National Health Service Bill

Private Business – in the House of Commons at 12:00 am on 26 July 1946.

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Order for Third Reading read.

11.15 a.m.

Photo of Mr Charles Key Mr Charles Key , Poplar Bow and Bromley

I beg to move, "That the Bill be now read the Third time."

This Bill is in many ways the major Bill of this Session. I know that there are others who will say about it disparagingly that it is a curative and not a preventative Measure, that it deals with effects without tackling causes. I do not accept that, but, even if it were true, we have to remember that this Bill attacks one of the greatest social problems of our day, the adequate attention to the sick and halt, the maimed and the injured members of our community. Whilst by other means this Government are actively engaged in improving the standards of nutrition, housing, clothing of the people, education and provision of employment in order to secure advances in the standards of life, to improve the health of our people, it will, alas, always be necessary that we should give early and adequate attention to the onset of diseases, the results of accidents and the effects of increasing age. That, in my submission, will be successfully accomplished by the fully developed services that will be provided under this Bill. For that reason it is, in my opinion, a Measure of which Parliament may be justly proud.

In its present form it differs little from what it was when we gave it a Second reading. No major change has been made. The tripartite character of the services remains; the machinery for their provision and administration is what it was. Nothing has been said or proposed in the stages between that and this to shake our confidence in the efficacy of the structure that the Bill involves. Minor Amendments have, of course, been made, and all of us will be ready to admit that in its present form it is better than it was. There still, of course, will be those who will regret this and the other provision or omission, and think that a better method of distribution of practitioners put forth in a provision or a particular financial set-up, is preferable to what is here adopted. That will always be the case, but democracy means not merely that when these things have been adequately considered the will of the majority must prevail, but when the set-up of the services is settled it is the duty of all to cooperate in making that service the success for which the conditions of our country insist. We shall do that I have no doubt.

Though I do not think that the time will be long, it may possibly take a little time to get into the right state of mind to operate the Bill as we should, but I am convinced that the doctors and doctored, hospital governors and municipal councils, Ministry of Health representatives and health service workers will all come together to work out in cooperation the details of this great service. That will be sooner and more efficiently done if the proposals are fully understood and the truth of what this Bill contains is made plain to all concerned. But that, alas, is not what is being done by such statements as are contained in the reasoned Amendment on the Order Paper, an Amendment which, like the one which was put down on the Second reading, shows, once more, the unsurpassed ability and unenviable facility of right hon. and hon. Members opposite to distort and misrepresent the great social programme which is being so successfully and so expeditiously fulfilled by this Government.

Let us look at the group of five inexcusable inexactitudes which the Amendment contains. First, it is said that this Bill discourages voluntary efforts and associations. The Bill does nothing of the kind. By regional boards, management committees and house committees, it widens and extends the opportunities for voluntary service in the management and control of hospital institutions. By extending to these boards and committees the power to accept gifts and hold endowments it encourages local voluntary efforts and, by guaranteeing the maintenance of the institutions and the provision, from public funds, of the money necessary for normal day to day expenses, it sets free voluntary contributions for purposes that are likely to appeal most strongly to private donors, namely, the improvement of amenities and personal comforts provided for patients. But what it does discourage is the unsocial belief that it will continue to be good enough for the provision of essential services for the common people to be dependent on the chance results of charitable appeals of various kinds. The days when our people will rest content with that as a method of providing social services are happily now past.

Then, the Amendment says that the Bill mutilates the structure of local government. Again, it does nothing of the kind. It has made no change in the structure of local government, except this: that where experience shows that it would be beneficial that in the carrying out of their functions as health authorities they should act jointly for the purpose, it makes possible their combination for that purpose under general boards, consisting of representatives of the authorities concerned. It is a queer idea that amalgamations for mutual benefits can be styled as mutilations. But then, Tory ideas are queer. It has, of course, been found necessary, in the interests of sound and efficient administration, to transfer some of the powers of local authorities from one authority to another, but, in so doing, we have made provision, in every case, for members of the authority from which the powers have been transferred to participate in their future performance by the body to which they have been transferred. In addition, new powers and duties have been given to the local authorities, and theirs will be a major part in the provision of the fully developed and efficient services which the Bill is designed to provide.

The third statement which is made in the Amendment is that the Bill dangerously increases Ministerial power and patronage. That is a charge which one would naturally expect from the quarter from which it comes. Every increase in the functions of the publicly elected representatives of the people is dangerous to the private interests of the privileged classes represented on the benches opposite. So long as largely self-appointed administrators of charitable institutions were left in charge, not only of the voluntary funds, but of considerable contributions from national funds as well, all was well. But as soon as the people, through their elected agents, determine to provide and manage the services for themselves then, of course, the situation, according to Members opposite, becomes dangerous. I am happy indeed in the knowledge that that danger is destined to grow.

