, supposing the size of the lists of patients were to be cut down, then the doctors would need to be paid more, because they have to keep up a certain standard of living which I am sure nobody wants to reduce. That, in turn, means that the taxpayer will need to submit to more money being paid for doctors. If this is not done the alternative will be that they will get what might be called a second-best service—I do not mean by that a second-rate service, but as I say, a second-best service.

The feeling at the moment—and I agree with it—is that more work should be found for general practitioners in hospitals; that they should be given posts as clinical assistants, and so on. This is a very good thing. But where are the doctors to come from to fill these posts? If you make more work for the general practitioner than he can do now, it will not be easy for him to give up some of his non-existent spare time to work in hospitals. This, again, comes back to the shortage of doctors. I saw a statement—admittedly it was in the daily Press, but it purported to come from the Ministry of Health—saying that there was a considerable shortage of consultants and they would want about 500 more during the next five years to make up the number: which means, again, that more doctors would be required in order to fill these post at the same time.

About a fortnight or so ago your Lordships were debating the Robbins Report on Higher Education, and both my noble friend Lord Brain and I referred to the need for new medical schools. I would mention again, as the noble Lord, Lord Taylor, said, that we need at least four new medical schools and that these should be started now, because even if we start to-day or tomorrow it will be seven or eight years before the doctors trained in them will be able to come out and do medical work.

There are one or two places which seem to me particularly designed for a medical school. One is Durham, which has just been separated from the University of Newcastle, and so we have the University of Durham with no medical school attached to it. I think the Ministry of Health propose to build a new 1,000-bed district general hospital near the city of Durham. The population served by Durham and Newcastle is in the neighbourhood of 2,900,000 or it may be a little more, and that seems to me to be a large enough population to serve two medical schools in the North-East of England. As has been pointed out, not only to me but by several other noble Lords, medical students, when they become doctors, tend to settle near the place where they qualified, and this would go some way towards solving the medical shortage in the North-East. Supposing something is done about new medical schools, I trust that that part of the country particularly will be taken care of.

There is another point which is always being brought up, and one hesitates to mention it again. One is always told how difficult it is that such a large number of junior posts in hospitals are staffed by doctors from foreign countries. I think I have said before to your Lordships that this is not fundamentally a bad thing; it is a good thing that these doctors should come here and be trained, because I think our training is second to none. Further, supposing these posts were taken by doctors trained in Great Britain, at present we should find ourselves in a dilemma, because when they finished their junior postsand the posts are not posts for a permanent career—there would be nowhere to put them. A certain number might be absorbed by an increase in the number of general practitioners; but, even so, there are at present some 4,000 of these people coming over and I think one should encourage foreign doctors to come. One should, however, be prepared for their numbers to fall off, and one does want more British doctors to fill some of the places, but not all the places, filled by foreign doctors at the present time.

Another point about which I think the Ministry should be able to give some real information is this. It is not a highly important matter, but a report appeared some years ago which stated that about one-third of doctors qualifying in this country emigrated permanently to foreign countries. That has been shown not to be right. The medical school at Birmingham held a long inquiry which showed that the figure, over 10 years, was under 10 per cent., and that was confirmed by an inquiry made at the medical school where I work, where we thought the number was about 6 or 7 per cent. But it seems unfortunate that we cannot come to some more definite figure about the number of doctors who go abroad. It is not an easy figure to compute. Various countries have certain regulations which make it difficult to appreciate what is occurring.

For example, suppose a young doctor wants to go to the United States and he gets a post in a hospital for one or two years—and a large number of our young men do go there for one or two years—quite often the hospital they want to work at makes them take out an immigrant's visa rather than a tourist visa, so that they appear among the list of immigrants, whereas they are going there for only a short time. It is the same in regard to New Zealand, where it was said that about one-quarter of the doctors going on the register in the last ten years came from Britain: this might well be explained by the fact that the New Zealand Government or medical profession, for various technical reasons, put all doctors who visit the country to give lectures or do a course on the register. This does not give a true picture of the number of doctors who settle there permanently. This is not a point I want to go into in great detail, but it would be an advantage if we could have some official idea of what number of doctors qualifying in Great Britain take permanent jobs in foreign countries.

Then one comes down to the question of what kind of education one can give to the medical student or young doctor who wishes to go into general practice. There has been a certain amount of talk as to whether that should be undergraduate or postgraduate education. It seems that there is not a great claim for a good deal of this education before the young man or woman is qualifies. They have a long and complicated curriculum at the present time. General practitioners total about one-third of the doctors in the country, and it would seem that one would not want to do a great deal of elaborate education of students for that kind of work: about one-third of students from the medical school where I work go into general practice. This may be a low figure compared to other schools. Many hospitals or medical schools now give their students a period towards the end of their time when they can make a choice of what they want to do. At the medical school to which I belong, a number of students are attached to a general practitioner for a month or so during that period. That seems to me a good way of giving them some kind of idea of what general practice can be like.

There are, of course, more complicated schemes. The noble Lord, Lord Taylor, referred to what happened in Edinburgh, where they have a professor of general practice. I am pleased to see that the Professorship is called after a close relative of mine. There the student gets far more of a picture of general practice, and that, I think, is a scheme which might be followed by other universities. I should not have thought that one wanted a very great number of these chairs of general practice, but a few which would not all work in the same way would give the students some idea of what general practice is like. One criticism made of the Edinburgh system—not a very fair one—is that the conditions under which the student works in the university general practices—they have two—will be so much better than the conditions in the general practice into which they go when they are qualified that it gives them a false idea of what general practice will be like.

Then one comes to postgraduate training, and here T agree with the noble Lord, Lord Brain, that general practice should be taken just as much as a speciality as the others, and one needs to work out some proper scheme for training in general practice for one year, shall we say, when the student has done his pre-registration appointments. At present various schemes are being worked in the country. I do not want to go into any detail, but there is the general trainee scheme which was put forward by the Ministry. There is also the scheme run by the British Postgraduate Medical Federation, financed, I believe, by the Nuffield Trust. Those are two schemes whereby the young man who wishes to go into general practice can get some training and experience. One of the difficulties of the first scheme is that some general practitioners tend to regard the trainee as an unpaid assistant, which, of course, was not the intention of the scheme, and which has made it a trifle unpopular.

Before I sit down I should like to refer to the new form which general practice appears to be taking. One knows a good deal about the importance of general practices with health visitors, district nurses and midwives attached to them and where they join in established group practice. The Report to which I referred was by the Nuffield Provincial Hospitals Trust, which did a survey of general practitioners in Lancashire which came out about a fortnight ago. It showed one rather curious thing: that a large number of doctors did not want to have nurses or health visitors attached to their practice. The same thing occurs in other parts of the country, too. That is no reason at all why, if a doctor wants, by working with a local authority, to get a health visitor attached to his practice, it should not be done. The medical profession is a comparatively conservative profession—if the noble Lord, Lord Taylor, will pardon my use of the word "conservative" in a general way. If the thing is going to be good they will come round to it in time and will settle down.

LORD TAYLOR

My Lords, before the noble Lord leaves that point, may I say that exactly the same thing as he is describing has happened in connection with the appointment schemes? Many general practitioners have said that they could not possibly work an appointments scheme. They have been persuaded to try, and to their surprise they have found that it has worked. The same thing happened when they tried to work with a health visitor. They said it could not be done, and then they have found it is very acceptable.

LORD AMULREE

That shows it is worth while persevering with the schemes, because if they are fundamentally good, people will come round to them.

I have one other remark I should like to make. There is a great deal more the general practitioners can do by working in close consultation with local authorities. They can make more use of the local authority clinics. One might possibly have a clinic for people growing old, where they can go and talk to the doctor there about their problems, which they would not do with the family doctor in his consulting room because they would have to wait too long. There are various things like that which might come in due course.

There are two points I should like to make in conclusion. Like the noble Lord, Lord Taylor, I think the present system of paying general practitioners needs to be revised—with that I agree—and also that we want considerably more doctors in the country. I cannot say what number, but I trust the Minister of Health will be able to give us some rough idea of the number we require.

4.48 p.m.

Loan COHEN OF BIRKENHEAD

My Lords, I confess that when I saw that the noble Lord, Lord Taylor, had put down this Motion for to-day I was a little disturbed, because I knew of the imminence of the meeting of the Review Body and the representatives of the profession. But I should like to say immediately that all my doubts have been dispelled, and all my anxieties assuaged, by the statesmanlike speech which the noble Lord made, since he confined himself to the principles and methods of bettering general practice, particularly remuneration, rather than trying to deal with the actual amounts or the range of practice remuneration.

I should like to congratulate him on the clarity of his exposition of the distribution of the "pool". Despite all its details, it was a most delightfully clear, concise exposition, and I feel that many practitioners should have been here to hear it. They would have been less confused about the so-called unfathomable complexities of the pool scheme. I would also congratulate the noble Lord on many other points in his speech, which I hope I shall deal with later, and thank him for the flattering remarks about the earlier Report on General Practice. I can assure your Lordships that the subsequent Report does not in any way irk me, because it has repeated many of the recommendations of the earlier Committee. I always bear in mind the observation of a very distinguished French author, who said that "everything has been said before, but since nobody ever remembers, it can all be said again". Perhaps your Lord-ships will therefore forgive me if I occasionally repeat one or two observations which have been made in earlier speeches.

In general, I support the thesis which the noble Lord, Lord Taylor, has propounded in relation to remuneration. I think, with him, that the capitation fee must remain the basis of remuneration, and that we are not yet sufficiently advanced to accept as a general principle a salaried general practitioner service; nor payment by sessions, nor, indeed, by items of service—a method which could, of course, lead to considerable abuse. On the other hand, we must always remember the major principle he enunciated: that remuneration must reflect both the quality and quantity of service which is given by the practitioner; and also (and this is of prime importance) that it must be sufficiently an incentive to ensure that the general practitioner group of our profession is not filled with, and not simply the refuge of, failed specialists. I think this point was brought out most clearly in the initial Spens Report, the Report of the Inter-Departmental Committee on Remuneration of General Practitioners, in 1946. Perhaps I may read a brief extract: General practice is the foundation on which all else is built. If its recruitment is not maintained—alike in quantity and quality—both as against other professions and as against other branches of the medical profession, no other health service, specialist or hospital service, however excellent, can make good the loss or even play successfully the part it should play. I regard that principle as of prime importance, yet over the last dozen years or so it seems sometimes to have been forgotten.

