HL Deb 24 February 1966 vol 273 cc365-89

4.36 p.m.

Order of the Day for the Second Reading read.

LORD CHAMPION

My Lords, I beg to move that this Bill he now read a second time. The main purpose of the Bill is to give effect to the Government's undertaking, recorded in the first report of the discussions between the Government and representatives of the medical profession on the profession's Charter for the Family Doctor Service, to establish a General Practice Finance Corporation.

Over the past year, the Government have been studying with the medical profession ways of improving the family doctor service. Two reports have already been published containing not only the proposals reflected in the Bill, but many others, including a totally revised capitation system of payment. A third report is expected to be published before very long, and the profession will then be offered a complete new contract, including new fees, following completion of the current review of levels of doctors' remuneration by the independent Review Body. Meanwhile, other measures, designed to help the family doctor with the problems he faces, and to some extent to lighten his load, have already been put into effect. There has been a notable attack by the Government on a broad front upon the problems facing family doctors. This Bill is to be seen against this general background.

The proposal to set up a Finance Corporation for general medical practioners was first suggested by the representatives of the profession in their Charter produced last March. This stated that one of the most difficult problems facing many family doctors, and particularly of new entrants to general practice, is to raise the capital needed to acquire or modernise premises and to repay out of income capital borrowed for this purpose. It was suggested that, in order to deal with this problem, an independent corporation should be set up, with adequate public funds at its disposal, to finance the purchase and modernisation of doctors' surgeries, to acquire surgery premises and lease or sell them to family doctors, as preferred, to build and lease to family doctors purpose-built premises and to help provide medical and practice equipment. The profession attached great importance to this proposal. Indeed, it was one of the four issues on which they sought prior assurances, before negotiation proper on a new contract began.

The Government accept that at present many doctors experience difficulty in obtaining the loans they need from ordinary commercial sources, because of the security required and the limited periods over which loans have to be repaid. For instance, a doctor may find that a commercial lender is unwilling to advance an adequate percentage of the value of a purpose-built surgery or of premises adapted for practice use; or he may find that the period over which the lender requires repayment is so short that he is involved in excessive annual liabilities. A particular difficulty arises in the case of a doctor buying a share in jointly-owned premises because he cannot offer the premises as a security. It is true that in England and Wales local authorities and in Scotland the Secretary of State are making available surgery premises for renting on an increasing scale. The Government certainly want to encourage such provision, but not beyond what the medical profession finds acceptable, and it is clear that for some time to come, the majority of doctors will want to practise from accommodation provided by themselves. But modern medicine and the best use of medical manpower require the use of well-equipped, purpose-built surgeries with accommodation for a supporting team. This involves capital investment which it would not be reasonable to expect the doctor to arrange unassisted. Unless some help can be given we shall not secure a service of the standard which to-day most doctors want to provide and the public have a right to expect.

The Government were therefore attracted by the profession's proposal that a Finance Corporation should be set up, to help with the provision of practice premises, and have gone a long way towards meeting it. The Government have undertaken to introduce legislation to establish a General Practice Finance Corporation with powers to make loans for the purchase, erection and improvement of practice premises to be owned by doctors, and with a reserve power to make loans for the purchase of equipment. The Government also undertook to consider further whether the Corporation should also be given reserve powers to acquire or build premises to lease to doctors, but they came to the conclusion that it would be inappropriate to duplicate the arrangements which provide for this to be done by public authorities. Furthermore, we thought that building and management would throw considerable burdens on the Corporation and it would not be wise to place such responsibilities on a new central authority of this kind. It seemed reasonable, however, that in suitable cases the Corporation might acquire a site (as distinct from premises) to let to the doctor on a long building lease at an appropriate ground rent. A doctor taking advantage of this arrangement would be relieved of the responsibility of finding capital for the site.

The primary purpose of the Bill now before your Lordships is therefore to provide for the establishment of the new body, which will be known as the General Practice Finance Corporation. The Corporation will be an independent statutory body empowered to make loans to family doctors working in the Health Service, whether full-time or part-time, for expenditure on practice premises, whether for construction, improvement, repair or purchase. It will also be able to acquire sites for practice premises for leasing to doctors. Initially, it will not be able to lend money for the purchase of equipment, but the Bill provides for it to be empowered to do so later by Order made by Statutory Instrument. The Corporation will raise its funds by borrowing, not from the Exchequer but from commercial sources with a Treasury guarantee. It will be required, over a period, to keep its expenditure in line with its income. Its members will be appointed by the Minister of Health and the Secretary of State for Scotland, and it will function in accordance with a scheme approved by them.

Thus, the Corporation will be essentially a financial institution. Its members will be mostly financiers and businessmen, but it is the intention to include among its members one or two family doctors appointed to serve as part-time members. The main reason for its establishment is to enable family doctors to get loans for premises in circumstances in which otherwise it would be impossible for them to borrow money, either at all or without involving themselves in excessive annual liabilities—though there is, of course, no question of restricting its facilities to doctors faced with these difficulties. Because it is designed specifically for family doctors, the Corporation will be able to take full account of their special problems in a way no commercial lender could, and its procedures will be tailored so far as possible to make loan transactions as simple and as straightforward as possible—though the formalities associated with the giving and taking of security et cetera cannot, of course, be dispensed with.