What are the powers they are talking about so much? All appointments to the bodies that will carry out the Minister's powers are to be exercised, according to the Bill, after consultation with the organisations concerned. The object of these consultations is to try to agree about the right type of people who will form the bodies and administer the services, and it is obvious to any unprejudiced person that appointments will not rest on the mere ipse dixit of the Minister. The Minister's agents, the regional boards and the hospital management committees, will have very considerable power. They will appoint and employ practically all the hospital staff, so that the question of patronage by the Minister in the administration of the hospitals does not arise at all. In the general practitioner service only one change has been made, namely the Minister's control, to a negative extent, in the distribution of doctors through the Medical Practices Committee. There is no power of a new kind in this department, which has been conferred on the Minister by this Bill. The powers that he has are powers of a kind which have been enjoyed for over 30 years by Ministers in relation to. medical and other benefits under the National Insurance scheme.

The fourth statement made in the Amendment is that the Bill, by appropriation of trust funds and benefactions, docs it in contempt of the wishes of donors and subscribers. That is an astonishing charge to make. The funds in question were given for the provision of a hospital service, sometimes for general, and sometimes for particular, institutions, but they were given, surely, for the benefit of people, and not institutions. Instead of doing what we might well have done, and saying, with regard to each one of these institutions, that their funds will provide so much for current expenses and so much for capital development, that we will recognise that, and will provide from public funds only that amount which is necessary to supplement what exists, we said "We will simplify the financial ad- ministration of this service. We will provide for the whole of the current expenses and capital development out of public funds. Then, having done what the donors wished, not with their money, but with public money, and without drawing on their funds at all, we will set those funds free to provide for others over and above the normal services." Moreover, in the spending of this money we have not made it controllable in the way in which the spending of moneys from the public Exchequer must be controlled. The spending of these funds will be left to the committees managing the hospitals to provide, in addition to the normal services, those services which they think best in the interests of the patients.

What we have to remember, in considering this charge, is that we are here providing a national service, a fully developed service with specialised institutions, and that many patients who, up to the present time, have been able to find treatment for their ills only in their little cottage hospitals, will get better specialised services elsewhere, going to other institutions never before made available to them. What I ask is this. Did the donors of these funds give them to the bricks and mortar of the cottage hospitals, or did they give them for the benefit of the patients who were housed in the cottage hospitals? Surely, they gave them for the patients, and in order, therefore, that the patients may benefit, that the good of the funds may follow them, no matter to what institutions they are sent, we have held— and, I claim, rightly held—that the real intents of the donors have been honoured by making the funds available to the patients wherever they may be, and not merely within the confines of any particular four walls. Hence, this Bill sets up a national hospital endowments fund to be used for the good of patients anywhere, no matter to what institution their needs may make it necessary to send them. I feel convinced that no dead donor will turn in his grave in resentment at what is being done in this scheme.

Lastly, we are told that the Bill undermines the freedom and independence of the medical profession. I think that, of the five charges, that is the perversion par excellence. What is the position? Every doctor in this service is free to enter or not, just as he chooses. If he enters, he is free to take or reject patients just as he will. If he enters he is free—and this, to many, will be a most astounding thing—to accept private patients if he wishes. But if he enters the service, he enters on the understanding that he accepts and observes the essential conditions of the service that he joins. Who in any service, private or public, can do any other than that? Has the freedom and independence of a doctor been undermined in the past because he has accepted a post as the medical officer of health of a local government authority? Has the freedom of the medical practitioner in a municipal or a voluntary hospital been undermined because he accepted a salaried appointment in the hospital concerned? What nonsense it all is. No body of public or private employees has ever had the same freedom as the medical profession will have under this Bill.

I challenge hon. Members opposite to name any service with the same amount of self-government as the general practitioner service under this Bill will get. The body that appoints the general practitioner, the local executive council, is to consist of 50 per cent. of professional members appointed, not by the Minister, but by the profession itself, and of the medical practices committee who are their real employer, apart from the fact that the chairman must be a medical practitioner, six out of eight of the members must be medical practitioners as well, and of those six, five must be actively engaged in medical practice. Yet it is said that all this undermines the freedom and independence of the profession. Misrepresentation could sink to no lower depths.

Photo of Mr Henry Willink Mr Henry Willink , Croydon North

I wish to ask a question which follows rather aptly after the Parliamentary Secretary's last sentence, because I think that, quite unintentionally, he has greatly misrepresented the Bill. To what did the hon. Gentleman refer when he said that the medical practices committee were the real employers of the doctors?