I am the first to decry any comparisons of the general practitioner's remuneration with that of the consultant or the specialist. It seems to me a fruitless exercise, and one that commonly leads to harmful recrimination. On the other hand, I emphasise that the pay of the general practitioner should reflect his service, and it should be such that it should attract many good men to the discipline of general practice. The noble Lord, Lord Taylor, has dealt with practically all the shortcomings of the pool system. I will say no more than to stress that unless a solution is found, particularly to the expense problem, at this stage, we shall still be putting a premium on bad practice; we shall be allowing the man whose practice has stagnated, who does not provide proper facilities, either for the comfort or for the service of his patients, to benefit at the expense of the good practitioner.

I will not say more about the merit awards which were mentioned, except to recall that in a previous debate, on April 27, 1960, I discussed the question of merit awards and found most of the criteria which had been proposed for them neither valid nor proper. But I did say that, despite the unlikelihood of arriving at a widely acceptable scheme based on any criteria other than age or length of experience, I believed that this proposal should be re-examined, but with a much larger amount in mind. Your Lordships will recall that the Royal Commission advised half-a-million pounds, which is a quite niggardly amount. It meant that only one in twenty-three or so of the practitioners would receive any additional merit award, as compared with one in three, or thereabouts, of the consultants or specialists. I also feel (because many of my general practitioner friends have emphasised this) that there should be some way of letting them know, before two years have elapsed, what their remuneration for a given period will be.

I recall very well, as I am sure will other Members of your Lordships' House, the battle over the goodwill of practices. I believe that it was solved correctly. I believe that, although there are advantages in the retention of goodwill, there are also disadvantages, particularly the fact that it so often bars a good man, because he has not the appropriate financial resources, from entering general practice. And if a man borrows the money it remains as a mill- stone around his neck for 20 or 30 years. On balance, there is no doubt that the right action was taken. I do not wish to say more on this aspect, except that I hope that, whatever scheme is evolved, it will not be so complex that the general practitioners who should understand it, will not be able to do so.

My Lords, I should like next to say a word about the needs in general practice, and I shall try to particularise this in regard to certain figures which must be borne in mind. I imagine that we shall all now agree that general practice is quite indispensable in the medical service of the nation. Sir George Godber, Chief Medical Officer of the Ministry of Health, has recently reiterated this in a masterly lecture which he gave to King's College. He said that he did not believe that we shall ever replace general practice in this country by a congeries of specialists because they would not play the part (which I hope to discuss in a moment or two) that the general practitioner must play.

Let me say also that I agree wholly with the noble Lord, Lord Brain, that general practice is a special technique. In fact, in 1950, there was published another Report (the noble Lord, Lord Taylor, did not refer to it) on General Practice and the Training of the General Practitioner, which insisted that general practice demanded a special training. I do not mind whether you call the general practitioner a specialist, or what you call him—I am not interested in the semantic niceties of the word "specialist"; there are too many people these days who remind me of Cowper's lines in "The Task": Those who, to the fascination of the name, Surrender judgment, hoodwinked. I might add, indeed, that there are many distinguished members of our profession who took umbrage at the time at the suggestion that a general practitioner is a specialist and has to pursue a special form of study. I shall deal with this later.

I want to say a word or two now about numbers. It is no use saying that we must have more doctors; that we must have more general practitioners; that we must have more specialists. We must realise some of the implications of such statements in regard to numbers. The general practitioners, as one knows, are more than 50 per cent. of the total medical force of this country at the present time serving in the National Health Service, and they deal with 90 per cent. of illness without specialist help. There is no doubt that in the last year or two there have been a few more students entering universities, and I like to believe that that might have been the result of the debate in which the noble Lord, Lord Taylor, and I took part a little over two years ago. I think it was the noble Lord, Lord Taylor, who, in the debate on the Robbins Report on December 11 (unfortunately illness prevented my being present on the second day, otherwise I might have answered his questions then), asked what this meant in terms of figures and whether somebody would provide detailed figures.

We have already heard that the increase in population in the next 20 years in the United Kingdom will be eight million—from 53.5 million to 61.5 million. I think it right to mention that the increase in those between the ages 0 to 4 will be about 820,000 and the increase in those over the age of 65 will be 2 million, which means in that age range an increase of 32 per cent. Fortunately this does not make very much difference, despite the fact that the persons in those age groups require approximately double the amount of general practitioner attention of any other age groups. This really means that to cover the population in 1981 with the same type of service which we are now giving will demand another 14 per cent. of doctors. This, of course, is only one parameter; it is not very significant, either. I agree with the noble Lord, Lord Taylor, that the slight increase in admissions to the general practitioner service over the number of withdrawals is not of itself impressive for many reasons.

Robbins, your Lordships may recall, suggested (in figures which are difficult to interpret, but I hope I have been able through a little research to ascertain them accurately) that although students of medical subjects—and it will be remembered that in the Robbins Report medical subjects included not only medical but also dental and veterinary students—form 13 per cent. of the present-day population of universities; in 1981 they would form only 6 per cent.; but of course since the population of universities is to be almost trebled in that period of time it is clear that there would be a significant increase in the number of medical students. And, if the noble Lord, Lord Taylor, will take it from me (I am quite prepared to explain the details of this calculation), there are at present slightly fewer medical undergraduates than the number he mentioned, because he included some postgraduates also. The Returns from Universities and University Colleges, 1961–62, published in September last show 11,138 medical undergraduates in that year. If we take the Robbins calculations there will be in 1981 14,200 medical undergraduates; that is a 27 per cent. increase, which is greater than the population increase.

Therefore, if one were thinking solely in terms of providing the population in the future with exactly the same type of service as exists at the moment, that number might appear satisfactory. But clearly it is not satisfactory. We know perfectly well that larger numbers of doctors will be needed for hospital purposes. Also, as a result of the Working Party, it is known that thousands of new consultants must be appointed. Moreover, the noble Lord has referred on many occasions to the number of students born abroad, well over 3,000, who occupy junior hospital posts in this country; and in my view these are unlikely to continue in such numbers, because the universities of India and Pakistan, the universities of developing countries, are now building medical schools, arid the number of medical schools, and therefore the number of hospitals for which they will have to provide staff, is increasing enormously. It is only some twelve years ago that in India there were about twenty or twenty-five medical schools, and to-day within a very short period there are nearly eighty, and that means that hospitals are increasing in size and will want help.

If I might interpose for one moment, the noble Lord, Lord Amulree, was anxious about figures for emigration. I think I can promise that within a comparatively short time there will he some figures, I hope more validly based than previously. These are derived from established records in which the fate of the registered medical practitioner can be determined; and this piece of work—again, as so many investigations, supported by a Nuffield Trust grant—I hope will be published within the next few months or so.

If we reduce the list to 3,000 and we have a pro rata change in the present lists, it means the number of general practitioners must increase to 25,670 on the basis of the present 22,000, an increase of 3,670. Here again I think it is clearly desirable to give the doctors even more time, if possible. I think also, however, that we have to remember that 3,500 may not be too much for many practitioners, and some are very good practitioners. There are many factors which play a part in determining the numbers on a list. Some of them obviously cannot be controlled, like the geography of practice and density of population, age distribution of patients, doctor's own age and his physical condition, the availability of hospital and other facilities. But what often determines the list is the practitioner's own skill, his industry, his keenness. After all, there are barristers who work twenty hours a day and seem to thrive on it. We do not want doctors to do that, but there are some doctors who could reasonably have a list of 3,500—and with ancillary help could do this work well. We must remember that a list of 3,500 does not mean that a doctor sees 3,500 patients each year. The fact is that a Social Survey—a Social Survey which was referred to in a Report which the noble Lord, Lord Taylor, will remember—shows that the doctor sees 2,300 if he has a list of 3,500.

LORD TAYLOR

Yes, but of those 2,300 patients whom he sees he sees each on an average about 4.8 times or rather more, so that the total number of doctor-patient contacts per year per 1,000 patients seen is something like 5,000.

LORD COHEN OF BIRKENHEAD

No, many more. The number is well over 17,000. But that is not the point. The point I am making is simply that if you have a list of 3,500 you do in fact see only 2,300 in the course of a year; and you see them all notionally, it is true, between 4.8 and 5.3 times, depending on the results of which particular set of investigations you are prepared to accept. But this is the fact. I It is not 3,500, although that is the num- ber on your list; it is 2,300, which is about 65 per cent. of those you have on your actual visiting list.

I think that, however, is usually too many. I think also we must bear in mind that at least three-quarters of the practitioners in this country have less than 3,000 patients on their lists. There is only one-quarter who have more than 3,000, and it is only in the very densely populated areas that even half the practitioners have more than 3,000. I think there are only four areas in which half the practitioners have more than 3,500—Barnsley, West Bromwich, Wolver-hampton and, I am interested to note, St. Helens. I do not propose to discuss this, because frankly I doubt if we should get much further but I think it ought to be brought out in relation to the 3,500.

I think the need for more doctors has been established. On the other hand, it is extremely difficult to be precise about the needs, the relative needs in various branches of the profession. In Lord Taylor's time—and it is not very long; it is not much less than mine—there has been a virtual disappearance of infectious diseases there has been a virtual disappearance of tuberculosis, and so of many of the chest services. And it may well be if there were discovered, for example, a method of dealing with cancer the whole of our radiotherapy services would disappear overnight. This is what makes immense the difficulty of forecasting.

But I am sure that Lord Taylor is right when he says that we must have more doctors. How are we going to get them? He suggests—and this I have myself urged—that clearly there must be some new medical schools. But we cannot expect that we shall have graduates coming from these schools within a period of ten years. Can we accelerate the production of medical graduates? The present schools cannot expand in their pre-clinical year, in which there is the bottleneck in anatomy, physiology, biochemistry and pharmacology, although they could take many more students in their clinical years. Unfortunately, most of the older provincial universities are built on sites which are already overcrowded. But is there not a possibility of the newer universities giving a Bachelor of Science degree in human biology, which would include anatomy, physiology, psychology and biochemistry, dealt with perhaps more generally, but still of tremendous value to potential medical students, which would exempt them from the pre-clinical examination and would, I believe, also make a contribution to the work of new universities? It would bring in a human element which, without a medical school, is often absent.

