General Practitioners (Danckwerts Award)

– in the House of Commons at 12:00 am on 30th October 1952.

Alert me about debates like this

Motion made, and Question proposed, "That this House do now adjourn."—[Mr. Buchan-Hepburn.]

12 noon.

Photo of Mr Hilary Marquand Mr Hilary Marquand , Middlesbrough East

In the short time that we have available, we wish to draw attention to a document entitled "Report of Working Party on the Distribution of Remuneration among General Practitioners," which was published some weeks ago.

This document has aroused sharp controversy within the medical profession since it was published, and there has been a good deal of correspondence, some of it quite acrimonious, in the medical Press and especially in the "British Medical Journal." I am therefore sure that general practioners everywhere are waiting with very great interest to hear what the Minister of Health has to say about it. On this side of the House we were very glad indeed to hear him say in the House last week: I shall be happy to consider any representations which are made on this important matter."—[OFFICIAL REPORT, 23rd October, 1952; Vol. 505, c. 1254.] We approach the subject, therefore, in a spirit of exploration, and shall try to explain to the right hon. Gentleman what misgivings we have felt and have had expressed to us about the contents of this document, in the hope that he will be able to help those who have those misgivings and indicate that changes in the plan can be carried out. The working party deliberated during the term of office of the Lord Privy Seal, and the present Minister has no personal responsibility for the document. I hope that that fact will have helped him to keep an open mind on the subject and that he will not feel himself committed to every word, comma and full stop in that document.

Photo of Mr Iain Macleod Mr Iain Macleod , Enfield West

Perhaps I should get this point absolutely clear. It is true that a change of Ministers took place about that time, but in fact the deliberations were not complete and I knew the details before they were communicated to the representative body of the profession. I therefore have, to that extent, responsibility for the document.

Photo of Mr Hilary Marquand Mr Hilary Marquand , Middlesbrough East

I certainly would not wish to mislead the House about the matter and I thank the right hon. Gentleman for that explanation. I was a bit wrong on my dates, but I still hope that the right hon. Gentleman will feel, as I think he indicated in his answer to the question, that he is open to consider representations on this matter. He still has time before the final decisions need to be taken and implemented. If I understand the matter aright, the redistribution of the money now made available to the central pool does not begin to take effect until 1st April next. We hope that between now and then it may be possible for our representations to have some effect.

One can hardly overstate the importance of the general practitioner service, within the National Health Service. The citizen usually makes his first contact with the service through his general practioner and certainly makes his most frequent contact with the service in that way. Without a good general practitioner service, the whole National Health system would break down. The first three years of experience of the National Health Service revealed defects in the working of the general practitioner service. I do not think there is any doubt about that, or any occasion for surprise that a new service of a vast and comprehensive character, covering for the first time almost the whole of the population, should not have been perfect in its initial operation.

Practitioners themselves made complaints from time to time about the very large number of patients whom some of them were asked to look after, and some suggested that they had insufficient opportunities for hospital practice or insufficient access to modern diagnostic aids in their practice. The younger men among them certainly complained very bitterly of the difficulties they experienced in entering practice as principals. Patients, in turn, expressed disappointment at the amount of waiting that sometimes took place in surgeries and about the slowness of development of the National Health centres. Ministers had their complaints, too, especially at the size of the drug bill.

It seemed to me a little more than a year ago—about 18 months or so—that some amendment of the system of remuneration of general practitioners might help to remedy the most serious of those evils. The system of payment of general practitioners was inherited from the National Health Insurance Act. It made available a global sum to be shared out among all general practitioners to cover their expenses as well as their earnings.

It is sometimes forgotten by the general public that the rate of remuneration covers the practitioner's expenses as well as his earnings, and that something nearly approaching £4 out of every £10 received has been found to go in essential and inevitable expenses. It is obvious that if a global sum has to be shared out among a number of practitioners, the fewer there are to share it the better chance any individual has of obtaining a more satisfactory income. In other words, a system of that kind lays itself open to the danger—I put it no stronger than that—of restriction of entry.