Photo of Mr Charles Key Mr Charles Key , Poplar Bow and Bromley

I meant that they are the people who have to give their approval to the decision of the executive council for the employment which the executive council are giving to the doctors, and being the authority which gives the final approval, I hold that, in the end, they are the chief employer of the doctor. As I said on the Second Reading, with regard to a similar set of objections that were raised to the Bill on that occasion, if this is all that the Opposition can find against the Bill, the case for it is proven up to the hilt, and if these fictitious faults are all that can be found, we can send this Measure forward with confidence to become one of the greatest social enactments for which this House has been responsible. In that certain knowledge, we on this side will give the Bill an enthusiastic Third Reading.

11.36 a.m.

Photo of Sir Hugh Linstead Sir Hugh Linstead , Wandsworth Putney

I beg to move, to leave out from "That", to the end of the Question, and to add instead thereof: this House, while welcoming a comprehensive Health Service, declines to give a Third Reading to a Bill which discourages voluntary effort and association; mutilates the structure of local government; dangerously increases Ministerial power and patronage; appropriates trust funds and benefactions in contempt of the wishes of donors and subscribers; and undermines the freedom and independence of the medical profession to the detriment of the nation. In moving this Amendment, I am, if anything, fortified in doing so by the remarks which the Parliamentary Secretary has made in moving the Motion for the Third Reading of the Bill. Nothing in the arguments which he has advanced leads me to desire to modify in any way the five terms of condemnation which are used in the Amendment. This Bill, with the Education Act, 1944, with the National Insurance Bill and the National Insurance (Industrial Injuries) Bill, make together a comprehensive scheme of social insurance which, in its aims and objects, goes beyond party They are essentially reforms which owe their initiation to the Coalition Government. One has only to think of the Education Act, 1944, which was fathered by a great Conservative Minister of Education, to recognise clearly that these social reforms are not the prerogative of any party, but are as much good Conservative policy as they are the policy of any other party. The difficulty with which we are faced is that, while on both sides of the House we are agreed upon the aims and objects, there are differences, based upon fundamental differences of principle, as to the way in which those objects are to be achieved.

As we see it, this Bill will provide a dull, a uniform, an unimaginative and a pedestrian health service. If we had had the opportunity of developing a Health Service Bill along the lines proposed by my right hon. and learned Friend the Member for North Croydon (Mr. Willink), we believe that we would have erected, in another Health Bill, a vigorous, adaptable, imaginative and progressive health service. Even in a Third Reading speech, one may endeavour to secure general agreement upon the defects of the present health services. It will be agreed firstly that they are uncoordinated, both nationally and locally. May I say, in passing, that I see many signs in the Bill that that lack of coordination will not be removed by its proposals? We shall have still half a dozen Government Departments responsible nationally for various types of health service and local services divorced one from the other—maternity services divorced, for example, from the hospital service—and we shall have health centre services where three or four authorities will meet in one and the same building.

The second defect is that the services fall unequally upon different sections of the community. The very rich and the very poor, speaking very broadly, are able to get the best of the services available. The dependants of insured people and the very patient middle-class are some of those who suffer most through the unequal incidence of the present services. Finally, they are financially unstable. It has been quite properly pointed out, and I thought with unnecessary emphasis by the Parliamentary Secretary as though he were emphasising some debatable point, that the present services are dependent too much upon private charity. There are, however, certain merits in the present services. First of all, they are a natural growth which has adapted itself to the needs of the people of the country. They are an outlet for private benovelence—and that is not a thing to be misprised. They are an outlet for voluntary public service and they have undoubtedly fostered the growth of a great medical profession and of many great medical institutions. The task of the reformer in this field is to remedy the defects which we all admit and to retain, so far as is possible, the proved advantages.

That can be achieved by centralised planning, by localised administration, by not being afraid to trust locally elected people with the spending of public money, by utilising to the maximum voluntary work in administration and by allowing the great professions to participate in the work with the minimum loss to their freedom. It was indicated, in the proposals that were put forward by my right hon. and learned Friend the Member for North Croydon how that could be done. It was by planned coordination of the services, with localised hospital services. The voluntary hospitals were still to continue to function as independent entities but financed by central grants in the same way as universities today are financed by central grants. Then we proposed that doctors should be paid by capitation fee and not by salary. By a scheme such as that we would have provided a universal and comprehensive health service containing the best of the old, and having removed the defects of the present system.

We find this Bill remote in principle, in practice and in spirit from those conceptions of what a health service should be. It is true that services are decentralised, but how is that decentralisation achieved? It is not by making use of the circumstances of local growth but by uprooting the present system, gathering it into the centre and then artificially devolving it outwards again. We find the least possible use being made of voluntary effort and the maximum central control of the professions, with every possible inducement to compel medical practitioners, if necessary against their better judgment, to come into the scheme. For example, the medical practitioner who chooses freely—in the terms which the Parliamentary Secretary used—to stay outside the scheme is to be deprived of the right of putting any of his patients into any of the hospitals in the scheme. As my right hon. and learned Friend points out, that means all the hospitals in the country. How can one say, with compulsion such as that—

Photo of Mr Stephen Taylor Mr Stephen Taylor , Barnet

The hon. Gentleman is surely aware that what the Bills says is that the practitioners concerned should not treat the patients in the hospitals but shall put any patient into any hospital, indeed, to receive any additional service under the Bill?