I think there is one other way—namely, by reducing the undergraduate curriculum from its present five years without the intern year, to four years. I think it is a little premature to ask for that, although I believe that that might well come if what I propose to say in a moment is accepted. I am sure that in the presence of the noble Baroness, Lady Summerskill, I had better not say that if we did not admit women to our medical schools we could, within a quite short time, increase by about 30 per cent. the output of male medical graduates who would remain in medicine. But this, I agree, would be a retrograde step. However, I hope that some means will be found whereby women doctors can be given a place in the medical service, if only part-time, when they are married, when they have family responsibilities, to make a contribution to that service.

What about the training of the general practitioner, which has been mentioned? I regret that the noble Lord, Lord Brain, has gone, because I wanted to criticise something which he said. He said that medical education had not, within a decade or so, advanced. But this is quite inaccurate. It is true that in 1858, when the first Medical Act was passed, a medical student when he was qualified was supposed to be capable of independent medical practice; therefore, he had to have a sufficient knowledge of the practice of medicine, surgery and midwifery. Since that time, when any new feature of knowledge has appeared, it has been accreted on to the curriculum and nothing has been subtracted. The result is that, until some ten years ago, the curriculum was virtually what Cromwell would have said of the laws of England— A tortuous and ungodly jumble. But in 1957, after many years of careful work, the General Medical Council, which is the body given the statutory responsibility of determining standards of medical education, and also of advising generally on the curricula, made a complete and revolutionary change in its outlook, and its recommendations have been published and are available for anyone to read. These recommendations of 1957, for the first time, made it clear that an undergraduate education was intended to establish for a student the foundations of medicine. It was to give him knowledge of the basic sciences; it was to give him an understanding of the scope and the potentialities of all branches of medicine, including general practice, and also of the obligations and the responsibilities of a medical practitioner; it was to introduce him to the preventive medicine services, and to tell him what local authorities might provide, and so forth.

That is why we at the General Medical Council have resisted in large measure the view that we should introduce into the undergraduate curriculum more psychiatry, more general practice and the like. What we wanted to do was simply to produce a man who had the basic knowledge, the foundations from which he could build by vocational training at a postgraduate stage. We have, therefore, in recent years introduced into the undergraduate curriculum all the advances in medical science, in physical, chemical and biological sciences, because there is not one of these which does not have its impact on medicine. Any new discovery in physico-chemical and biological sciences is immediately applied to medicine. And we have stressed the need of course for early diagnosis.

It is only right, also, that I should say that the concept of postgraduate training for the practitioner is fully described in the report of the British Medical Association Committee on General Practice and the Training of the General Practitioner, published in 1950. There they advised that there should be a three-year post-graduate training, specially designed to the vocational needs of the general practitioner. I regret to say that little notice has been taken of it; it was rejected by the British Medical Association Representative Body. I believe that there should be this vocational training. I think it might well be for three years. I think that it might try to ensure that the general practitioner is made aware of his continuing responsibility for patients, and how to use to the best advantage all facilities, be they hospital, local health authority, home helps, health visitors, midwives, the ambulance service and the like, and all the voluntary services which are available to him—so that he can give the best service; also, for the first time—because he does not learn this in hospital—that it is the family as a unit to which he owes an obligation, and that it is at preventive medicine and health education, the achieving of positive health, that he must aim.

But, of course, that is not enough. Plato said that education was a lifelong business; and indeed it is. With the accelerating speed of the advance of medical knowledge, it often happens that in five or six years, in some particular division of medicine, the whole of the old theory and practice is outmoded. Therefore, a man must keep up with his knowledge. To this end, the National Health Service hitherto provided certain courses; medical societies, some of them dating from the 18th century, played a great part. Then there was a man's own reading, his contact with hospitals, and so forth. But there was no organised post-graduate training, and it was once again to the Nuffield Provincial Hospitals Trust that we looked with gratitude for the impetus which has come to postgraduate education. Over £300,000 has now been spent by the Trust to help to establish in each hospital region in the country a proper Postgraduate Committee, with a Dean of Postgraduate Studies who will ensure that there is adequate post-graduate education for practitioners. I regret that this was not done fourteen years ago when it was advocated. This gives an opportunity for much experiment. The noble Lord, Lord Amulree, has mentioned one in the Wessex Region, and there are many others. And I am glad to say that the Ministry of Health are now playing a much greater part in fostering and supporting the postgraduate education of general practitioners and others.

By postgraduate education we hope to achieve certain aims. We hope to preserve and increase the practitioner's knowledge and technical competence, and so keep him abreast of contemporary advance and possibly increase his share in research. I should like to pay a tribute to the College of General Practitioners which has undertaken very valuable research, particularly into the value of certain therapeutic measures. Secondly, we want our schemes of postgraduate education to prevent what was in the past one of the greatest defects of medicine—the isolation of the general practitioner from the general stream of medicine, from hospital and preventive services. Only if he is part of the stream can he best serve his patients. Finally, we want to provide the stimulus without which any professional work loses its vital spark and sinks to an empirical and uninspired routine. This, we as doctors, should never allow; for we must ever remember that we have been entrusted with a task whose place in the scheme of things was implied by Cicero, when he wrote: Men never come closer to the gods than in giving health to men.

5.22 p.m.

VISCOUNT WAVERLEY

My Lords, I, too, am most grateful to my noble friend Lord Taylor for initiating this debate. Few have taken so much interest in the problems of general practice as he has, and few are better qualified to recommend solutions to these problems. Of all the debates on medical subjects since I became a Member of your Lordships' House I cannot think that any has been more important than to-day's, save that on the Ten-Year Plan—to which, of course, to-day's debate is complementary. I feel that on the extent to which Her Majesty's Government pay regard to the various points that have been raised to-day may well depend, to a large extent, the future of medical practice as we know it in this country.

General practice is a particularly British conception. Anybody who has had experience abroad of other methods of doctoring will, I am sure, agree that anything that nurtures and fosters all that is best in our general practice system should be done. Before this debate I consulted with a number of my more go-ahead general practitioner friends—young, middling and older; in urban, rural and semi-rural practices; single-handed or in partnership, large and small. I think it fair to say that no absolutely firm conclusion emerged on any point—due not so much to professional disarray as to the fact that no two practice problems are quite the same, and also that these people were strong individualists. My remarks to-day are therefore but a distillate of these consultations and of my own views, for what those are worth. I certainly do not claim to speak on behalf of any other individual doctor.

Your Lordships have already heard from noble Lords who understand more clearly than I the curious and anomalous workings of the central pool, so I do not propose to say anything more about that; nor indeed, anything very much about remuneration. However, I agree with my noble friends Lord Taylor and Lord Cohen of Birkenhead that a capitation fee system is the best. I just wonder, though, whether there might not be some "loading" of those patients on the doctor's lists who are over the age of 65 or under the age of five. Such a disproportionate amount of work is vested in these age groups.

In regard to the present per capita system of payment there is, however, an aspect to which I wish to draw attention—it has, in a sense, been mentioned already. It is an aspect which, I feel sure, is responsible for a great sense of frustration. At the present time per capita payment is weighted in favour of the not good doctor against the good. The not good will have large lists, poor premises and negligible ancillary help; whereas the good doctor, in most cases, will have voluntarily restricted his list, and provided good premises—to a significant extent out of his own pocket. And from the same source he will also have provided the necessary ancillary help, such as secretaries and, in many cases, dispensers. As a result, his net income will be considerably lower than that of his colleague. I think it likely that there is no learned profession in the world where the disparity between effort and reward may be so great as in the profession of general practice in this country.

Two problems are posed here. First, the question of devising a better method of payment of practice expenses: expenses now to an appreciable extent met out of the doctor's own pocket. Most family doctors to whom I have spoken have said that they would prefer this matter to be taken out of the general income structure and paid for by direct grant, either by executive councils or in some other way. They recognise that this change would necessarily mean a degree of control and supervision—even to an extent of standardisation of premises and equipment. But they would accept this because it would give them a means of providing better care for their patients.

The second problem posed is whether some system of differential payment, so that the best receive the greatest reward, is desirable; and, if it is desirable, whether it is practicable. I agree with other noble Lords that the principle is desirable; I have not the least doubt of this. Its practicability is another matter. I should not, however, have thought it beyond the wit of man to devise some method by which merit is rewarded. I agree with my noble friend Lord Cohen of Birkenhead, that it is quite clear that no possible method of discrimination could act in any way equitably unless a very much larger sum of money than that proposed was provided for the purpose of differential payment. To choose one per cent. or so of doctors by any conceivable method of selection would be quite impossible. To choose, say, 10 per cent. would not, perhaps, afford so much difficulty. Reward simply for seniority in general practice does not commend itself to me, but it is favourably thought of by a number of my general practitioner friends, and not only those who are themselves most senior. The notion should, therefore, certainly be kept in mind. I most earnestly hope, though, that some method will be found for rewarding good work and, by implication, penalising bad.

My Lords, in order to attract into the general practice of the future the sort of person on whom a satisfactory, or more than satisfactory, service depends, it is indispensably necessary to make the general practitioner's work as intellectually satisfying as possible. There seems little doubt that the status of general practice has fallen. Of course the relative status of most professional men has fallen as the public has become better educated, better informed and, in many respects, I think, more demanding. But I believe that the status of the general practitioner has perhaps fallen proportionately more.

I suggest that a most important factor in this status decline—if it has indeed occurred—has been the tendency to separate off the general practitioner service from the hospital service. The public read in the newspapers, hear on the radio of and see on the television what they often rightly regard as marvels of scientific medical expertise being practised within the hospital service. They know that their family doctor, their general practitioner, is largely excluded from that service, and are all too liable to regard him simply as a signpost to that service. They are all too often quite imperfectly informed of his highly diversified skills, although they usually, I am pleased to say, appreciate his dedication, kindliness and his tremendous hours of work. It is to me paramount that those doctors who wish it should have access to the hospital service and in a variety of ways, if those widely versed in modern diagnostic and therapeutic skills are to live intellectually satisfying lives in their chosen branch of the profession.

As I have the honour to work in the hospital service, it is this aspect of the Gillie Report which particularly interests me. I should like to consider some of the Reports recommendations, but in an arbitrary order, so that I can leave till the end the one that I find most difficult. First, there is the decline in the domiciliary consultation in the sense of its being a true consultation. Except in exceptional emergency, I will not do them unless they are true consultations, but I know that they are increasingly so done. I feel sure that the explanation for this decline is largely a question of lack of time. In my speciality, general medicine, a consultation usually takes three-quarters of an hour, with history, examination, and discussion with the general practitioner and then with the relatives. The general practitioner is so pushed for time that he may feel that he cannot spare it. This is highly regrettable, because these consultations are of immense value—apart from anything else—educationally, for the general practitioner and the consultant. I suppose, too, there may be some vexation that in that three-quarters of an hour the consultant earns four times the annual capitation fee for that patient. There can be no sort of doubt that access to open departments of pathology and radiology spare out-patient departments, often save patients long and anxious waits before they can get appointments in out-patient departments, and add enormously to the interest of the general practitioner's work.