When I looked at the position, I could not but be worried at the rapid growth in the number of salaried assistants. In 1948, there were 17,438 principals and 562 salaried assistants working for them. In 1951 there were 18,195 principals and 1,724 assistants. In other words, the number of principals had increased by about 4 per cent. and the number of assistants by 206 per cent. Among those assistants were numbers of youngish men and women who had returned from the Forces or from overseas in the Colonial Service and who wished to enter the profession, but found it impossible to obtain places as principals. Among them were some very hard cases indeed.

I wanted to remove some of these defects, at least in part, during my period of office, if I could, in the interests of national economy, as well as in the interests of the poorly paid doctor and, above all, in the interest of the patients.

At the time I took office I found that a claim by the doctors for an increase in the size of the central pool had gone through all the appropriate stages of negotiation and all the appropriate stages of discussion by the machinery laid down for carrying out negotiations of that kind. It had gone through all the stages and agreement had not been reached, so my right hon. Friend the Member for Greenock (Mr. McNeil) and I had no alternative at that time but to try to settle this matter by personal negotiation.

We agreed from the outset that there was a prima facie case for an increase in the size of the central pool because, during the years from which it was first established and the inception of the National Health Service, until that time there had been a considerable rise in prices involving a very considerable increase in expenses. I have already explained that expenses form a considerable proportion of the doctor's total remuneration. There was, in addition, the normal ordinary feeling of doctors, like other persons, that their incomes should rise if general prices and the cost of living rose considerably.

At that time my right hon. Friend and I asked ourselves whether we could help make an effort to get a wider, broader and more comprehensive agreement about the whole of the Service, to settle the immediate question of an increase in remuneration and at the same time to include in that wider settlement a removal of some of the defects to which I have very briefly alluded and advance to an improved Service in a better atmosphere. Here I must explain that there was a sharp difference of opinion between the doctors and the Ministers about the method by which the size of the central pool was calculated. That method of calculation was supposed to implement the findings of the Spens Report, on the basis of which the general practitioners had originally entered the National Health Service.

The Spens Report is an extremely complicated document and there is not time, nor do I propose, now to explain it. The doctors claimed that the system adopted and the result arrived at had not implemented the Spens Report; the Ministers said that it had. We thought the Spens Report had been implemented; the doctors thought not, and felt very strongly about it.

My right hon. Friend and I felt that, after the negotiations—and they were prolonged negotiations—we might be able to make an advance towards the better Service which we wanted if we could get this bone of contention out of the way, and we were confident that our case was a good one. The doctors, I am glad to say—I willingly recognise it—met us half-way. We agreed with them to ask an independent person to adjudicate on this complicated question of whether or not the Spens Report had been implemented and, if not, what would be necessary to do so. We agreed that, and at that time the General Election took place; we went out of office, and our successors took over.

Mr. Justice Danckwerts was selected as the adjudicator of this detailed question. I make no complaint whatever about that; he was selected in agreement. It is important to realise, as I do not think it is generally realised, that Mr. Justice Danckwerts was not asked to arbitrate a wage claim, but simply to adjudicate this one question: Was the Spens Report implemented and, if not, what adjustments needed to be made in the size of the central pool to bring about that implementation? We had agreed to the reference of that particular point to adjudication on one condition only, and definitely on that condition. The second part of our bargain, so to speak—I hope that colloquial language will not be misunderstood—was that there should be a Working Party to work out a new method of distributing the money. The Working Party had agreed terms of reference: To secure an equitable distribution of the Central Pool based upon the recommendations of the Spens Committee, the object being to enable the best possible medical service to be available to the public, —the object which was principally in our minds the whole way through— and to safeguard the standard of medical service by discouraging unduly large lists; at the same time to bring about a relative improvement in the position of those practitioners least favourably placed under the present plan of distribution, to make it easier for new doctors to enter practice, and to stimulate group practice. The General Medical Services Committee, which is the negotiating body on behalf of the doctors on all these matters, gave an assurance to my right hon. Friend and to me that: it would be the aim of its representatives to work harmoniously with a desire to provide the best possible service for the public and make possible a better and happier atmosphere among the doctors who take part in it. So we were agreed between us that improvements in the Service were necessary and should be part of this procedure of adjudication and Working Party combined.