Photo of Sir Hugh Linstead Sir Hugh Linstead , Wandsworth Putney

If we accept the view which the hon. Member puts forward, are we not, in fact, depriving the patient of the right of being treated by the doctor of his own choice and compelling the patient to use the doctor who goes with the bed? One must draw attention to what we can only describe as the bribe of £66 million of the taxpayers' money which is being used to sweeten that pill for the medical profession.

Photo of Mrs Lucy Middleton Mrs Lucy Middleton , Plymouth, Sutton

Will the hon. Member please explain how that situation differs from the situation which obtains at the present time?

Photo of Sir Hugh Linstead Sir Hugh Linstead , Wandsworth Putney

To which situation is the hon. Lady referring?

Photo of Mrs Lucy Middleton Mrs Lucy Middleton , Plymouth, Sutton

To patients being treated by doctors who are on the staff of the hospitals to which they have obtained admission?

Photo of Sir Hugh Linstead Sir Hugh Linstead , Wandsworth Putney

I think I am right in saying that in the great majority of cases the general practitioner who so desires can follow his case into the hospital—[HON. MEMBERS: "No."]—and that no obstacles are put in the way of his doing so.

Hon. Members: No.

Photo of Mr Percy Wells Mr Percy Wells , Faversham

It may be so in the case of the very rich but certainly not in the case of the poor.

Photo of Mr Douglas Clifton Brown Mr Douglas Clifton Brown , Hexham

The hon. Member addressing the House should be allowed to proceed without so much interruption. Other hon. Members may have an opportunity later on to make their own speeches.

Photo of Sir Hugh Linstead Sir Hugh Linstead , Wandsworth Putney

Now I would refer to the specific objections which have been brought forward against the Bill. The first is the excessive concentration of power and patronage in the hands of the Minister. The Parliamentary Secretary did say that the publicly elected representatives of the people would have this power and that we ought not to be afraid to give it to them. That is a very curious way of describing civil servants who are in the Ministry of Health. I doubt whether they would recognise themselves as "publicly elected representatives of the people". The Parliamentary Secretary pointed out that all powers of nomination could be exercised by the Minister only after consultation with the appropriate organisations. But those organisations are to be selected by the Minister for the purpose of consultation. Furthermore, the chairman of a very large number of those bodies are to be selected by the Minister alone, without consultation with anybody.

The power and the patronage which the Bill places in the hands of one Department of State is enormous. Every hospital passes into the hands of the Minister. All planning and all development are subject to his approval and are his responsibility. He has the power of the purse and the power of the veto over the whole development of the health service of the country. We know why it is being done. We can see, without any suggestion of malevolence on the part of the Minister, that it is an easy, quick and tidy way which appears to him to provide the means of producing an efficient service. But the risk in this concentration of power is that it may equally well provide a poor, dull and rigid service. All the evidence goes to show that once one accumulates these enormous powers within one Government Department, drive, enthusiasm and vitality go out of the work of that department. I have had many years of doing business with the Ministry of Health and I know how difficult it is for senior officials to get their desks clear of files so that they can plan. We shall have that same process taking place on an enlarged scale when this Bill comes into operation. We shall have an administrative bottleneck in Whitehall. I cannot see how time will be found by the Minister or his advisers to plan the proper and enthusiastic development of this service.

We refer to the mutilation of local government which this Bill brings about. It is not only local government but local effort of all kinds which is going to be mutilated. The Bill will kill the voluntary hospitals. It will prevent a very large number of people who now give local voluntary service from continuing to do so because it will amalgamate hospital committees into committees managing thousand-bed units, and to that extent it will cut down the possibilities of voluntary participation. The local government structure of the country, in spite of what the Parliamentary Secretary said, will be mutilated. If one takes the whole of the hospitals away from the London County Council, what other word than "mutilation" can one use of the results of that upon the L.C.C. health service? The Government will take away those hospitals to new and remote control by Regional Boards, many of them 100 miles away from some of the hospitals they are administering. In order to compensate the larger local authorities for losing their hospitals, the Bill will take away from the smaller authorities all those domiciliary services which ought to have their roots in their own localities and will put them in the hands of the big authorities. In London that is being done despite an agreement between the London boroughs and the L.C.C., and contrary to the desires of the majority of the London boroughs. It seems in that respect that the Socialist wind bloweth where it listeth. There are occasions when they are prepared to move in one direction, but when circumstances seem to call for a volte face, they are quite prepared to blow in another direction.