Loans from the Corporation are unlikely to be cheap or below the current rate of interest, but the expectation is that it will be able to lend for longer periods than the ordinary lender, and on less onerous conditions, without requiring higher than normal interest. Your Lordships will wish to know that the profession's leaders fully understand that the Corporation will have to operate on a sound commercial basis and that it will not be a means of subsidising doctors. In this connection, I should mention that the new proposals for remuneration of family doctors provide for payment by the executive council of a notional rent to those who own their premises. This arrangement will place practitioners in a better position to meet interest charges on loans. The second main provision in the Bill provides for a modification of the prohibition of full-time salaries for family doctors. I will deal with this provision in more detail later.

I will now describe the clauses of the Bill in more detail. Provision for the establishment of the Corporation is contained in Clause 1, which also makes it clear that this new body will be independent and will not enjoy any status or immunity of the Crown. Any property it holds will not be the property of, or property held on behalf of, the Crown. Your Lordships will find the details of constitution of the Corporation set out in the Schedule to the Bill. This provides, among other things, that the Corporation shall appoint its own staff and meet the cost and other administrative expenses from its own financial sources. There is, however, power for the cost of salaries or fees paid to members, as well as their expenses, to be met from Exchequer funds.

Details of the primary functions of the Corporation are set out in Clause 2 of the Bill. These are to make loans to family doctors for the acquisition of sites or premises; the conversion or construction of premises; and the alteration, enlargement, repair or improvement of premises. The Corporation may also advance money to enable a doctor to repay a loan previously obtained from another source for one of these purposes. This might occur, for example, where a doctor wishes to repay a loan over a longer period than the original lender will permit. A doctor succeeding to premises which the outgoing doctor wishes to sell, and in respect of which a Corporation loan has been made, will be able himself to apply for a fresh loan whether the original loan has been repaid in whole or in part. Doctors who qualify for an Exchequer grant towards the cost of an approved project for the improvement of their practice premises will be able to apply for a loan from the Corporation for the balance. In all cases the site or premises must be used wholly or in part for the purpose of general practice in the National Health Service, but may include a combined surgery-residence. It is not envisaged that doctors who practise from their residence will have their loans abated because some of the expenditure relates to the residential accommodation; nor will there by any abatement in respect of the use of premises for practice outside the National Health Service, but doctors whose practice is substantially private will not be eligible for loans. Clause 2 also gives the Corporation power to purchase sites for leasing to doctors, but the Corporation will not have the power of compulsory acquisition.

Clause 3 contains the reserve power for the Corporation to lend money to doctors for the purchase of equipment, or to let any such equipment to doctors under hire-purchase agreements. Because there is as yet no evidence that practitioners are generally unable to obtain the assistance they need from existing sources of finance in order to purchase equipment, provision is made for the Corporation to exercise this power only if and when the Minister and Secretary of State make an Order by Statutory Instrument. Because the Corporation's funds are to be guaranteed by the Exchequer, I am sure your Lordships will appreciate than the Government must have some direct concern with the conduct of its affairs.

LORD SILKIN

My Lords, may I interrupt the noble Lord? Does this give a complete discretion to the Corporation to lend money? What rather worries me is that there is no qualification at all. A doctor may be qualified, and under this Bill can apparently get assistance to start up in practice and have his premises—and possibly equipment—provided for him without his having had any practical experience at all. Is there not to be some kind of qualification or discretion on the part of the Corporation as to whether it advances money to a doctor who has not had adequate experience?

LORD CHAMPION

My Lords, the Corporation will be permitted to lend money only under a scheme, and this scheme, I imagine, will take care of the point raised by my noble friend, but I will look into it and let him know if there is the slighest element of doubt. The Corporation will have to be a responsible body and will have upon it doctors who, I am fairly sure, will be competent to take care of this point. The arrangements for this are contained in Clause 4, which requires the Corporation to carry out its functions in accordance with a Scheme which it has prepared and had approved by the Minister of Health and the Secretary of State acting jointly, and to comply with any direction they feel it necessary to issue. I hope your Lordships will accept that these arrangements are reasonable and those are the arrangements to which I called my noble friend's attention.

It is envisaged that the scheme will set out the general framework within which the Corporation will operate. It may need to cover such matters as the nature of the priorities to he given both to different types of loans and to different classes of borrowers; the terms on which loans will be made, and—an admittedly difficult point—whether loans should be recalled on the premises ceasing to be used for National Health Service purposes, and the establishment of a reserve fund. A particular point to be covered will be the need to confirm that either the Minister or the Secretary of State, as appropriate, is satisfied as to the location and standard of the premises before a loan is issued. Special mention of this is contained in the second subsection of Clause 4. I am sure your Lordships will agree that practice premises ought to be sited so as best to serve local needs and to facilitate co-ordination of general practice with other branches of the Health Service.