As is well known, Mr. Justice Danckwerts found in favour of the claim by the doctors. He found they were right in their contention that the Spens Report had not been fully implemented; that the central pool had not been large enough to carry out the terms. I confess that I was surprised, and I said so at the time, by the extent to which he found that proved. I do not want to take refuge behind anyone else; I accept full responsibility, but I had felt all along that we had implemented the Spens Report. But, having felt it was the right thing to do and resorted to an independent opinion, there is no sense in complaining when that opinion goes against one.

My right hon. and hon. Friends and myself made no attempt to resist the passage through the House of the Supplementary Estimate which was necessary to implement the Danckwerts adjudication. The back money has been paid, or, I understand, it is in course of being paid. There it is, we say no more about that: I do not think there is any necessity to discuss it.

What remains is the second part of the bargain. It was an essential part of the bargain—no one denies this, although some have not fully understood it—that, although Mr. Justice Danckwerts did not accept the claim of the doctors that as much as £16 million extra should go into the central pool for the year 1950–51, he did put the figure at about £10 million. When I heard that announced, although, as I freely admit, it surprised me, it seemed that at any rate it had one great advantage.

If so large an amount of money was to be made available, the chances of the Working Party getting a really satisfactory improvement in the Service, a better atmosphere and all the other things which were laid down in the agreement were very much improved. We had hoped that with this considerable amount of money available, the Working Party would have been able to get a scheme of improved service, better distribution and better opportunity among the doctors which would have been a really thorough and completely satisfactory change. But when we read the Report of the Working Party we could not agree that it had, and we declared that we felt that a great opportunity had been missed. We issued our statement to that effect on 24th June, and on 27th June no less a body than the Fellowship for Freedom in Medicine issued a statement in which they said: We believe that a great opportunity has not been fully grasped. I do not suppose anyone will suspect Lord Horder of having copied a statement from the Labour Party, and it is a very significant coincidence that Lord Horder and his organisation, studying the Report of the Working Party, came to exactly the same conclusion as I and others on this side of the House, studying that same Report.

Let me, then, try to explain briefly where and why the Working Party's Report fails to give us the justice and the better Service we had a right to expect. I have seen and read on this matter about 80 letters. I have them here in case anyone else might wish to inspect them.

I should like to say, in passing, that the writers of these letters will be able to read this debate, and I hope they will forgive me for not having replied or even acknowledged the receipt of the letters. I have no resources whatever behind me to enable me to carry out secretarial work of that kind. I am grateful to all those who wrote to me and expressed their point of view. As well as letters which I have received, as no doubt Members in all parts of the House have done from their medical constituents, there has been a great deal of correspondence in the medical Press in the form of articles, etc.

One can sum up the extent to which we feel the Working Party failed in its task of achieving a satisfactory redistribution and an improved Service by considering the matter under the headings of each of the main terms of reference in turn. The first term of reference was to discourage "unduly large lists." That meant endeavouring to reduce the very large lists which some doctors have, especially in the more thickly populated parts of the country, which make it extremely difficult for the general practitioner to give the sort of service to each of his patients which a good doctor would like to give.

The Working Party has proposed to reduce the size of the maximum list from 4,000 to 3,500. I should like to ask the Minister if it is true that the number of patients involved, that is, the number to be released, as it were, from these larger lists and made available accordingly to other doctors with smaller lists and smaller incomes, is only 500,000? That figure has been given in the "Medical World." The Fellowship for Freedom in Medicine, in their publication, said that it must be under one million.

I should be glad to know from the right hon. Gentleman, if he can find out by the time he replies, whether these are accurate figures.

Photo of Mr Iain Macleod Mr Iain Macleod , Enfield West

It is an important point that may affect other Member's speeches, and I can tell the right hon. Gentleman now that, on the best information available to me, the figure is two million.