We find in this Bill a very serious attack upon the sanctity of contract and the right of people to dispose of their own goods as they themselves desire. It has always been the foundation of community life that a citizen can turn to the State for the protection of his property. That in fact was why people came together into communities. Now we find the reverse of that process setting in, and the State proceeding willy-nilly to take away from the citizen, alive or dead, his own property and the right to do with it as he wishes. An illustration of that which will appeal most to the ordinary people of this country is this interference by the Minister with the seven-year covenant. Here are people who have agreed for a period of seven years to make a payment to a hospital. The Minister is now taking over from the hospitals the benefit of that covenant and is saying to the covenantor, "Whether you like it or not, in future I am going to be the beneficiary of this covenant."

Photo of Mr Aneurin Bevan Mr Aneurin Bevan , Ebbw Vale

Do I understand the hon. Member to say that I am taking away from a particular hospital the value of the covenant when in fact far more money is being given to the hospital under the scheme than it possesses now?

Photo of Sir Hugh Linstead Sir Hugh Linstead , Wandsworth Putney

All that I am saying is that the Minister is putting himself, without the consent of the covenanter, in the position of receiving the benefit of that covenant. The opinion of the covenanters when they find that they have to make their cheques payable to the Minister instead of the hospital will probably be unprintable. What makes the thing more farcical is that I am perfectly certain that if the covenanters refuse to make their payments to the Minister, nothing will in fact happen to them at all. I cannot see the Minister issuing hundreds of thousands of county court summonses to collect odd five shillings and guineas from these people. If that be so, the hollow-ness of introducing this provision into the Bill for the sake of tidiness is apparent at once. The Minister will learn the opinion of existing donors under these covenants. He has no opportunity of knowing the opinion of those who have passed on and whose benefactions he is taking away—[An HON. MEMBER: "Neither have you."] They cannot protest, but he will get from the opinion of those who are living, with whom he is interfering, some indication of the opinion which would be held by those who have passed on—

Photo of Mr John Baird Mr John Baird , Wolverhampton East

Is the hon. Gentleman suggesting that covenanters should stop paying the covenants now?

Photo of Sir Hugh Linstead Sir Hugh Linstead , Wandsworth Putney

I would say that where the purpose for which a covenant has been made has been so substantially altered, the covenanter has every moral right to cease paying his covenant if he desires to do so.

We find in this Bill, in spite of what the Parliamentary Secretary has said, provisions which will have the effect of putting the medical profession in chains. We have first of all this element of negative direction, forbidding a man to go and practise where he believes there is need of his service and compelling him to go somewhere else. We find in the prohibition of the sale of medical practices the removal of a natural and quite honourable inducement to give increased and better service. It has been said, perhaps a little cynically but none the less truly, that instead of competition to get patients, we shall have competition to avoid patients. This Bill interferes with the rights of medical practitioners to choose their partners. The selection of a partner rests ultimately with an executive committee. It deprives a medical practitioner who chooses to stay outside the scheme, of access to hospital beds. It supplants by means of new tribunals the professional disciplinary committees which have looked after the discipline of the great professions for a century—[An HON. MEMBER: "Very badly."] If we add together the emphasis upon general practice taking place in health centres together with the power of direction and the prohibition on the sale of medical practices, the answer is that in the course of a few years we shall reach a goal which is quite welcome to hon. Gentlemen opposite but will be the death of a free profession—that is, a salaried medical service. It is in that direction undoubtedly that the provisions of this Bill arc heading—

Photo of Dr Hyacinth Morgan Dr Hyacinth Morgan , Rochdale

The hon. Gentleman keeps maintaining that a salaried service means the death of the profession. Is it not a fact that the British Medical Association has agreed under this Government and other Governments to State medical services in the Colonies, and has never revoked such agreement?

Photo of Sir Hugh Linstead Sir Hugh Linstead , Wandsworth Putney

The hon. Gentleman, as a member of the medical profession, will have ample opportunity of discovering in the course of the next few weeks what his professional colleagues have to say about this.

Photo of Dr Hyacinth Morgan Dr Hyacinth Morgan , Rochdale

That is not an answer to my question.

Photo of Sir Hugh Linstead Sir Hugh Linstead , Wandsworth Putney

If the point raised requires an answer, there is all the difference in the world between a small salaried service and making submission to a salary the general condition applicable to the whole of the service and the whole of the profession. The Minister will doubtless say, as the Parliamentary Secretary has indicated, that the apprehensions expressed on this side of the House with regard to the development of the service are groundless. He will say that he has no intention of producing the kind of results that I have indicated. Nevertheless, the power resides in his hands to do that. We have seen a change in the Minister's outlook as the Bill has passed through Committee, but that change is not reflected in the structure of the Bill as we have it now for Third Reading and we, in this House, cannot rely upon our assessment of what an individual Minister may or may not do with an Act. We have to look to the future, and we have to visualise the structure of this new service in relation to other legislation which has to be passed during the course of the next two or three years.