The Finance Corporation could not itself be expected to form views on siting of premises, since this requires local knowledge and is a matter for the existing Health Service authorities and the profession. Your Lordships will wish to know that the profession's representatives understand that the Corporation will need to ascertain from the Health Ministers that premises are suitably sited and of suitable standard before making advances. Similarly, the Corporation will need to confirm that the Health Ministers are satisfied as to the location before acquiring a site for leasing to a doctor. The Health Ministers will look for advice to the Health Service authorities concerned and there will be a central committee on which the profession will be represented to advise on policy, including general questons of priority, and on referred cases. Specal administrative arrangements will be made for Scotland.

The financial arrangements are covered in Clauses 5 to 8 of the Bill. Clause 5 places an obligation on the Corporation to conduct its affairs in such a way that over a period it breaks even financially. The Corporation will raise its own funds by borrowing and will have to pay the full appropriate market rate of interest. Accordingly, in fixing its lending rates (and the ground rents for sites) it will have to take into account not only the interest it has to pay on the borrowed capital but also its administrative overheads and the need to cover any capital losses it may incur. We hope these will be small.

The Corporation is empowered to borrow the money it requires for meeting its obligations or performing its functions under the provisions of Clause 6. This enables the Corporation to borrow by the issue of stock and temporarily by way of overdraft or otherwise. It is not expected that it will make a public issue of stock: it is likely to place its borrowings by direct negotiation. The Government have no reason to think that the Corporation will encounter difficulty in finding the money it needs. The Bill specifies that, initially, total borrowings shall not exceed £10 million, but this figure can he increased to £25 million by Order, if the House of Commons so approves. These limits exclude borrowings for the purpose of repaying moneys previously borrowed. Your Lordships will no doubt realise that it is not possible to make any precise forecast of the funds the Corporation is ultimately likely to need. In proposing an upper limit of £25 million the Government think they have made ample provision. This is particularly so since the bulk of the money is likely to be issued in the form of loans which the doctors concerned will repay by instalments and which will then be available for reissue. Both limits have been fixed after discussion with the profession's representatives.

Clause 7 deals with the Treasury guarantee. It empowers the Treasury to guarantee the redemption or repayment of the Corporation's borrowings and covers the arrangements for the fulfilment of any such guarantee. Under the provisions of Clause 8 the Corporation is required to keep proper accounts and records. This clause also provides for a copy of the Corporation's annual report, with the audited accounts included, to be laid before each House of Parliament. Clause 9 makes superannuation provision for both members and officers of the Corporation.

My Lords, I mentioned earlier in my speech that, apart from establishing a Finance Corporation, this Bill modifies the present limitation on payment by salary. At present, all general practitioners are independent contractors: that is, they contract with the State to provide general medical services and, like the solicitor or architect who contracts with an individual to provide a service, they supply their own staff, premises and equipment in return, and receive fees which recognise this responsibility as well as reimbursing them for the professional services they provide. General practitioners are thus in a fundamentally different position from doctors in the hospital service, who work in premises and with staff and equipment that are provided for them, and are paid a net salary. The obvious advantage of this arrangement is that the doctor, not having to spend any of his time on making the necessary business arrangement, is free to concentrate on treating his patients. This is no less important in general practice than in the hospital service, particularly in a time of shortage of doctors, when it is so necessary to husband the time of these highly trained and skilled people.

My right honourable friends the Minister of Health and the Secretary of State for Scotland therefore welcomed the proposal in the charter that general practitioners should be able to choose to be paid by salary. The Second Report of the negotiations which was issued last October set out the Government's intention to try to organise in association with the profession's representatives a number of groups of doctors so that payment by salary could be applied to as many as possible of those who desire it and who are not working in circumstances where it would be inappropriate—for example, where the doctors are providing their own premises, staff and equipment. This will not, however, be possible under existing legislation, since the National Health Service Act of 1946 was amended in 1949 to prohibit payment of general prac- titioners by salary except in special circumstances.

This amendment was introduced to allay the fears of the profession that the Government wished to force them into a full-time salaried State medical service. In fact, this was no more the intention then than it is now, but the modification of this prohibition which is introduced by Clause 10 of the present Bill will in practice still leave the profession absolute protection. First, it allows for payment to be made by salary in an area where, exceptionally, an adequate service is not being achieved by the normal arrangements and special arrangements have, therefore, to be made under Section 43 of the 1946 Act. The clause does not involve any change in this respect, since this would have been among the special circumstances which the 1949 amendment exempted from the general ban on payment by salary. Where the clause does involve a change is in allowing for a doctor to be paid by salary, with his consent, if he is practising in circumstances that are to be prescribed in regulations.

The Government hope that the advantage of payment by salary will become so clear that in time there will be a general desire among general practitioners to be paid in this way, but the Government have no intention of attempting to achieve this desirable end otherwise than through the voluntary agreement of the doctors concerned. That is why the clause requires that the individual doctor has to give his consent to be paid by salary. It also provides for the profession to be consulted over the regulations that will prescribe the circumstances in which a doctor may be paid by salary. These regulations will, by virtue of clause 12, be governed by Section 75 of the 1946 Act and therefore be subject to annulment by either House. Thus, the protection which was given to the profession in the 1949 amendment is in effect maintained, but I hope that, with the passage of time and with experience of payment by salary, general practitioners will come to feel that such protection is superfluous and that this form of payment, which involves no loss of clinical freedom and which allows the doctor to devote his time to the care of his patients, is as appropriate for general practice as it is for the hospital service.