I now refer to hospital attachments by general practitioners, which in the first instance should, in my view, be to out-patient departments. The generality of young doctors whom I have had a chance of consulting believe this to be one of the important ways in which the hospital service can help the general practitioner service. These were all young men who had finished their preregistration year of hospital work and in a number of cases had also done one or more further years of hospital jobs. Almost all of these arrive in general practice because they wish to be general practitioners, and the whole Health Service should be anxious that the special skills which they have acquired during their post-graduate years should be maintained. We in the hospital service by providing the vacancies, and the Minister the money, must make it possible for them to maintain this interest.

There are, of course, practical difficulties. These young men come into the practice as junior partners, and are expected to be fully employed about their practice activities. But these are the very people that the hospital service needs. The moment for them to take up an appointment at a district general hospital is the moment of their arrival in practice in the neighbourhood. Such a hospital appointment should be a career, permanent until the doctor wishes to terminate it. It is only thus that the special skills that they have learnt as undergraduates and during their immediate postgraduate period can be retained and then maintained during the predictably rapid increase in all branches of medical knowledge. Means must be found both for senior partners to bring in an aspiring junior and for that junior to be able to requite all the money and time and effort that has gone into his training.

The recommendation of the Gillie Committee that there should be medical centres at district general hospitals for formal and informal meetings of gen- eral practitioners for exchange of views, for consultation with a member of the hospital staff who has been appointed as clinical tutor and where library facilities are also available, deserves the strongest support. Of course, these centres already exist in many hospitals. We in Reading have a very good library and a flourishing medical society; and, for that matter, a flourishing clinical tutor. Their value cannot be exaggerated.

I come now to what I think is a rather more perplexing problem: the question of general practitioner access to hospital beds. I do not doubt the value of that type of hospital bed such as now exists and into which a general practitioner admits his own patients as an extension of domiciliary care, where, for one reason or another, such as home conditions or incapacity of the relations properly to nurse the patient, hospital admission becomes necessary. These should certainly be retained and even, perhaps, increased. A number of outlying hospitals at present working as small, acute medical units will become redundant with the centralisation that will follow the building of the hospitals envisaged in the Ten-Year Plan, and I think that these could well be translated into general practitioner hospitals to serve a more limited but, nevertheless, very important function.

I confess, though, that I am much more doubtful about the question of the provision of general practitioner beds in the new district general hospitals themselves. I know that this recommendation was made by the Platt Working Party and, again, by the Gillie Committee. The Gillie Committee Report, however, refers to administrative, clinical and personality difficulties which might arise, and I thought sounded a cautionary note. I also fear that these difficulties will arise, and in my view to an extent that may well make the project unworkable. In any case, I feel sure that, again to quote the Report, … experience having shown that a driving distance of anything more than at most 30 minutes, and probably less in most cases, is likely to prevent the practitioner from visiting regularly or frequently, on this ground alone their usefulness would be so curtailed as to be nugatory.

My Lords, it now remains for me only to hope that, at the end of this debate, there will be a heartening message that Her Majesty's Government are determined to do everything possible to sustain and strengthen what is best in our general practice tradition, and to see that now and in the future no reasonable steps to improve career prospects and conditions of work are neglected.

5.41 p.m.

LORD AUCKLAND

My Lords, apart from my noble friend the Parliamentary Secretary to the Ministry of Health, I am the only noble Lord taking part in this debate who is not professionally connected with the medical profession. This may have some advantages or it may have some disadvantages, but at least it can be argued that I am not an interested party in that sense of the phrase in the rivalry between the specialist and the general practitioner, if that state of affairs does in fact really exist. From these Benches I know we are all very grateful to the noble Lord, Lord Taylor, for giving us the opportunity of discussing this matter, and for the extremely fair-minded and comprehensive way in which he has dealt with it. This is essentially a human problem, because it affects not only the medical profession itself but the general public, who are served by general practitioners and other medical staff.

I myself have, I suppose, limited qualifications to speak in this debate, in that I serve on two hospital management committees and am therefore confronted with some of these problems as they arise; and I also have a number of friends who are themselves general practitioners. I have taken the trouble to see and contact some of them, and to obtain their points of view. I therefore hope that if technically I get some of my facts a little muddled up I may crave some indulgence. Having been given varying points of view, I should like to put some of them very briefly to your Lordships.

Most general practitioners to whom I have spoken are critical to some degree of the capitation system. They feel that, to some extent at least, it destroys incentive. They feel that in some cases they have particularly difficult jobs to do and perhaps difficult patients to handle, and that some of the remuneration for this is not entirely fair. I myself, not being in the medical profession, cannot possibly judge on this from a professional angle, but I hope that the working party which is due to be formed fairly soon, as I understand it, will give a great deal of consideration to this.

Then, the pool system has been mentioned. I was talking only last night to a great friend of mine who is a general practitioner in a coastal resort in South Devon, a resort which is expanding quite a lot. People retire to this particular part of the world and, naturally, being elderly people, in many cases they need more medical attention than perhaps their younger counterparts. As I understand the pool system, it is that only selected items are in fact reimbursed to the medical practitioner, and that he is sometimes given a raw deal over some of the jobs which he performs. Then, a salaried service has been mentioned to me by one or two of these practitioners. This of course has a number of administrative difficulties and would probably be very difficult to work out according to the grade of doctor, type of area and type of person with which he has to deal.

But, my Lords, the really stinging complaint which has been made to me is one which the noble Lord, Lord Taylor, and others have mentioned—that with regard to the ancillary services. Some general practitioners must have secretarial help, possibly a nurse or other assistant, whom they have to pay out of their own salary. Now this does seem rather wrong. After all, very often a company director can run an expense account for such services. As I understand it, a general practitioner cannot. I certainly do not propose to discuss whether a general practitioner's pay is adequate or not. That is not within the terms of the Motion, and with this Committee sitting it would be quite improper for me or anybody else to pronounce judgment. But I do feel that there is a case for at least some allowance to be given to these people, certainly in certified cases, by way of payment for this help which they require.

LORD TAYLOR

My Lords, will the noble Lord permit me to interrupt him for one moment? They are in fact paid, all of them, but the trouble is that it is an average payment. It is an average payment to all, attached to the capitation fee; and it does not matter whether they have spent the money or not, they still get the average. The unfairness is that the fellow who spends it ends up with less in his pocket than the fellow who gives a worse service and does not spend it.

LORD AUCKLAND

I am extremely grateful to the noble Lord, Lord Taylor, for explaining the system to me and to the House, because I think it is generally recognised that the system as it stands at present does, at least in many cases, operate unfairly.

Then there is the question of rates on a surgery, and I quote again the case of this friend of mine who lives in an area of South Devon, where rates have risen. He has still to maintain his surgery, keep it clean and properly decorated, and properly staffed. I believe the rate burden carries no rate deficiency grant which is paid to the doctor himself. There seems to me to be a good case for items such as this to be looked into.

One or two theories have been put forward as to how the general practitioner could be helped. One suggestion, which I do not particularly support in principle, is that the patient should pay an agreed charge for a first visit. This charge could be made according to the type of treatment needed. If a blood count is to be taken, for example, he would be charged more than for a routine visit; and if it is proved that the case is wholly genuine, part or all of the fee he pays should be refunded. I know that goes against the principle of a free National Health Service and is, therefore, not strictly acceptable on those grounds, but I put it forward to the Government as a suggestion only.

Something has been said about group practice, and I think most people would acknowledge that the more group practices there are the better it will be for both doctors and patients. It means if a doctor falls ill, as he is wont to do just like anybody else, there is somebody in the group practice who can be kept informed of a patient's history and case and to whom he or she can turn. In the particular group practice in South Devon which I have mentioned the three or four doctors each specialise in a certain subject. There is an anaesthetist, a doctor fully experienced in midwifery, and one with considerable surgical experience. This, it seems to me, is the ideal group practice.

I do not think the Government ought to be too heavily attacked on the shortage of doctors, because reading the recent debate in another place on the National Health Service I noted that the Minister of Health said that over the past twelve years the number has increased encouragingly. The real problem is the location of these doctors. In the Midlands and in the North, particularly around Newcastle and similar areas, there is a great shortage of doctors. There may be fairly obvious reasons for this. Perhaps they are not areas where there is residential property which a doctor would like for his family. But it is essential, particularly as many of these areas are becoming development areas and therefore more and more people will be moving to them, that sufficient doctors of good calibre are found.

There are two possible solutions which, as a layman, I might put forward. The first is not a particularly attractive one. It is the possible direction of labour so far as doctors are concerned. There could be some scheme whereby a doctor is at least persuaded that he must go to a particular area. Obviously, there are objections to this scheme, but, again, I put it forward as a possibility. The second suggestion is that some incentive payment, either by way of salary or in expenses for his secretarial or nursing help, could be given as an incentive to the doctor to go to the area where he is very badly needed.

This brings me to the problem of the New Towns. In the New Towns to be built—as in the present New Towns—there will inevitably be a young population, there will be a number of young married people and childbirth will be on the increase. It is essential that there are enough doctors with experience in midwifery to cope with this problem. I was looking at the doctors' register to-day, and I noticed the figures for the New Town of Stevenage, which I happen to know fairly well. There the proportion of doctors to the growing population did not seem to me to be encouragingly high. I would ask my noble friend whether he can consult with his right honourable friend about ways and means of getting sufficient doctors to these areas.

My Lords, there is also the matter of cottage hospitals. In the cottage hospital the general practitioner can come into contact with his patients—something he cannot always do in the general hospital. Many people are very worried about the Government's plan to close some of these cottage hospitals. I know that some may well have to be closed, on financial grounds: but there are many doing excellent work in which general practitioners can keep an eye on their patients rather than send them into hospitals which already have long waiting lists. One has only to read of the situation at Luton and Dunstable Hospital yesterday, to which many of the victims of the accidents in the fog on the M.1 were taken. The resources of the doctors and the nurses there were stretched to the absolute limit. This is just one instance. At the present time too many people are having to be transferred to general hospitals where there is often not enough staff.