Photo of Mr Hilary Marquand Mr Hilary Marquand , Middlesbrough East

That is encouraging if true, because had the figure of 500,000 been true it would have meant the giving of very few additional patients indeed to the other doctors. I am very glad to have that information. It still remains true, however, that 3,500 patients is quite a large number for an individual doctor to look after. No doubt some of my hon. Friends if they have the good fortune to take part in the debate, will be able to say a little more about that in detail.

I cannot make a positive suggestion about this matter without access to the sort of information which only the Minister himself has. One did feel, however, that though it is right to reduce the maximum list to 3,500, and though no doubt as a first step an arbitrary reduction in the maximum figure could not be carried any further, there might, none the less, have been some provision for the tapering off of the capitation fee, say, between 3,000 and 3,500 patients so as to give less inducement to obtain the maximum number. I put it no higher than that.

The second term of reference was to bring about a relative improvement in the position of those practitoners least favourably placed under the present plan of distribution, … As the Fellowship for Freedom in Medicine say, these fall into two groups, the unestablished doctors and the small list doctors. I will leave the first group, the unestablished doctors, until I reach the third term of reference. Let us consider for a moment the problem of the small list doctors.

The greatest volume of complaint about the Working Party's Report, and perhaps the greatest intensity of complaint, has come from them. Of the 80 letters I have seen, 64 voiced the grievances of small list doctors. No doubt there is a great variety among them: some may be elderly and unwilling to take any more patients; some may be incompetent and unable to keep any more patients. But that is not the whole of the story.

Many of them—large numbers, I am sure—are young or middle-aged people, who, as I have already said, have not yet had a full opportunity to develop any practice. Perhaps I may quote one example from the letters of this kind which have been sent to me. This is letter from a woman doctor, and of course, in considering it, one must recognise the fact that women doctors do not always find it so easy to build up a practice as do male doctors. But no one in this House will say that we do not want women doctors in general practice.

I will quote her actual words: I was overseas for the whole period of the War most of that time as Superintendent of different hospitals. On my return to England in 1947 I started Practice as a principal.…The number of patients on my List 1st April, 1949 … 20, in April, 1950 … 128, next year 294, in 1952 … 531, present date … 631. There is a doctor who is evidently competent, who evidently attracts additional patients, who is evidently making a good and moderately successful effort to build up a practice. Yet here are her financial results: The following are extracts from my Accountant's figures:Net loss for year ending 1948–49, £331-odd.Net loss for year ending 1949–50. £173-odd.Income for 1950–51, £50 4s. 10d.Income for 1951–52, £79 0s. 10d.(This figure excludes the cost of my car, £650.) A doctor nowadays must have a car.

She concludes, perhaps her calculation may not be completely accurate but it cannot be far from the truth: It appears I will receive approximately £10 only … from the Danckwerts Award. That is under the Working Party's proposed re-distribution.

It has been published in the "Medical World" that some doctors—it is difficult to believe this is true—will actually be worse off under the new scheme of redistribution. I do not think that is consistent with a term of reference stating: to bring about a relative improvement in the position of those practitioners least favourably placed.… Not merely an absolute improvement, let the House note, but a relative improvement was asked for.

The "British Medical Journal" of 9th August, presumably reporting on something they had agreed with the right hon. Gentleman, said: A sum of £50,000 will in future be set aside annually to help elderly doctors. If in practice other categories of doctors (especially those with small lists) turn out to have lost under the new arrangements, something can be done to help them when the final settlement for the year is made. A substantial sum of money is likely to be available for this. We should like to know how substantial it will be, and how they will have to apply for that money. There is this substantial sum. Will it be on the basis of a means test? If the sum of money is really substantial, if there is plenty of it available, might not it be provided now to meet the grievance of the small list doctors by some increase in the capitation fee, shall we say between £250 and £500?