These, my Lords, are the proposals in the Bill. Although they deal with only part of the ground covered in the extensive negotiations which have been going on over the past year, they are none the less an important part. They are designed to contribute to the general objective of enabling family doctors to use their training and their skills for the greatest benefit to their patients, and to practise in the National Health Service with a greater sense of personal and professional satisfaction. I beg to move.

Moved, That the Bill be now read 2ª. —(Lord Champion.)

5.3 p.m.

LORD NEWTON

My Lords, I am sure the whole House is grateful to the noble Lord, Lord Champion, for the great care he has taken to explain this Bill to us in all its detail; and for a Bill which has not many objectives, important though they are, there is a lot of detail. I am slightly apprehensive about some of the possible consequences of Clause 10, and I will come to that later. Apart from that, I welcome this Bill; and because I always believe in giving credit where credit is due, I would congratulate the Minister and his Department on it.

This Bill is the result of very long discussions with the medical profession. I fancy that anybody who has been concerned with the administration of the National Health Service at the top, if I may put it in that way, will agree with me that it is extremely difficult to find ideological dogmas to pursue, which I happen to think is a good thing. Moreover, it is equally difficult to manufacture ideological issues simply for the sake of doing so. For example, the periodic fulminations about the iniquities of queue-jumping in hospitals by fee-paying patients do not really make very much impact, because the general public do not see why people should not, if they so wish, spend their money upon their own health and that of their children. Indeed, every year there seems to be a growing tendency for more and more people to take out insurance policies to that end.

Again, the Government can abolish prescription charges for no better reason man that they have always said they would. But, of course, the matter is not anything like so simple as that, as the Government have now found. And I should not be at all surprised if, secretly, the present Minister did not regret considerably the action he took a year ago (and which he had to take because he was committed to it), if only for this reason: that the results of that action have put a most powerful stick in the hands of the Chancellor of the Exchequer which I have no doubt he uses when the Minister comes to him to fight cuts in the hospital building programme.

In my view, the Minister has come with credit out of these protracted discussions with the medical profession during the course of last year, and he has not had an easy time. The doctors' trade union is the most powerful union in this country. I had not realised that until I went to the Ministry of Health. But in fact it is not the least surprising that that is so, because every human being knows that from the cradle to the grave he is in actual or potential need of the services of doctors. I cannot think of any other learned profession of which the same thing can be said.

Although, of course, one hears often enough criticisms of different aspects of the National Health Service, I cannot recall ever meeting anyone who complained, strongly at any rate, about the level of national expenditure on the Service as a whole—except, of course, the Chancellor of the Exchequer and his colleagues. Unhappily, the same cannot be said about the equally important service of education. And the reason for that is simply that when their children have grown up, people are apt, human nature being what it is, to ask themselves what they get out of the high cost of the national bill for education. On the other hand, the same people realise that throughout their lives they continue to get much from the high cost of the national bill for health.

I am glad that this Bill empowers the Finance Corporation to make loans, rather than grants, to general practitioners in respect of their premises. I am sure that that is the right thing to do, as well as being, as I understand it, what the profession wanted. So I will resist the temptation of pulling the leg of the noble Lord, Lord Champion, by reminding him that the Minister, Mr. Robinson, when in Opposition used to say that a Labour Government would, in the case of group practices, replace interest-free loans by grants. When a sinner repents he should be praised—at any rate, in my view.

LORD CHAMPION

I like the way the noble Lord resisted that temptation of pulling my leg and the Minister's about what he had said.

LORD NEWTON

I can only say I am glad the noble Lord, Lord Champion, has never had the occasion to discover what I am like when I am really tempted.

The Bill itself, of course, does not do anything to promote explicitly a growth of group practice. But I recognise, of course, that there is a new inducement towards this desirable end in the new supplement to the basic practice allowance. I have never sought to conceal my belief in the benefits of group practice. I hope it is a development that will grow, and I hope also that when it does grow, more work will be done in health centres. I saw some examples of this type of arrangement when I was Parliamentary Secretary, and I was much impressed by what I saw.

I do not think there is any need for me to make any detailed comments on the first nine clauses of the Bill. They were quite clearly explained to us by the noble Lord, Lord Champion, and I certainly have no criticism of them. I should like now to come on to Clause 10, which allows doctors to be paid by salary, if they so wish, in circumstances to be prescribed. I am quite sure that this provision in the Bill is right, broadly for the reasons which the noble Lord himself gave. But I also think that the Minister has been right to proceed, as he has, cautiously in this matter, and I am glad that there does not appear to be any intention of compelling general practitioners, against their wishes, to be paid by salary. Whatever view the Department, the Government or anybody else outside the profession may take of this method of remuneration, that is to say, payment by salary, it is still not popular in the profession as a whole, and I think that that reflects credit on the profession.