Finally, my Lords, may I say that this is a human problem, to which the newspapers have paid some attention. The Evening Standard to-day has a very cogent leader. It says: Doctors in Central London, particularly, are placed in an appalling position by the completely prohibitive price of surgeries". This is not only a problem of Central London, but is one common to many of our cities all over the country. I hope that the Government will regard this problem with the urgency it deserves.

6.0 p.m.

BARONESS SUMMERSKILL

My Lords, having listened to all the contritributions to this debate (and, unfortunately, most of them have been made by doctors) I have only one criticism to make; that is, that I think noble Lords have been a little too detached and a little to academic in their approach to this problem. They have not been seized with a sense of urgency. Last week an unprecedented thing happened in Westminster. Six thousand doctors—a splinter group, I understand, of the B.M.A.—made a protest and demanded that one of their colleagues in the House of Commons should present a Petition to Parliament. I was very struck by the comment made by the leader of this group, when describing his feelings as a general practitioner to the Press. He said, "I am exhausted".

Although the speeches to-day have been interesting, not one noble Lord has made a practical suggestion about what should happen immediately. Surely we should have in our minds the fact that these men and women have conic to the end of their tethers. Have they had patience? My noble friend Lord Taylor, who opened this debate, held up two Reports—the Gillie and the Cohen Reports, one made ten years ago, on the subject which we are discussing to-day, and the other made ten years later, on the identical subject—though I think that the terms of reference of the noble Lord's Committee were wider, because they were allowed to discuss remuneration.

LORD COHEN OF BIRKENHEAD

My Lords, we were not allowed to discuss other than the methods of remuneration. We could not discuss the range, which is what is troubling the practitioners at the moment.

BARONESS SUMMERSKILL

My Lords, I am not prepared to accept that. The practical suggestions that I am going to make are on the methods of remuneration—and I was pleased that the noble Lord, Lord Brain, touched on this matter. And I want to prove to your Lordships that it is the method of remuneration from which many of the doctors' problems stem, including some of the frustration from which they are suffering to-day.

It has been clear from the speeches that have been made that the conditions of service of general practitioners, whether they be good or bad, reflect in some measure the conditions prevailing in other parts of the service. The happy, or near-happy and contented man or woman practitioner is one who is part of a comprehensive team. Yet, despite these two Reports, nothing has been done during the last ten years; and I think it is relevant to point out that, after twelve years of power, the Conservative Government, after the forthcoming General Election, will leave the National Health Service with a grave shortage of doctors (the figures have been given to-day), of nurses (that is not disputed), of midwives (a complete national scandal) and of all classes of auxiliary workers, all of whom comprise the team upon which the general practitioner leans. The team is not there. And the existing staffs in the National Health Service are underpaid, over-worked and dissatisfied; and, as the doctor I have quoted says, exhausted.

During this twelve-year period, the seven Ministers of Health we have had (and I am sorry that the new Minister has not been here this afternoon to listen to this debate) have had one thing in common—an eagerness to convene Committees. Surely to-day we should expect to hear from the noble Lord, Lord Newton, who is to wind up, what decisions have been made and what action should be taken.

I am greatly surprised that the Annis Gillie Committee did not adopt a more imaginative approach. I would sum up the recommendations of the two Committees under two heads—namely, those to increase the doctor's remuneration, and other material benefits, and those designed to introduce him into the hospital service by a side door. There is nothing new about all this. Previously, the general practitioner worked in the hospitals under the name of "clinical assistant". The Cohen Committee rechristened him "medical assistant", but on second thoughts it was decided that this was rather disparaging and the Annis Gillie Committee now suggest" staff physician" and "staff obstetrician". They also suggest that they should improve social relations by establishing medical centres at district hospitals and that these should be developed for informal meetings. I am not denying, of course, that the medical practitioner should be given every opportunity of serving in hospitals, as he has been doing as clinical assistant in the past. I welcome the fact that he should go into out-spatients' departments. There are many hospitals where consultants would be only too delighted if men they have known in their student days would come in to give them a hand.

But all this is not the crux of the situation, and we should be deceiving ourselves if we were to devote our speeches to what the general practitioner might do in hospital. What they want, these exhausted 6,000, is to have their burden eased and to establish the general practitioner as the very hub of a medical service staffed by contented men and women. I want to evoke in your Lordships' minds the picture of the general practitioner. I am the daughter of a general practitioner, and I can still, when I hear a bell ring during the night, hear my father go to the window and put his head out and say, "Yes, I will be there, Mrs. Brown, very shortly". I have also in my family many general practitioners and specialists. I have had the opportunity of observing their work and the contribution they make to society, and also of knowing precisely what their remuneration is.

May I remind your Lordships of the contribution that the general practitioner makes to our society? It is he, in the first instance, who has to diagnose whether a complete stranger, coming from an overcrowded waiting room, has an organic disease or is a malingerer, a hypochondriac, or is suffering from a psychosomatic complaint. He might even have to make his diagnosis in a slum at night by the light of a candle—that is not impossible, even in our time. What is more, his whole livelihood may be at stake, if he errs in his diagnosis. Is it surprising that coronary thrombosis is an occupational disease of the general practitioner and that his expectation of life is fairly low?

It seems to me that the Gillie Committee failed to do any new thinking about the general practitioner's problems. They said, in paragraph 98: A family doctor is responsible for his patients and on call 24 hours a day seven days a week, both by professional obligation and by the terms and conditions of his contract in the National Health Service. This continuous responsibility makes it necessary for him to have a deputy to release him from time to time. "From time to time"—what a masterly understatement! Surely they should have said that the general practitioner must have frequent and regular relief and adequate holidays, secure in the knowledge that a good locum is available. It is astonishing that a Committee of this nature should seek to perpetuate the legend of a doctor being available for 24 hours a day, in these days when the tendency is to plan for a shorter week and more time for leisure for the unskilled worker. Why is a doctor, with heavy responsibilities—and I would say greater responsibilities in the modern world of medicine—supposed to be as alert in the twenty-fourth hour of his day-and-night session as he is in his first?

Now an attempt has been made—and the 6,000 who made their protest the other day know this very well, because most of them are Londoners—to relieve the exhausted general practitioner with the emergency doctor service. This emergency service is doing excellent work, and without complaint from the patients. What does the Gillie Report say about this important supplement to medical practice? It says: The weakness of the system is the deputy's lack of knowledge of the patient. That comment marks the failure of the Committee to identify themselves with the hard-pressed doctor. What if the patient had gone to the hospital in the middle of the night? He would see a deputy doctor. And he would also probably see a deputy during the day if he went to the hospital without an appointment. No criticism is ever levelled at a specialist for using a deputy, but only at the doctor most in need of relie—fnamely, the general practitioner.

So, in the first place, I think it should be made clear that this House recommends that this fine public servant should be given better conditions of work, and in his own family life more rest, more relief, more holidays, and a certainty that a locum shall be available. This, surely, is not being generous. This should have been done years ago. Yet we have sat back, waiting for one committee after another, and even to-night a noble Lord has suggested that we might set up another committee.

Of course, so far as accommodation is concerned, it is accepted that the general practitioner should have good premises and adequate equipment. But these are the material factors in his professional life; and I agree with the noble Lord, Lord Taylor, in describing the kind of equipment and support he might have in running it. But these doctors who are now protesting while supporting the principle of the National Health Service, are protesting because the present structure of the Service does not enable them to concentrate solely on the preventive and curative aspects of medicine and thereby experience that fulfilment which springs from practising a vocation. Some of them made that quite clear last week. This has nothing at all to do with the amount of money which the State might give them to buy premises and subsidise them in any other way.

I agree that the crux of the matter lies primarily in the structure of the system of payment, and for this reason. The noble Lord, Lord Taylor, has suggested means whereby the capitation system (and other noble Lords have supported the capitation system) can be adjusted to meet the demands of the general practitioner. I am of the opinion that the experience of many years of the National Health Service should have taught us that the capitation method of payment is fundamentally wrong, and that tinkering with it cannot change the basic faults. The capitation system is so devised that the doctor who is the most successful headhunter is also the most successful financially. Who can support that proposition? But that is fundamental to the capitation system.

The very essence of a good medical practice is that there shall be a good doctor-patient relationship in which the patient is completely honest with the doctor and the doctor can reciprocate. But honest advice is not always palatable in the medical consulting room to-day. There is a constant demand for the new tablets, pills, powders, creams and mixtures, irrespective of the fact that, as the doctor knows, there has been no adequate clinical trial of these products. We must remember this: that functional illness forms the largest single group of complaints, and, consequently, a request to go to the hospital often comes from the patient to the general practitioner, and a legitimate refusal by the doctor is not well received. This, of course, is partly why two-thirds of the total referals by family doctors to hospital are for information before the doctor undertakes the treatment himself. Time after time in reports they say: "Many of these patients and outpatients should not be here. Many of the beds in our hospitals are filled by people who could have been treated at home." But the pressure that is put on a doctor in the consulting room by the neurotic is so great that after a time he reluctantly makes out a certificate and says: "Go there"; and when the patient arrives at the hospital he has to have a thorough overhaul, which necessitates the time and work of a number of people.

If a doctor tells the absolute truth, that neither tablets nor mixtures are needed, or that in the National Formulary there is a product equally effective but much cheaper than the proprietary drug, he invites unpopularity. The old-established doctor who has treated a patient from childhood may risk this; but he knows that advice without prescription is rarely acceptable, and, if it is repeated, may lead to the patient's transferring to another doctor and taking the whole family with him. The doctor earns about £1 per head for each of his patients, and if the patient has a family of five or six, this can mean that if he is offended he goes home to his wife, or the wife goes home to the husband, and says: "Take these cards to another doctor". That can be the reward for intellectual honesty in medicine to-day in the ordinary consulting room.

News travels very quickly in congested areas. While the well-established doctor may not lose a patient, his reputation for withholding drugs may not attract new patients. The pharmaceutical industry has created an army of pill addicts, and a young doctor may well reach his maximum list of 3,500 by acquiring a reputation for prescribing a wide variety of new drugs. Therefore I say the capitation system does not encourage the best medical practice. What is the cost of drugs now? We now spend £110 million a year more on drugs than is paid to all the general practitioners in the country. I say that a salaried service would be the death knell of the less reputable drug-houses. They regard the National Health Service as their milch cow.