It may be easy to justify making 20,000 doctors State servants, or even 50,000, 60,000 or 70,000 nurses or 100,000 hos- pital staffs, but when you are adding to that hundreds of thousands of miners and hundreds of thousands of railwaymen, then you are making a change in the structure of our community which is not quantitative but qualitative. It is impossible to consider a Bill of this kind without relating it to the general progress of allied legislation.

Photo of Dr Leslie Haden-Guest Dr Leslie Haden-Guest , Islington North

It is progress, of course, the hon. Member agrees?

Photo of Sir Hugh Linstead Sir Hugh Linstead , Wandsworth Putney

Progress is movement in any direction—[HON. MEMBERS: "No."] —and all that I can see in this Bill is movement in any direction for the sake of movement.

What I have said supports the Amendment I have moved, but I think those of us who served on the Standing Committee would not desire to conduct this Debate on a negative note. If one admits the premises upon which this Bill has been constructed—and on this side of the House we condemn them as being false and harmful—then I think those on Standing Committee C would desire to say that they believe the present Minister will bring enthusiasm and vigour to his task. We find real danger of sterility, of a bottleneck in administration; we believe that there will be a second-rate service as the result of the provisions of the Bill. But nevertheless we would recognise that we have here now practically a fait accompli, and the least we can do is to give the Minister our good wishes and to express the hope that the lessons which I really believe he learned—although he was careful to give no visible indication that that was so—the lessons which in fact sank into the Minister during the progress of the Bill in Standing Committee, will have their result, and that he will lighten the centralised direction, and give full play to initiative and enthusiasm and professional freedom, remembering that those are the things that have built the greatness of British medicine.

12.4 p.m.

Photo of Commander Sir John Maitland Commander Sir John Maitland , Horncastle

I beg to second the Amendment.

In doing so, I wish to speak from one particular angle; that is, the angle of the countryman and of how this Bill as it is now before us, affects him and the countryside. I want, in other words, to consider the question of what the countryman gets for his 10d. First, on the credit side, it is absolutely right and true to say that he may expect a better specialist service when specialists are available; a better planned system of hospitals; and he may be certain of being sent to a hospital specially equipped to deal with his particular complaint. It is, however, germane to any great national health scheme, as my hon. Friend the Member for Putney (Mr Linstead) said, that these things should be so, and there is nothing very particular in this Bill because it is obvious that any national Bill produced by any party, all of whom were pledged to do so, would have had this result.

But there are certain disadvantages—I tremble to call them discredits—attached to this Bill. In the past, the countryman, who has to live a much more individual life than the townsman, has had considerable control over the small and possibly not so efficient hospitals—they may not be so efficient but they do their best—in existence in the country. If he has not liked the people on the committees, he has been able to remove them directly. [HON. MEMBERS: "Oh."] Oh, yes, he has, quite certainly. What has he now? Over a scattered area, there is set up a hospital management committee dealing probably with something like 1,000 beds. He cannot get at that hospital management committee except through his Member of Parliament. That is really the only way he can bring pressure to bear with regard to general principles or things which he thinks are being done wrong. He cannot go straight to the source as he has been able to do before and, of course, if you feel that you have people very much on your tail, as many small hospital committees have felt, then it does tend to keep you up to the mark. Of course we shall do our best to keep the Minister up to the mark as well.

I make a special appeal to the Minister to consider very carefully the geographical conditions of these great areas which he is to bring in under the hospital management committees. It is very important that he should do so and I am sure he agrees at the bottom of his heart. We on this side of the House are desperately sorry that so much of the personal element has passed, or will pass, with this Bill. These problems do not affect the townsmen; theirs is a much easier position under this Bill. They will get, as I think I shall be able to explain in a moment, rather more for their 10d. than the countrymen. Later I want to make certain suggestions to the Minister on how this might, be overcome, but now let us come to the third part of the Bill, of which undoubtedly the key point is the provision of health centres. Obviously, to anybody who knows the countryside, the problem of health centres is a very difficult one. In a great city it is true you can have your efficient health centre something we have all read about, something we all hope for, something we shall all get but how different it is in the country. We realise that there must be temporary arrangements, smaller health centres and so on in the meantime, and we hope that these will go on while experiments are made in how best to deal with this problem for the country.

That brings me to the point, that this Bill raises an important question of principle. I believe that this Bill, with its universal subscription of 10d. a week, will not bring equal benefits. So here is a problem which we in the country are faced with more and more acutely, whether we shall get equal benefits for equal contributions. We have, first, the health services. Then we have, in the third part of the Bill, those services which are being dealt with for us by the local authority. That means a very heavy increase in the rates to get anything comparable to the services available to the townsman. I beg the Minister to keep that point prominently in his mind, and when the time comes for block grants and general reconsideration of this problem, to give it his full consideration. In this third part of the Bill, there are, I maintain, perhaps the most important parts which affect the countryside. In particular the ambulance service. I say that because it means transport, and transport and communications are the keys which can make these services work in the countryside. I particularly ask the Minister to give attention to these questions of communication and transport when he comes to issue his instructions to the local authority as he is entitled to do under the third part of the Bill.