I was slightly surprised—I had not expected this—that the noble Lord would go quite so far as he did in indicating that it was the Government's hope that before long general practitioners as a whole would see the great merits of remuneration by salary. I think that in fact he went further than the Government spokesman did in another place. Of course, from the point of the Minister, any Minister, and from the point of view of the Department, there might be considerable advantages from payment by salary of general practitioners. If we ever had a general practitioner service in this country which was mainly, or largely, a salaried one, then I imagine that the Minister of the day would require wide powers to direct doctors where they were to work. I am quite sure that I should, if I were the Minister. What a difference that would make to solving the problems of the under-doctored and unpopular areas, which I imagine is just as much a headache now for Ministers in the Department as it was in my day!

Nevertheless, I hope most sincerely that the general practitioner service in this country never will become either mainly, or even largely, a salaried one, because I am quite sure that it would alter fundamentally the cherished relationship, the personal relationship, between the family doctor and his patients. It is no good the Government's answering—at any rate they cannot allay my fears by the answer—that already the hospital service is a salaried one. Of course it is. I do not think I need go into my detailed reason for saying this: I hope that it is self-evident to your Lordships. But the relationship between an in-patient in hospital and the hospital staff is not in the least comparable with the relationship which obtains, or ought to obtain, between the family doctor and his or her patient; and I think many members of the medical profession realise this for themselves. Moreover, if the general practitioner service ever did become wholly, or mainly, a salaried one, might there not be a risk of all sorts of undesirable and disagreeable controversies and arguments arising about such matters as working fixed hours, payment for overtime, and all the rest of it?

My Lords, I will leave that at that. I have nearly finished, but I would just say that I rather regret that the Bill does not empower the Minister to make a limited experiment, for a trial period, of charging fees for services which could afterwards be recovered, either wholly or in part. It would be most interesting to see the results of such an experiment. I am not saving that because I have an ideological bee in my bonnet on this matter—far from it. Indeed, so far as the Health Service is concerned, I hope that I have no bees in my bonnet at all. But the reason I say this is that I suspect that abuse of the general practitioner services in this country is far more prevalent than Ministers ever find it politically prudent to admit. However that may be (this is the last thing I want to say), of one thing I am absolutely certain; to get one's priorities right is much the most important aspect of financing the National Health Service. As I said at the beginning, in general I welcome this Bill, and I certainly wish it well.

5.17 p.m.

BARONESS SUMMERSKILL

My Lords, anybody listening to this debate, anybody who has come here believing that politics could not be injected into the field of medicine, must have changed their mind after having listened to the speech of the noble Lord, Lord Newton, and indeed having contrasted it with the speech made by my noble friend Lord Champion. In his opening remarks, Lord Newton said that he fully agreed with the provisions made in the first nine clauses, and then he jumped the nine clauses. He hardly devoted a word to any of them, except to say that he approved of them. He then proceeded to explain why he did not approve of a salaried service.

I must confess that before this I had thought that I understood Lord Newton. Incidentally, he said that he had no bees in his bonnet. Does he not realise that a bee has been buzzing loudly during the last ten minutes? He seems to be completely ingenuous about the difference between a salaried service and a paid service. Indeed, he actually stated that he thought the relationship between a doctor and a patient was, let me say, warmer, more understanding, more sympathetic if money passed between them. I do not want to be diverted, but I was so astonished to hear the noble Lord make that—

LORD NEWTON

My Lords, this is all very agreeable and I do not mind in the least the noble Baroness complaining about what I said; she has often done so before, and I have no doubt she will do it again. But she has quite mistakenly put words and phrases into my mouth which I did not use. If she will be good enough to read my remarks to-morrow in Hansard, she will see what I said. May I just say that the reason why I did not expound at length on the first nine clauses of the Bill was because of the time and because of subsequent business.

BARONESS SUMMERSKILL

My Lords, I assure the noble Lord that he has my great respect. He did some excellent work at the Ministry of Health. I know all about the work he did then. If he will read Hansard I think he will find that, while I did not repeat his exact words, my interpretation of what he said about a salaried service is correct. On the other hand, my noble friend Lord Champion, coolly and calmly, dealt in great detail with the first nine clauses. But suddenly when he came to Clause 10 he became warm, he showed a Welsh emotion, although it is only his wife who is Welsh. Nevertheless, he showed a warmth of understanding that inspired me in such a way that I hope that, when I come to make my observations, my noble friend will become a convert to my way of thinking. Also, when he hears what I have to say, I ask him to have in mind a picture of the Welsh Valleys which he knows so well, which along with other industrial areas are desperately in need of doctors.

While I cannot support the first nine clauses, I can wholeheartedly support the latter part of the Bill embodied in Clause 10. The other provision offers a means whereby a young general practitioner can by-pass the usual money lenders and secure a loan from the General Practice Finance Corporation. Clause 5 makes it clear that the borrowing power will have to operate on a sound commercial basis. My noble friend emphasised that aspect of it, and said that the Corporation would contain financiers and businessmen—which made me shiver. It will also include a few part-time general practitioners —poor general practitioners, who will not understand the financial side at all, but who are nevertheless being injected into the set-up.