Of course, one cannot attack the virtues of the average doctor, who can well claim that he is being virtuous when he looks after his family—a very noble aspiration; and, indeed, that is what he has to do. He has his expenses. He dare not adopt an absolutely truthful approach to every hypochondriac or neurotic who comes and sits by his side. There is a conflict between loyalty to his family and loyalty to his conscience. This, I say, is an intolerable dilemma in which the doctor should not be placed. Is there any other group of workers, professional or otherwise, paid on a capitation basis where truth may be calculated to reduce the income? None at all, except in the world of the general practitioner, a world where, surely, truth is the very essence of his vocation.

I believe—and I mention the noble Lord, Lord Brain, in the first place, because he is the first one who has supported the point, by mentioning that there is some support for a salaried service—that this nettle has not been grasped in all these Reports because the people who have reported are afraid of the old guard. A salaried service is something which would be welcomed by the young, honest, fine, new doctor who is coming along and who wants to give his time and energies without feeling that he must be careful not to offend the patient in case the patient might withdraw his patronage.

What should be the form of a salaried service? If the principle was decided upon, of course the form should be discussed by a group of people whose purpose is to establish the best service possible. I would say that it could be carefully devised to take into account those aspects of the service which give doctors most concern to-day. Mention was made about what happens to the ageing doctor. It is a most remarkable thing—and the noble and learned Lord who sits on the Woolsack will, I am sure, agree with me—that a judge acquires experience over the years and, therefore, there is not always this pressure to get rid of him. Yet, in the world of medicine, as a doctor gets older he has this experience of not being quite so mobile. He cannot run up three flights of stairs to the sick patient at the top, and he slows down. It is a ridiculous state of affairs to think that this man, who has acquired all this knowledge in general practice, should have a smaller list than the more active young man down the road because the neighbours watch the old doctor and say, "Poor old Dr. So and so, he's getting on." That is the wrong approach. We must devise a salaried scheme whereby the experienced man, as the years go on, receives a better remuneration. So, first of all, I would say there should be a basic salary, based on a formula related to length of service and age.

Now we come to expense. I agree with all that has been said about that to-day. Of course, the man or woman who has some wretched little accommodation, without much help, can acquire a big list and at the same time have very low expenses. Expenses could be assessed separately so that the most conscientious practitioner would not be penalised.

We now come to the question of country practices with long distances and scattered population, and the under-doctored and less attractive industrial areas. We think of these places and try to help those men. But with a salaried service these people would have special consideration having regard to their needs and the less pleasant conditions of work. I believe matters of this kind are fundamental to the harmonious working of the general practitioner service and must be considered. They have been consistently ignored by those who fail to recognise the winds of change in the world of medicine. Let us hope that this debate will have succeeded in focusing the attention of the new Minister and his advisers on the pressing need for radical change.

6.25 p.m.

LORD NEWTON

My Lords, your Lordships will not be surprised to learn that as this debate has progressed I have felt even more lonely, confronted as I have been with the powerful contributions of no fewer than six eminent members of the medical profession. As my noble friend Lord Auckland said, had it not been for his intervention, for which I am much obliged, I should be the only layman. And not only that, I should have been also the only representative of the patient and the taxpayer. I also recall some observations of the noble Lord, Lord Morrison of Lambeth, during last Wednesday's debate on the structure of Government. The noble Lord said that my right honourable friend the Minister of Health had not enough work to do, and that he did not need two Parliamentary Secretaries. On that, I would merely say that during the three years that I have answered for the Minister of Health in this House I have found my task considerably easier during this past year that I have been a Parliamentary Secretary in the Ministry, and I have felt myself to be better equipped. I hope that that has been reflected in the service that I have been able to give to the House.

LORD TAYLOR

My Lords, may I say how much I agree with what the noble Lord has said, and how heartily I disagree, and did disagree, with my noble friend on that occasion? I think it has been a good thing indeed that the noble Lord has been a Parliamentary Secretary, and we hope that we shall always have a Parliamentary Secretary or a Minister of State from the Ministry of Health.

LORD NEWTON

My Lords, I am much abashed and grateful for what the noble Lord, Lord Taylor, has said.

I sensed that this would be a very interesting debate, and it certainly has so proved. Quite a lot of what has been said by your Lordships was not aimed at me at all—and I am not complaining about that. The noble Baroness, Lady Summerskill, certainly laid about her.

BARONESS SUMMERSKILL

About time, too!

LORD NEWTON

She injected a Party political note into the debate, which I am not sure went down very well. She also criticised very strongly the Report of Dr. Gillie's Committee, and she attacked her fellow general practitioners for over-prescribing. So far as the Government are concerned, I hope that she will read to-morrow the opening paragraphs of the speech of her noble friend Lord Taylor this afternoon, and what he said in particular about the attitude of Her Majesty's Government over the last twelve years to the National Health Service. What he said was far from uncomplimentary—I think he would agree with that.

There was one other thing which the noble Baroness said. She said that it was a great pity that my right honourable friend the Minister of Health had not been here listening to this debate. No doubt if my right honourable friend had been a Member of your Lordships' House it would have been he rather than I who would have replied on behalf of the Government. I can tell the noble Baroness what my right honourable friend has been doing this afternoon. He has been receiving a deputation from the British Medical Association on matters closely related to the subject we are discussing.

There is a good deal I want to say on my own account, so I apologise in advance if I am not able to reply to all the points. I will, of course, write to noble Lords, should that be necessary. In view of the strictures of the noble Baroness about the Gillie Report, I think I should tell your Lordships that the Government accept without reservation the Gillie Committee's conclusion on what should be the field work of the family doctor. In other words, we agree with the Committee's description of good general practice. That, I think, is the answer that I shall give to the noble Lord, Lord Brain, who suggested that we must decide what the pattern of general practice should be. He suggested yet another Committee of inquiry into that. As regards proposals for action in the Gillie Report, many of those are directed, not at my right honourable friend but at the doctors themselves, and to some extent, also, to independent outside bodies, like the universities. Of these it is not for us to signify acceptance, but we agree broadly with what the Committee recommend, and we will certainly use our influence, in so far as we have influence, in that sense.

We welcome the Committee's emphasis on the interdependence of the family doctor and the hospital service, and I would mention that the introduction of the new medical assistant grade which is at present under discussion with the profession, will provide further ways for general practitioners to participate in hospital work. Indeed, many of the recommendations of the Gillie Committee which were addressed to us are already our policy. An obvious example is improving the diagnostic facilities provided by hospitals for general practitioners. Incidentally, we have made arrangements to enable general practitioners to use syringes supplied by the hospitals, free of charge, for the collection and despatch of pathological specimens.

Following some of the observations of the noble Viscount, Lord Waverley, I would say that we respectfully agree with the Gillie Committee's views on the subject of domiciliary consultation and of training, education and research. As to operational research, on which the Report laid stress, we have started a survey of work now being done by general practitioners to see whether, and, if so, how, we ourselves can give more help. In short, my Lords, we accept most of the recommendations which the Gillie Committee made.

Some of your Lordships talked about undergraduate education. That, of course, is a matter for the universities and not for us but we certainly hope—and we are entitled to hope—that the universities will not be forgetful of the need for general practitioners. I, for one, certainly hope that the extremely interesting ideas of my noble friend Lord Cohen of Birkenhead on the subject of what the new universities might possibly do will be considered by those whose business it is to consider them.

As regards postgraduate education and preparation for general practice about which the noble Lords, Lord Brain, Lord Amulree and Lord Cohen of Birkhenhead spoke, I listened very carefully to what they said; because, although postgraduate education is mainly in the hands of the universities, it is certainly a matter with which we in the Ministry are concerned, and we hope very much that the success of the experimental Nuffield Practitioner Traineeship schemes in the Wessex and Newcastle regions—where the young doctor spends some time in hospital and some in general practice—will encourage other regions to make similar arrangements. I know, for instance, that one is proposed for the Bristol region.

As regards established doctors, it is our hope that as many as possible will attend periodic refresher courses of a week or a fortnight. The scheme now agreed with the profession, to pay £60 once in the course of a five-year period to a doctor who attends a certain minimum number of lectures and so on, is helping to increase the demand for this type of education, and (and this is important) the universities are greatly increasing the facilities for it. Doctors who attend university courses have their fares, fees and expenses paid for up to a fortnight's training every year. This is close to the 5 per cent. of professional time which the Committee recommended should be spent in this way.

My Lords, coming now to Lord Taylor's actual Motion, both the matters referred to in it arise because of the way family doctor services are provided under the National Health Service. If it were a straightforward matter, and if the Minister provided the services, payment would be by salary; the only argument would be as to the amount, and a long-term plan would obviously be an essential part of that picture. But, as it is, the services are not provided directly. Contracts are made with independent professional men whereby they undertake certain obligations in respect of certain National Health Service patients. It is therefore necessary to decide how fees should he calculated in relation to services rendered. That is why—and I suggest that it is scarcely surprising—there is no hard-and-fast plan specifying the location and size of premises, numbers of doctors and numbers of supporting staff.

My right honourable friend, on the other hand, has a responsibility for securing the provision of these services and an interest in the standard of provision; and they play a dominating and sometimes exclusive part in the general practitioner's own working life. It is therefore absolutely right that the Government, and Parliament, should consider whether the arrangements for remuneration are likely to produce the best results for the patients, and whether there is more that could be done in the way of forward planning in spite of the limitations in which way the services are provided.

Methods of remuneration have predominated more than anything else in this debate, Like the noble Lord, Lord Taylor, and the noble Lord, Lord Cohen of Birkenhead, I think it is right to deal only with methods, since the amount and principles which govern its determination are best left to the independent Review Body. But methods will no doubt he of concern to the Review Body, too. As to methods, we have to-day the capitation fee and the pool system, the two main elements in the payment of general practitioners, because of the determination of the profession not to have a salaried service. That is the historical reason. An alternative sometimes suggested to the capitation system is that there should be payment of fees in respect of each item of service performed by a doctor; and this, of course, is the system employed in the payment of dentists. Its drawbacks are that in involves a doctor in a considerable amount of paper work and some measure of supervision over the amount and kind of treatment he gives. Under the capitation system a doctor assumes responsibility for a group of people and treats them according to his own professional judgment and conscience, without reference or accounting to any higher authority, and subject only to disciplinary proceedings in the event of a breach of his terms of service.