Again, that is only a tentative suggestion; I do not put it forward firmly. I do not know what the effects of it will be, and I know these things have to be discussed. But one does want to feel that a relative improvement can come about for doctors who deserve it without their feeling that they have to submit themselves to an unpleasant and distressing examination of the full state of their income and, for all I know, their property and all those other things.

The third term of reference was to make it easier for new doctors to enter practice. What we have in mind at that time was the large number of salaried assistants. I am told that today the number is 2,300 and that there are, in addition, 500 hospital registrars seeking employment. Let me be clear. I am not saying there should be no assistants full-time. It is a reasonable thing that a young doctor should begin in that way; but a man should not be an assistant year after year, and be given a number of patients to look after in respect of whom he knows that his principal is drawing in fees very much more money that he is paying his assistant in salary. That causes resentment and bitterness and does not make for the better Service we all want to see.

I know that the Working Party's Report does claim to have found ways of encouraging practitioners to take partners rather than assistants. I recognise that Indeed, I think they have found a very useful way of doing it by means of a special loading, and by saying that that loading would not apply in the case of patients attributed to an assistant, thus encouraging the principal to turn his assistant into a partner. But grave misgiving has been aroused, none the less, among all these unestablished doctors by the use of the term "permanent assistant" in paragraph 5. I think the right hon. Gentleman must be aware of that, and I hope that he may clear up the misunderstanding.

It is most important to clear the minds of those men who feel bitter about it. Numbers of them have signed circulars about it, and sent them to their Members of Parliament, with the idea that the right hon. Gentleman is contemplating a continuance of this system of their being assistants for year after year, and of continually being fobbed off with one excuse after another that partnership cannot be arranged.

Because of the fear that the reduction in the size of maximum lists is not sufficient to make possible a satisfactory redistribution of patients, these young men fear that the system of assistantship is likely to be perpetuated. Surely a method could be found of reassuring them. It might perhaps amount to prohibiting the continued employment of assistants by any principal after a certain time. Or would it not be more reasonable that, instead of saying that 2,000 patients will be attributed to an assistant, to put the figure at 1,000, or, if that is too small, at 1,500, to reduce the amount of the profit, so to speak, which the principal will make out of the employment of the assistant; and therefore to increase the incentive, which I admit has been given to him, to turn an assistant into a proper partner?

We also need a safeguard against the possibility of establishing unfair partnerships, and this could be done easily by agreement without amendment of the Working Party's Report. Young men fear that, too. I have not invented these things they are what have been told to me. It is feared that it might be possible to offer a partnership which is really unfair but which would meet with the requirements, while entitling a principal to extra fees. The British Medical Association does supply model contracts for the employment of assistants, and I wonder whether they could be persuaded to draw up a model contract for partnerships which would give a safeguard of that kind.

I come now to the fourth term of reference—to stimulate group practice. From the point of view of the public and the patient, this is the most important of all the terms of reference given to the Working Party. The suggestion of group practice is certainly no novelty, and it is certainly not an invention of any particular person or party. Long before the National Health Service started, the British Medical Association set up a Medical Planning Commission which surveyed the then existing National Health Insurance Service, and that Commission said: Diverse as are the views on the organisation of medical services, there is general agreement that co-operation amongst the individual general practitioners in a locality is essential to efficient practice under modern conditions. They are strong words, but I agree with them. Though views vary on the form of the co-operation, the principle of the organisation of general practice on a group or co-operative basis is generally approved. I have more quotations here from the White Paper of 1944 and from a speech made by the right hon. Gentleman himself at the opening of Woodberry Down Centre, but time is getting on and I know that other hon. Members are anxious to speak, so I will omit them.

We are all agreed about this, at least in the form of the essentiality of group practice under modern conditions to the proper practice of medicine and to giving the general practitioner the proper opportunity of adequate diagnosis and the rest of it. Of course, the obstacle to the extension of the full system of health centres, which is the ideal way of carrying out group practice, is finance. I am not suggesting for a moment that any money in the central pool should be used for building health centres. Far from it, but it was part of the bargain on which I agreed to the reference to an adjudicator that group practice should be "stimulated." That was the word which was used—not a pious blessing, not even "encouraged," but "stimulated."