When money is lent to doctors, no doubt the actuaries are well aware that a loan to a medical man or woman offers one of the best securities in the country. The average doctor, like most professional men, believes that the non-payment of a debt is a reflection on his professional integrity. At a recent party of doctors I was asked whether a sound commercial basis meant an interest rate at the prevailing 7 per cent. Perhaps my noble friend will confirm that when he comes to reply. The young doctor, of course, will be very interested in the rate which is charged. It will be the very young doctor who is just starting out who will want this help. The more mature man is already well established in his practice.

Two elderly doctors reminded me that their practices were taken over at the inception of the Service and they are being paid at the rate of 2 ¾ per cent. on the capital value. Could not the Ministry lend the capital of the older man, which they refuse to release, except on retirement or death, to the younger doctors at 2 ¾ per cent.—or is my simple non-commercial mind not approaching this question in the right way? If the Ministry is going to take 7 per cent. from doctors to whom it lends money, surely the time has come when the percentage of 2 ¾ per cent. which is being paid to the older doctors in this country should be reviewed. Here is a pool of money which could be lent by the elderly doctors, if they cannot get it in their old age, to their younger colleagues. If the Ministry are not prepared to do this, they may well risk a charge of usury.

Although all doctors are interested in the details of how this will be made a commercial proposition, it is not the terms of the loan to which I object so strongly so much as the principle involved. In my view, the money-lending provisions of the Bill will effectively postpone the date when general practice is taken out of the field of private enterprise—the field which is approved of by the noble Lord, Lord Newton, but of which I myself do not approve. It seems to me to be a grave mistake to perpetuate an outmoded method of conducting general practice at a time when it is of profound importance to keep the doctors in this country. Does the noble Lord think that this will prevent emigration? I cannot believe that the best way to establish a Service of contented, dedicated young doctors is to hang a big debt round their necks. Indeed, in another place it was said that a doctor may spend his whole professional life paying off the debt. The noble Lord has already said that if a doctor already has a large loan and has not managed to repay it, he can transfer it to the new Corporation—which is an indication of the number of years the doctor has been involved in trying to pay off his debts.

A doctor is engaged in the most responsible work in the community, and my noble friend Lord Champion laid emphasis on this point. Yet these provisions will ensure that he will be subject to all the anxieties associated with a burden of debt. I come from a medical family —I have lost count of the number of doctors in my family—and I know how doctors conduct their lives. I know that the doctor will be deterred from taking adequate holidays for rest and recuperation with his family which will involve him in further expenditure. He will be conscious of this debt all his professional life. At a time of increasing leisure and shorter hours for others, the overworked general practitioner is in silent revolt. The provisions of this Bill are perpetuating certain conditions of general practice which have already led our doctors to leave the country. The situation is serious. We are losing 900 doctors a year —half the output of our medical schools. That is the problem with which we are faced. This is one attempt to improve the situation, but in my opinion it will touch only the fringe of the problem.

Why must a young general practitioner start with a load of debt? He is already bringing with him into the Service invaluable mental equipment which he has acquired over many years of labour. In my father's time it was possible to get qualified in five years; later on, in my time, it rose to six years. Now there is a pre-registration year, and it is difficult for a doctor to go into practice within seven years. This is the equipment that these young men and women are bringing to their great profession. My noble friend mentioned some of the other people who work in medicine. One thinks of the well-remunerated specialist who works in the hospital. He does not have to borrow money at 7 per cent. to pay for the consulting room and its equipment, and the waiting room which he uses for his patients in the hospital. What of the medical officer of health, for whom we all have the greatest respect? The medical officer of health and his assistants who work in the health centres and the maternity and child welfare clinics do not have to carry a burden of debt in order to pay for their consulting rooms and waiting rooms. Is anybody suggesting that general practitioners' work is inferior, because they have to pay for the rooms they use for their patients? I regard this proposition as an anachronism.

The young, idealistic doctor should enter general practice, after a long period of training, armed with all the new knowledge of medicine, without a burden which overshadows his life. He should be encouraged in every way to pursue his calling with all the zest and enthusiasm which first prompted him to enter medicine. Years of struggle, to pay a debt which he will feel that he should never have been forced to incur, will lead to disillusion and cynicism.

I would say to my noble friend whose duty it has been to introduce this Bill that it is paradoxical that a Bill which contains these outmoded provisions should contain in the tail, Clause 10, the first suggestion in a Statute of a salaried medical service. This I wholeheartedly welcome. But I suggest to him that the two propositions are incompatible. The young doctor originally attracted to a salaried service, yet in debt to the Finance Corporation, will be forced to opt for a method of payment which may give him more money but not the impetus to give of his best work. The salaried doctor practising from publicly-owned premises will be master of his soul.