The pool system aims to ensure that, while not paid by salary, doctors practising in the general medical service shall, as a whole, be able to make a living at a level considered fair alike to themselves and to the taxpayer. The system, as such, has not in the past been the object of strong criticism. I am bound to say that it occurred to me more than once this afternoon, listening to your Lordships, that it might seem that the system has been under constant attack for many years. But there has recently been more awareness on the Dart of the profession that earnings from the other official sources may fluctuate from year to year and thus affect the remuneration available for general medical services. For example, as the noble Lord, Lord Taylor, himself mentioned, the smallpox epidemic of 1962 led to a large volume of vaccination and payments by local authorities for vaccination records. The abnormal drain on the pool had a noticeable effect on the remuneration of those doctors who did not participate in it, and this, together with the realisation that the deductions to be made on account of non-general medical services income generally are likely to increase as time goes on, has led to widespread criticism of the system; and the position has possibly been aggravated by the endeavour, made on the recommendation of the Royal Commission, to devise fees which leave a far smaller sum than formerly to be distributed each year as a final settlement. This has made fluctuations in the size of the pool balance more apparent. I understand that the profession intend to ask the Review Body to consider the structure of the central pool and to recommend, in particular, that it should in future be calculated without reference to earnings from other sources. Your Lordships will understand that at this stage I must refrain from further comments.

I listened with care to Lord Taylor's views on what one might call the straight capitation fee, without any pool. I take it that one would have to decide what the care of a patient for a year is worth and then pay that amount for every patient on the doctor's list, regardless of his other income. This, of course, would hardly be consistent with a guaranteed net average income per doctor, which the profession have wanted hitherto.

LORD TAYLOR

My Lords, would it not be fair to say that this idea was really thrust upon the profession as a result of the Spens Report? That is how this idea of a guaranteed average income came about. The noble Lord has put it quite fairly, but I think it was something which came to them as a result of the Spens Report, and I must say it would seem sensible that payment should be related to work done, as indeed the capitation fee does so relate it.

LORD NEWTON

My Lords, what I said was that the profession have wanted hitherto a guaranteed average income per doctor, and I believe that to be true. I do not think it would be easy to see how a fair capitation fee would be worked out. The noble Lord, I think, said he wants it re-assessed every three years.

As to weighting, either on account of age or on account of extra work, we have in the past, as the noble Lord knows, suggested differential remuneration, but the profession have not felt able to agree to what they regard as unfair discrimination between practitioners. I have been most interested to hear the views of your Lordships on this subject this afternoon. No fewer than four members of the medical profession, the noble Lords, Lord Taylor, Lord Brain and Lord Cohen of Birkenhead, and the noble Viscount, Lord Waverley, all seemed to me to indicate in varying degrees that they thought the profes- sion had possibly taken a wrong view in the past. I am not seeking at all to reject out of hand Lord Taylor's idea of what I said one might call a straight capitation fee, but I am a little dubious about it, for the reasons which I have given.

I now come to practice expenses. The agreed method of allowing for expenses is to credit an appropriate amount to the pool of remuneration, the actual sum to be credited being determined annually by means of a small sample inquiry into doctors' income tax returns carried out by the Board of Inland Revenue, on lines agreed between the Health Departments and the profession. That, plus the agreed average net remuneration, multiplied by the number of doctors is then the gross sum available for the remuneration of general medical practitioners. After deduction of income received from other official sources, it is distributed mainly in the form of capitation and other fees and payments, which are thus gross payments which include an element of about one-third for expenses.

This method of determining the sum to be reimbursed for expenses overall, and the method of distributing that sum, has considerable advantages for both the profession and the Health Departments alike. It means that the expenses are independently assessed, doctors are not called upon to disclose details of their spending to the Health Departments and, since the figures are ascertained annually, any increase in spending is automatically allowed for in the pool total. The built-in incentive to economy which the system of distribution provides makes it unnecessary for the Health Departments to exercise any other control over the level of spending. It is, however, this last feature of the system—the "egalitarian" system of reimbursing the individual practitioner—that is being criticised, on the ground that it results in a good deal of unfairness between doctors, whose expense ratios necessarily vary widely, and acts as a disincentive to those who would like to improve their standards of practice and need to incur higher than average expenses in order to do so.

It is, of course, normal for self-employed professional men to receive gross fees out of which they meet expenses incurred on whatever scale they think proper, and the Royal Commission thought that a system of refunding approved individual expenses would be inconsistent with the status of a general medical practitioner in contract with the National Health Service. Nevertheless, the Government accept that the present method leads to quite unintended differentials in net incomes, and we have taken the initiative in starting to explore with the profession the possibility of introducing a system for the more direct reimbursement of expenses of certain types.

My Lords, there is no blinking the fact—and the noble Viscount, Lord Waverley, did not seek to do so—that the more precisely the expenses incurred by a doctor are to be reimbursed to him personally, the more detailed and complete the control over the amounts he may claim has to be; for it is clearly impossible to contemplate here, any more than in any other section of Government finance, a 100 per cent. grant for money spent at the sole volition of the recipient. We have expressed the opinion that direct reimbursement over the whole range of expenses might involve a degree of control unacceptable to the ordinary doctor, even if it proved practicable or, indeed, were thought desirable. Instead, we have suggested that a more promising approach may be to concentrate on particular items of expenditure which, because they may impose especially heavy burdens, probably form the hard core of the problem, and which may be amenable to some form of special treatment. The two in mind are: expenditure on the employment of ancillary staff, and outgoings on the practice premises. Informal discussions are being held with the profession on the possibility of going some way towards reimbursing expenditure differentially on these items.

Before I leave the subject of remuneration I wish to make it clear that the Government have no wish to defend the present system as the only possible method of providing fair reward to general practitioners. We recognise that it can be represented as deficient in financial incentives to improvement of standards. Indeed, we ourselves have in the past suggested ways in which better standards might be recognised by higher remuneration, within the pool system, but none of those suggestions has proved acceptable to the profession. Capitation fees, however, have many advantages, for both Government and profession, as the main method of payment; and if this principle is accepted the scope for relating pay to quality of work done is limited. As to the pool, the present arrangements are what the profession have desired for many years, and we, for our part, have no reason to suggest major changes; but if the profession feel that some different system would make for better practice, we shall study with care and interest their reasons for this change of view.

My Lords I come now to planning of general practice. The distinction between the method of providing general medical services and that for the other parts of the Health Service is very relevant. The Minister has direct responsibility for the provision of a Hospital Service; he, with his agents, the Hospital Boards and Committees, decides what is to be built and where, and employs the necessary staff. Similarly the local health and welfare authorities decide the scope, location and staffing of their services. The general practitioner service is provided by general practitioners themselves and, as I have already said, the part which public authority plays is to make contracts with them for the provision of services.

As regards the provision of such things as surgery accommodation, therefore, the general practitioner is in principle much more nearly comparable with a solicitor than with a hospital authority. The general practitioner is an independent professional man and, whatever arguments one may hear from time to time about doctors practising under the shadow of Government restrictions, he essentially runs his practice in the way in which he chooses. He is free to practise where he wishes, subject only to the limited "negative direction" exercised by the Medical Practices Committee on the basis that in some, relatively few, areas there are enough doctors, and he is free to practise in the manner which he thinks right, his contract with the Health Service providing only for certain minimum standards.

It would involve a very considerable change indeed from the present concept of general medical practice if the Government were to take it upon themselves to produce a formal ten-year plan for its development. I recognise that there are arrangements whereby doctors can practise from health centres provided and staffed by public authorities—the noble Lord, Lord Taylor talked about this—but these are optional arrangements of which doctors can take advantage or not as they please, and very few have so far shown the desire to do so. Only if the generality of doctors were willing to practise in this way would it be appropriate to plan for the future in terms of this kind of provision, and we should in fact then have moved over to a totally different concept of general practice.

I am not, of course, implying that the Government should take no part at all in influencing the evolution of the general medical service. There are many ways in which we help directly and indirectly to foster good general practice. For example, the introduction of "loadings" payments in 1953 was designed to increase remuneration disproportionately for the doctor with the middle-size list; the introduction of notional loadings has favoured doctors in partnership; and there are the group practice loans, initial practice allowances, and currently the negotiations with the profession on the direct reimbursement of expenses. At the present time my Department is engaged in helping doctors to take advantage of opportunities for postgraduate education. Our regional medical officers are willing to assist and advise doctors in any way they can.

Although I have been at pains to emphasise the consequences of the independent status of general practitioners, the last thing I wish to do is to dissociate the Government from any responsibility for future developments. Indeed, the Minister of Health's responsibility for seeing that there is a general medical service inevitably involves him in taking a constructive interest in its development. At any moment of time a forward look is essential as a guide to policy, but I feel bound to admit that I do not believe it would be either appropriate or practicable to attempt a formal development programme parallel to the other two which we already have. The Minister discharges his duty by negotiation, in discussion and by the use of influence.

Opportunities often occur for taking action at quite short notice. An obvious example is that changes in the amount of remuneration produce opportunities for reforming methods of distribution. Opportunities must certainly be taken whenever they occur, but they are unlikely to be foreseeable a long time ahead. I am sure that it is right to be flexible in the approach towards those ends which are universally acknowledged and which are clearly set out in the Gillie Report which—and this is significant—did not in any way suggest that general practice would be well served by the introduction of a formal plan. I give the assurance that my right honourable friend will not shirk his part in any move for the improvement of general practice, and I should now like to deal with some particular aspects of the matter.

The first is the number and distribution of doctors. I am afraid I cannot answer the specific question which the noble Lord, Lord Amulree, addressed to me about emigration, but I would assure him, and your Lordships as a whole, that what we can do is to look to the future and to foresee future requirements both in general practice and elsewhere. But there are serious limitations to forward planning since the Government do not decide how many general practitioners there shall be or where they shall practise. Nevertheless, the size of the doctor's field of work as described by the Gillie Committee is directly relevant to future numbers: that was one of the reasons why the Government sought their advice.

As your Lordships know, it was announced just before Christmas that the University Grants Committee had been asked to advise what additional provision should be made in the light of the review that had been undertaken. The Committee recommended that at least one new medical school should be planned and that, at the same time, the possibilities of further expansion of existing medical schools should be examined. The Government have accepted that advice. That is not the end of the story. The Government recognise the obligation to keep the whole problem of prospective medical manpower needs constantly under review. I am afraid I cannot say any more about that.

LORD TAYLOR

My Lords, what I really wanted to know was the method by which it is done. Is it the University Grants Committee which decides how many doctors there are going to be, or is it the Ministry of Health?

LORD NEWTON

We carry out a review and form an estimate of what we think is going to be required. Then the University Grants Committee are asked to say what the machinery should be for producing that sort of number. It is these reviews which, as I say, we have constantly to make.