I conclude by saying that this is a Bill which we must all wish well. Once the battles are over, the Minister need have no doubt that we will all do our best to make it a success. So far as I am concerned I shall do my best to make it a success. That is the basis of British legislation. But this Bill is only a stage, it is only a step, and it will lead to a better realisation of the need and the importance of the health of the people as our greatest asset. We bitterly regret that this Bill does not contain the better things of the past as well as the things for the future. We believe that it lacks humanity. We believe that it should have brought in far more freedom both for the administrator and the patient. For those reasons we shall oppose it in the Lobbies this evening.

12.13 p.m.

Photo of Mrs Bessie Braddock Mrs Bessie Braddock , Liverpool Exchange

Having sat in silence for many hours in Standing Committee C, I now break the silence which I then voluntarily imposed on myself. Many of us on this side of the House were concerned, in the first instance, with some of the recommendations or suggestions in the Bill. But having given it full consideration, many of us, who have served on local authorities and on hospital committees for many years, felt that the foundations of the Bill would give for the first time, to every individual in the country, the right bylaw to have the fullest possible assistance with reference to health and illness. I would like to have seen, in other Bills, the right by law of the citizens of this country to have the things that are necessary. I would like to have seen in the National Insurance Bill the right of every citizen in this country to work. But on this occasion, and in this Bill, for the first time within my knowledge of political history, the citizens of this country will have the right to the best that the country can give them in regard to health services.

I listened for many hours to long speeches by the Opposition in the Standing Committee. I could not help feeling that some of the Members who took part had very little knowledge indeed of the actual working of hospital services in this country at the present moment. The hon. Member for Putney (Mr. Linstead) who moved this Amendment said that the voluntary hospital system was a natural growth. It was nothing of the sort. The voluntary hospital system established itself because Government after Government in this country refused to accept the respon- sibility of establishing hospitals for the community at large. I pay my tribute to the work which the voluntary hospitals have done in this country in lieu of the work which the State should have undertaken as a responsibility. But when the Local Government Act, 1929, gave the right to local authorities to appropriate the institutions, as they were at that time, under the control of the boards of guardians, those local authorities who accepted their responsibility, commenced to build up their municipal hospitals at a much faster rate than the voluntary hospitals were able to maintain. Since 1930, we all know that the voluntary hospitals have gradually declined in their ability to meet their financial responsibilities. This Bill actually saves the voluntary hospitals from complete extinction in a very short time. It gives them exactly the same degree of status as that to which the best of the local authority hospitals have been built up.

Irrespective of all the opposition, which in my opinion is on many occasions simply by-play from the other side of the House, I am certain that hon. Members mud believe that this Bill is the biggest stop forward that has ever been proposed in this House of Commons, in an attempt to keep the people of this country healthy when they are well, and to deal with them kindly when they are ill. What has happened with reference to voluntary hospitals? They are not voluntary in the actual sense of the word. The amounts bequeathed by people of good will or paid during their lifetime have never been sufficient to meet the total cost of treatment in voluntary hospitals. Voluntary hospitals became the plaything of those people who had money to spare, and felt that they would like to donate it to some good cause. Since 1930, the costs of hospital administration have gone up terrifically, in municipal hospitals as well as in voluntary hospitals, but because the municipalities are able to levy a rate to maintain their hospital service, they have been able to progress at a much faster rate than the voluntary hospitals.

I have had the honour to be the only woman member representing Liverpool on an advisory hospital committee in Liverpool, and there we had working what I might describe as a small edition of the Bill which we are now discussing. There was a realisation in the local authority that the voluntary hospitals, the university and the municipal hospitals must keep pace with one another. Twelve years ago we established such a committee in Liverpool. We have been able to get complete agreement with the university, voluntary hospitals and the municipality on free treatment and on the question of a teaching hospital, where teaching should be done and how it should be done. Having had that experience, I feel that this Bill is an extension of that small attempt which we made in Liverpool to coordinate the whole service.

For the last two or three days we have again been treated to headlines about what the doctors will do. I do not believe that the doctors of this country would ever take the line that they were not prepared to treat people who required treatment. I feel they are sensible enough and have sufficient imagination and foresight to know that this scheme will be their salvation, that it will give them an entirely different status of medical knowledge and superiority. In the past only a few people have been able to rise to the very highest points of the profession. With the provision of teaching facilities and opportunities to deal with every section of the community, which there will be under this new service, I can see this country coming to the front and attaining the highest possible level in its medical services.