The noble Lord has quite rightly said that local authorities are providing premises. Premises are being provided in other ways, and they are let to doctors at what I hope is a very moderate rent. I should not object to a moderate rent. But I really see no reason at all why these doctors should not be treated in the same way as the medical officer of health and the specialists in hospital, with accommodation provided for the patients. If this is done, I am convinced that the doctor will give the most honest advice and the best treatment to the patient.

I am sorry that the noble Lord, Lord Ferrier, has gone, because he so often leaps at me when I say this. The consumption of drugs by the population of this country, and all over the world, now verges on the ridiculous. If a doctor is paid a salary he will give the most honest advice and the best treatment to the patient, and this may involve withholding some of the expensive drugs which now drain our medical service. I think that the bill for drugs in this country is now £100 million a year, and most of them are unnecessary. I believe I am right in saying that nearly 75 per cent. of these are proprietary drugs, for which there is a much cheaper alternative. But what can he done by the doctor who is being paid—as the noble Lord, Lord Newton, says he should be —on a capitation basis or by a fee? I have said this before, but it should be repeated. The patient comes in with a primitive faith in some drug, tablet, powder or medicine, and if the doctor —knowing that his waiting room is full —refuses to agree with the request to write out a prescription and hand it to the patient, then, of course, there is a chance that the patient will leave, and the doctor, paid on a capitation basis, will lose. Let us think of this man with the big debt at 7 per cent., which he is now invited to take from the Finance Corporation. Is he going to tell the absolute truth to the patient and say, "All you want to do is to eat less, drink less, smoke less and you will feel much better. You do not want any drug at all"?

We have now established a form of medical service in this country where the pharmaceutical industry is allowed to produce all these untested drugs and to flood the country with them. Our waiting rooms are full of otherwise intelligent men and women who have a curious faith, which is quite primitive, like the faith in the witch-doctor of Africa, in some tablet. If we could only look at the medicine cupboards throughout this country we should see the bottles of pills, the pots of ointment, the bottles of liniment, unconsumed but for which the taxpayer is paying.

This debate is historic. We have heard for the first time that we may now get a salaried service. If we get a salaried service, the doctor will be able to speak boldly to the over-fat patient, to the obese patient, to the cougher, to the chronic misery who finds that if he can go to the doctor he can privately "belly-ache", as the doctors call it. The doctor should be free to say, "Get out. Get some fresh air. Take your wife to the theatre and get out of this place. This is not the place for you." But he cannot do that, and no doctor in this country can tell his patients the truth. To-day we are asking that these poor young doctors should have put on their shoulders a burden of debt which will once more close their mouths. Dare they tell their patients the truth when they know that this means losing money? No, my Lords, they have got to repay the money.

LORD HAWKE

My Lords, is the noble Baroness advocating the reimposition of prescription charges, and that the resulting money should be used as salaries for doctors?

BARONESS SUMMERSKILL

I should remind the noble Lord that I have been a Parliamentarian for 27 years, and I have never been drawn by that kind of interjection. I am glad to find that I have some sympathy in this case, because this is fundamental to the Bill. Are we going to put a great burden on the doctor which will make him hold his tongue when he should be talking to the patient, or are we going to give him his freedom? I am asking my noble friend to see to it when he goes back that the doctor is given his freedom, so that his only concern will be to give his patients the most honest advice. If the doctor is paid a salary, if he has accommodation which is free, just like the specialist or the medical officer of health, then he will give his advice without having to have second thoughts about his own pocket. Finally, I would just say this to my noble friend. This gift-horse, which the noble Lord on the other side of the House welcomes, does not bear a careful examination of its mouth, and I ask my noble friend—because there is plenty of time —to take it back for further consideration.

5.37 p.m.

LORD AUCKLAND

My Lords, from the Back Benches on this side of the House, I should like to give a reasonably warm welcome to this Bill—a rather warmer welcome, I suspect, than the noble Baroness, Lady Summerskill, gave to it. I do not propose to follow her into the ethics of drugs in medicine cupboards. I prefer to return to the Bill. The Bill had a very full discussion in the other place, but there are still a number of rather gaping holes in it. Clause 5 is the one which causes me the most concern. I have tried to read this clause carefully. I think I understand it, but I wonder whether it is going to work in practice, because, as I understand the clause, the solvency of the Corporation is going to depend very much on the prevailing bank rate, and with the present fairly high bank rate I can see the Corporation having a certain amount of difficulty. I noticed from the debate in another place that it would be possible to borrow at a lower rate of interest, and I wonder whether, when the noble Lord, Lord Champion, comes to reply, he could expand a little on the matter of Clause 5.

I turn now to Clause 2, and I note that compulsory purchase is not going to be used in obtaining premises. I think that is welcome, but there may be areas—and I am thinking, particularly, of conurbations, say, Manchester or Sheffield—where premises are already in short supply. I should have thought that houses in a derelict condition might be purchased at a fair compensation rate and converted into decent premises.

There is another factor relating to this Bill which I think is important, and that is whether the young doctor who has recently come out of medical school and is perhaps not so well off as the established doctor will get any preference from the Corporation if he wants to set up a practice. I think this is vital at a time when we are short of doctors, particularly in industrial areas. In point of fact, the amount which the Corporation has at its disposal seems to me to be pitifully small. As I understand it, it is £10 million but can be increased to £25 million if the other place pass an Affirmative Resolution. At a time when we are so short of doctors this seems to me to be a rather paltry sum of money.