As to distribution of doctors, the National Health Service Act provides that every general practitioner who wants to take part in the Service may do so, subject only to the exception that the Medical Practices Committee can refuse an application if in their view in the particular area concerned the number of doctors is already adequate. At present about 6 per cent. of the population live in such areas. Despite the absence of other than negative powers the distribution of doctors has improved very considerably since 1948. This improvement was most marked in the early years, when over half the population lived in under-doctored areas, and by 1962 this proportion was down to one-sixth. The Gillie Committee have recommended, and we agree, that more should now be done to improve distribution.

There are still places where most people are on lists of over 3,000 and we shall seize every chance that occurs to get more doctors into these areas. On the occasion of the last two general increases in remuneration, the initial practice allowance, payable to doctors starting to practise in under-doctored areas, was increased disproportionately. We shall examine the possibilities of making general practice in the present under-doctored areas more attractive professionally by such things as opportunities for postgraduate study and opportunities to work in hospital; and we shall also watch constantly and closely to see whether the negative control through the Medical Practices Committee is working well enough, or whether there should be tighter control of the filling of vacancies in areas with enough doctors, or a change in the definition of such areas. We and the Medical Practices Committee fully recognise our responsibility in these matters. I hope that that is enough to satisfy the noble Lord, Lord Auckland.

In regard to premises, it is certainly arguable that it follows from the concept of the general practitioner as an independent practitioner that the initial provision of his premises is a private matter for him. The Royal Commission did not discuss that in any detail, but it is fair to say that as regards capital it was the basis on which they worked. They discussed the comparison between the general practitioner and other professional men. It is equally arguable that this purist doctrine goes too far. The doctor's contract with the service is concerned with the adequacy of the premises provided by him. The National Health Service has a considerable interest in the standard of provision by individual general practitioners because of its bearing on the quality of service to patients. Again, one cannot ignore the fact that at least in some places it is becoming increasingly burdensome to provide the sort of accommodation in the sort of central position which is traditionally acceptable.

In one important respect the purist doctrine has been breached over the last ten years: that is, the provision of loans for doctors in group practice. The object of these loans is to encourage the formulation of group practice because, to quote Lord Taylor's survey of general practice: … experience has strongly suggested that the doctors in a successful group practice do offer the public a better medical service than each could offer on his own". The Committee on General Practice, of which Lord Cohen of Birkenhead was Chairman, also came out in favour of group practice and they produced the detailed definition for use in the loans scheme, which was started in 1953. The money came out of the central pool and, being "the doctor's own money", it was not considered to go against the principle that doctors provide their own capital equipment. The Royal Commission recommended, however, that these loans should be a direct charge on the Exchequer and this was accepted.

The Gillie Committee have now gone further and recommended that loans should be available to all doctors. This is in line with the argument, heard increasingly, that the Government, who spend so many millions on capital equipment for hospital and local health authority services, should surely do something for the general medical services as well. The most extreme view that has been put forward, and which demonstrates the logical conclusion of this line of argument, is that the Government should directly provide surgery accommodation.

The status of the G.P. being what it is, arguments in this sort of form are obviously not acceptable. Acceptance would fundamentally change the character of the State's relationship with family doctors in a way which it is far from certain would be universally welcomed. It is a long step from interest-free loans for a particular purpose which the Government are anxious to promote, to financial assistance for any general practitioner who wants it in setting himself up in practice.

My Lords, Ministers have to say so often from this Box that something needs to be "carefully considered", that it is difficult to say it with conviction. But I am certain that it is true of this matter of premises. It may be that there are some circumstances in which the individual G.P. does need help with the normal business of finding capital through the various channels open to him. It may also be that the kind of help which would be of most value is not necessarily direct financial help. The profession themselves have just set up a practice advisory service which will be available to advise on the details of practice accommodation and might, for instance, enable a G.P. to use accommodation which, without advice, he would have considered unsuitable. However that may be, I do not think that there is any more that I can say on this subject to-day, except that the ideas of your Lordships will be studied.

A word about ancillary staff, which was discussed particularly by the noble Lords, Lord Taylor and Lord Auckland. General practitioners already have a good deal of ancillary help, but it is generally agreed that they should have more, and this view was strongly supported by the Gillie Report. The staff employed directly by doctors are mainly secretaries and receptionists, though sometimes there are nurses, too. Such helpers can do much to improve the service to the patient they also relieve the over-worked doctor. Pay- ments by doctors for the employment of ancillary staff rank as practice expenses and are reimbursed in full overall. It has been argued that the present system of distributing practice expenses acts as a disincentive to the employment of staff because the doctor has that much less to spend for other purposes and because of the egalitarian nature of the system to which I have referred. This is one of the reasons why we are discussing the possibility of more direct reimbursement for this expenditure, and we hope that if such a scheme can be agreed it will lead to an increase in the number of ancillary staff employed per doctor.

The noble Lord, Lord Amulree, discussed the use of local health authority staff by general practitioners. We have been concerned to encourage authorities to arrange the duties of their staff so that they can work closely with individual general practitioners. This may be done by attaching, for example, a health visitor to a particular practice, part-time or even whole-time. I do not know the exact extent to which this is done, but clearly it is both widespread and increasing. In my own county of Hampshire, for example, one hundred family doctors have health visitors attached to them, and I understand that the results are excellent. No doubt local authorities will have regard to the possibilities when making their own staffing plans for the future. If there were any method by which such plans could be co-ordinated with plans for staff employed by general practitioners themselves, one would certainly want to explore it.

My Lords, I am afraid I have spoken for a long time, but in conclusion I should like to try to summarise briefly the arguments I have attempted to put before your Lordships. Undoubtedly a good deal of discontent is being expressed by general practitioners at the moment, and this is a matter of concern to the Government. In so far as the discontent is about levels of remuneration or the pool system, it will no doubt find expression in the case that is to be presented to the Review Body. In so far as there is discontent about the way expenses are reimbursed, the Government recognise that there is a problem, and we have taken the initiative in raising it with the profession.

In so far as there is discontent because the family doctor feels he is "out in the cold" when it comes to planning the future of the health and welfare services, nothing could be further from the truth. In the hospital and health and welfare plans it has been made clear that the future development of the services depends on the family doctor, and the Gillie Committee have painted an inspiring picture of him—a picture based on what the best doctors are already doing.

That the Government cannot issue a blueprint for the development of general practice itself cannot, I should hope, be a ground of discontent to reasonable people, unless they are discontented also with their status as independent practitioners, with the right to develop their practices in their own way. If there is discontent about working conditions, it may well come back to the problem of distribution of practice expenses, because under the present system increases in these expenses are automatically added to the total pool of remuneration. Interest-free loans are available towards the cost of setting up group practice, through which many of the doctors' problems of time off and better working conditions can be solved.

In view of these things, I submit to your Lordships that the Government are entitled to ask to be acquitted of the charge that they are not helping the family doctor to equip himself with the facilities and tools he needs to provide a good standard of service for his patients. We could scarcely do more within the structure of general practice as it now exists. We believe that answers to present discontent can be found within that structure, if Government and profession work together to identify possibilities of improvement that do not call in question the fundamental principles on which the structure is based. The Government are ready, as always, to play their part.

7.8 p.m.

LORD TAYLOR

My Lords, I have warm personal feelings for the noble Lord, Lord Newton, but I think I have never heard a worse case deployed, or a more disappointing one.

BARONESS SUMMERSKILL

Hear, hear!

LORD TAYLOR

It had, however, one great advantage: it let the cat out of the bag. I was very careful indeed in what I said in opening this debate not to blame the Ministry for the maintenance of this monstrous system of remuneration; but the noble Lord, Lord Newton, made it perfectly clear that this is really what the Ministry of Health want. I have suspected it for a long time. In fact, not only do the Ministry of Health want it, but the Treasury want it, too. I will tell your Lordships why they want it. The noble Lord said—and I made a note of his remark—"It certainly has advantages for the Health Department". It certainly does have advantages for the Health Department! It is one of the grossest swindles ever perpetrated on a serious and decent profession. And I think it has been perpetrated because they have been tricked in negotiation by the Health Department. They were not as clever as these clever civil servants—that is what happened. The Health Department said "Yes, you can have any increase; we will raise your pay for this, that or the other. But, of course, it will come out of the pool."

LORD NEWTON

My Lords, is the noble Lord saying that this has been going on ever since 1948?

LORD TAYLOR

I am saying that it has got worse and worse, and finally a situation has been reached where, if you were to propose to offer the medical practitioners the pool again in another form, they would rend and tear you—and it would serve Her Majesty's Government right.

I think the speech to which we have just listened shows the ghastly task which is facing the British Medical Association's negotiators. I am horrified and shaken to the core. Your Lordships have heard deployed the case for more doctors; you have heard it deployed twice in this House, and it is a serious, a real and a terrible case. What is the answer which we have been given?—one new medical school, and enlargement of existing medical schools. Yet the noble Lord, Lord Cohen of Birkenhead, who I venture to say knows more about medical schools than either the noble Lord opposite or the Ministry of Health, says they cannot be enlarged. He is quite right; they cannot be enlarged. This is a major national problem on which the Ministry of Health have let the Minister down with an appalling brief. I am simply shocked and horrified at the statement to which we have listened.

I am very glad, indeed, that we have had this debate now, because it has shown us what we are up against, and I did not know before. I want to thank all my noble colleagues who have taken part in this debate. Your Lordships will have noticed that there was unanimity among noble Lords speaking on almost every point. I need not go over the points made; I need not argue the case for Durham's having a medical school. These are small matters. But the serious business is this: that if we are to be fobbed off, if the doctors are to be fobbed off, with another pool in a slightly different form, and if the negotiators on behalf of the doctors try to fob them off, there will be very serious trouble indeed. I suppose that as a politician I should be grateful, but I must say that I think it is a miserable, shocking and sorry story.

LORD COHEN OF BIRKENHEAD

My Lords, I wonder whether I might just correct one small thing which the noble Lord, Lord Taylor, said of my speech. What I said was that pre-clinical facilities could not be expanded in existing medical schools, but that there were in fact clinical facilities which, if the pre-clinical instruction could be given elsewhere—and I suggested it might be given in the new universities—would help to produce a small number. My own university could expand its clinical facilities by 50 to 100 per cent.—and I think there are other medical schools that could do much the same—but not its pre-clinical facilities.

LORD TAYLOR

My Lords, I entirely agree with what the noble Lord says. That is perfectly fair. I must very reluctantly ask your Lordships' leave to withdraw this Motion.

Motion for Papers, by leave, withdrawn.