There are plenty of medical men in this country who welcome this Bill most sincerely and who will be prepared to give of their best irrespective of whether they are likely to lose a few pounds in the application of its principles. I think their financial stability and standing will rise considerably under the new scheme; but, supposing they do lose something, is it suggested that a person who has taken all the training necessary to become an efficient doctor or specialist will weigh the advantage of a few pounds per year, or a few pounds per week, against what he can gain in experience by having the fullest access to every feature of health administration in the country? I do not believe that. I know many doctors in the Liverpool area—I represent the Harley Street area of Liverpool, as my Division includes a district in which there are many highly-qualified medical men— who welcome this Bill and who are prepared to work the scheme with unimpaired efficiency.

We have recruited some of the finest types of medical men to the municipal services of the country. They are waiting an opportunity, both in voluntary and municipal hospitals, to cut out completely the present uneconomic method of dealing with hospital services. The practice of having small hospitals, with a small number of beds, dotted here and there about the country as separate entities is uneconomic. It costs far too much and we do not get a benefit corresponding to the present cost. In reference to health centres, they are something which the Socialist Party have desired for a long time. We want to feel that every citizen has the same opportunity. When I talk about citizens I am referring to those people of the poorest sections of the community who are not in a position to buy good medical treatment and who require to have it offered to them as a right in return for the services they render for the good of the country, when they are allowed to do so, in other words, when there is plenty of work for them to do.

When the hospital services go over to the regions and the health services become the responsibility of the local authorities, is it suggested that those municipal councillors who are given the responsibility will not vie with each other in their ability to build up in their area the very best hospital health centre services? It may be in certain sections of the country where there are bad hospital conditions, due to the bad type of representation that there has been on local authorities, that those local authorities will lag behind in the question of health centres, and the application of health services in the area; but the Minister is given the right, if that local authority does not face up to its responsibility, to suggest and insist upon a way whereby improvements will be made. The power given to him under this Bill is something he will use to the best advantage.

I know many other hon. Members wish to speak and I conclude by welcoming this Bill and congratulating the Minister heartily upon the manner in which he has presented it and the courage with which he has acted. I assure him on behalf of the Liverpool area, and other areas in Lancashire which I know intimately, that we as members of local authorities as well as Members of Parliament will take every opportunity of putting into operation what we consider to be a complete Socialist Measure in order to ensure that the whole of our people will have the advice and treatment which they require.

12.26 p.m.

Photo of Mr David Eccles Mr David Eccles , Chippenham

I count myself fortunate to follow the interesting speech made by the hon. Lady who represents the Exchange Division of Liverpool (Mrs. Braddock). In the brief remarks that I intend to make, I will try to deal with that part of her speech which referred to the future status of the medical profession. The hon. Lady told us she represented the Harley Street of Liverpool. I was born in the Harley Street of this city. I make my speech as the son of a doctor. Indeed, my father, grandfather, and great-grandfather all qualified at St. Bartholomew's Hospital, and it is my conviction that if Lord Dawson of Penn, who was my father-in-law, had lived two more years, we should now be debating a better Bill. For as long as I can remember, the doctors whom I have known advocated large changes in our national health services. They were quite aware that the parallel systems of municipal and voluntary hospitals were inadequate. But they always maintained that when the time came to make those changes, nothing should be done for the sake of pure politics, or for administrative tidiness, which would compromise or injure the independent character, the standards, or the prospects of the medical profession and all those who helped them to attend the sick.

If I can show the House that this Bill, with its splendid objective, does in fact deal an unnecessary and serious blow at the standards of the medical profession, I feel I should be expressing the views which my father and Lord Dawson would have held about this Bill, and at the same time, supporting the Amendment which my hon. Friends have moved from these benches. I take it that the essence of the controversy between the medical supporters and opponents of this Bill is the doctor's responsibility. To whom should the doctor be responsible—to his patient, to the State, or to both? The Bill lays down that he should be responsible to both. Can a man serve two masters? Judging from his speeches, I think the Minister has never really appreciated the consequences of his solution to this dilemma of responsibility.

I admit that the medical profession often have not made their own case to the best advantage. They do not always carry the conviction which they ought to carry when they insist so stubbornly upon the value of freedom of choice. The House will admit that this Bill weakens the freedom of choice—I will show how later. I imagine many hon. Members opposite will say, "What does that matter since freedom of choice never really existed for anybody but the rich?" The Bill takes away the single duly to the patient and substitutes for it this double responsibility to the State and to the patient. It does it in this way. The Minister is dealing four shrewd blows at the general practitioner's freedom. First, he prohibits the purchase and sale of practices. That means that the goodwill which the doctor ought to strive to build up will no longer be encouraged and will no longer be measured by a reasonable reward. Secondly, the doctor loses his right to practise anywhere where he thinks his services may be wanted, and that means that a son may not be able to follow his father—.

12.32 p.m.