The noble Lord made reference to the fact that private practice would not come under the provisions of this Bill, and for the most part I agree with that. But there are a number of doctors who have a fairly wide National Health practice and a reasonably wide private practice. I wonder whether there is going to be any yardstick as to how this is going to be determined.

Finally, I should like to ask the noble Lord whether any preference is going to be given to the development areas under the terms of this Bill. I am thinking particularly of East Anglia and of Bletchley, and possibly the West Country, where a number of people from the Greater London Area are expected to be moved. This is going to put a large burden on the family doctors in these areas, particularly so far as premises are concerned; and I should have thought that if the Bill was to apply to any particular section of the medical community, this must come high in the queue. As I say, this is a Bill which can in general be welcomed. For fairly obvious reasons, the Government will want it on the Statute Book fairly soon, which will mean that a Committee stage would only hold things up. But there are, as I have mentioned, one or two difficulties in the Bill to which I hope the Government will direct their attention.

5.43 p.m.

BARONESS GAITSKELL

My Lords, I should like to congratulate my noble friend Lord Champion on the clarity with which he explained this Bill. He brought to my notice a point which I missed when I read it. All the provisions of this Bill are good ones, and long overdue. If they had been included in the original National Health Service Bill many anomalies in the Service would have been avoided—and here, I am afraid, I completely disagree with my noble friend Lady Summerskill in her attitude on this matter. If the doctors had not been so much against a National Health Service it would have been a better one from the start. Doctors are notoriously bad politicians—

BARONESS SUMMERSKILL

Honest politicians.

BARONESS GAITSKELL

—and as in any negotiations the parties to them sometimes have to play politics to reach a compromise, in the negotiations with Nye Bevan the consultants at the time outsmarted the general practitioners, who, helped by their own innate conservatism, got the raw end of the deal.

BARONESS SUMMERSK Here

Hear, hear!

BARONESS GAITSKELL

They recoiled from the idea of a salaried service, and so did not think in terms of amenities or conditions of service. They thought only of fixing the top limit of patients per doctor as high as possible. This produced a situation in which, in spite of a shortage of doctors, there was a pool of unemployment—something that could not have occurred in a salaried service. They were obsessed by their anxiety about the mystique of the personal relationship between doctor and patient. I think that today a great many more family doctors are considering a salaried service with more sympathy than they have ever done before.

Admittedly, the National Health Service introduced benefits to the community generally, but the general practitioner, belonging to a profession which demands a greater degree of dedication than any other, and in which mind and heart have to be deployed if he is to be a really good doctor, lost out in the first round. The better he was, as a result of the National Health Service Act, the less he was able to earn, because if he spent money to make his surgery attractive, or if he bought the latest equipment, the cost of the improvements had to come out of his own income. What sort of an incentive was this to him to improve his practice? Then if, by any chance, he wanted to take a refresher course, to bring himself up to date, when could he possibly do this? He has a twenty-four hours a day job; he is not paid when he is ill; he has to provide a locum, which costs £2,000 a year; and he does not get holidays with pay.

The new Health Minister is the first to understand "the doctor's dilemma" of the medical profession, and in this new Bill the provision to help doctors acquire premises is a thoroughly sound and sensible one. It is ironic to think that, before the National Health Service began, doctors could borrow money to buy a practice and then pay off the loan. There has recently been a case in Lambeth, I am told, where three local doctors put in for a practice that had been vacated. It was allotted to two women doctors from outside who could not take it up because they could not find premises. I have personally known a case where the committee allotted a doctor two practices, and another case in which, when a doctor who was an assistant applied for a practice near his home, it was given to another doctor who already had a large practice. In the end, this particular doctor was forced to take a practice a long way from his own house. Of course, the arbitrary fashion in which the committees appoint doctors is responsible for anomalies of this kind, and the new Bill will go a long way to stop this kind of thing from happening.

The clause allowing a doctor to be paid a salary where the provision of general medical services is inadequate is also a great advance in the right direction. After all, we give dockers a bonus for handling dirty goods, but we do not compensate general practitioners if they have a far-flung practice, or a practice in a very unattractive neighbourhood. Paying them a salary in special circumstances will help to equalise the conditions under which they work. There is no doubt that the trend in the National Health Service is towards group practices, which will give doctors the leisure which everyone needs and has a right to expect, and perhaps towards a salaried service throughout the profession, if they finally decide that they want this. Certainly every step the new Minister of Health has taken, and is proposing to take, is improving the lot of the doctors in the Health Service, the family doctors. His provisions are full of common sense and humanity. The general practitioner, as well as getting a better deal from the Government, will be in a position to give a better deal to the community.

LORD SHEPHERD

My Lords, I beg to move that the House do now adjourn during pleasure for the purposes of the Royal Commission.

Moved accordingly and, on Question, Motion agreed to.

House adjourned during pleasure.

House resumed.