Yet what does the Report of the Working Party say? One short paragraph of five lines is devoted to this subject and it says: A sum of money should be set aside (provisionally £100,000 is shown) so that it may be possible, if necessary, to introduce further measures to stimulate the formation of partnerships working as a group practice. It may, however, be found that the other measures which the Working Party has proposed will go far in this direction. That does not sound like stimulation to me. It does not sound like an honest, vigorous determination to stimulate the adoption of group practices which is so important from the point of view of the patient and the public, as well as from that of the medical practitioner, who wants to use his art as fully and thoroughly as possible. Detailed suggestions as to what might be done in the formation of group practices on a modest scale and without vast expenditure will, I hope, be given by some of my hon. Friends behind me, if they are successful in catching your eye. Mr. Speaker.

I appreciate the difficulty in which the right hon. Gentleman no doubt finds himself. He cannot go forward without agreement, I know, but he has told us that he is willing to listen. I believe that he will be willing to try to remove some of the imperfections in this scheme, and I have tried in what I have said to avoid exciting party feeling. Though I was severely criticised in the "British Medical Journal" for raising the matter at all, I have refrained from any criticism of the British Medical Association.

To get an improved new scheme requires the good will and determination of the right hon. Gentleman and the British Medical Association as well, so I ask them, in the spirit in which I have tried to address the House today and display some of the grievances and feelings that exist, to remember the words of the General Medical Services Committee, when they said to me: It would be the aim of its representatives to work harmoniously with a desire to provide the best possible service for the public, and make possible a better and happier atmosphere among the doctors who take part in it. There need be now no fear that anyone is going to say, "If you want the money you must vote for the whole document." Let us try to see whether the right hon. Gentleman, in agreement with the General Medical Services Committee, can go forward to effect improvements on the lines which I have suggested, in which case he will meet with no opposition at all.

12.42 p.m.

Photo of Mr John Vaughan-Morgan Mr John Vaughan-Morgan , Reigate

The right hon. Gentleman the Member for Middlesbrough, East (Mr. Marquand) has made a rather long, but very temperate and modest speech. I think the writers of the 80 letters sent to him will be disappointed in not having had acknowledgments or replies to their letters, and even more disappointed at how few constructive ideas the right hon. Gentleman has put forward today.

I should like to remind the House that we are discussing, not only the Report of the Working Party, but the Danckwerts Award as a whole, and, when the right hon. Gentleman said that he had tried not to excite any party feeling, I thought that was a little cool, considering the record of his party as a whole in this matter.

This quiet Adjournment debate today has a long pedigree, which goes back to 25th March of this year, when my right hon. Friend the Lord Privy Seal came to the House and announced the terms of the Danckwerts Award. It was received—let us be quite frank with ourselves—with surprise in all quarters of the House, until we had had time to consider it and to learn what had led up to that award being made.

During the exchange of views that then took place, the right hon. Gentleman the Member for Middlesbrough, East did not ask any questions about that award other than to ask whether the Working Party, which was part of the agreement, was making its Report or not. The atmosphere of discussion changed very rapidly thereafter. A few days later, when we were engaged in discussing the Health Service (Charges) Bill, one back bencher on the opposite side of the House referred to this award as having shocked the great majority of the people of this country.

That was not answered by the right hon. Gentleman, as far as I can trace, in any of our debates then or later. The only contribution he made was an article in the "Daily Herald" of 27th March, which merely related the facts to the readers of the "Daily Herald," and must have added bewilderment to the sense of shock which they were already suffering.

But the matter was not allowed to rest there, and, despite the responsibility of the right hon. Gentleman for the origins of this award, a week later, on 5th April, 1952, the Labour Party at Transport House issued a document called "Talking Points," which, I gather, goes to all party workers and speakers in the constituencies. This document started off by inveighing against the wicked Tories for making charges under the right hon. Gentleman's Bill, and ended up by giving Labour's view: The Labour Party is shocked by the size of the award. A Labour Government would have put its case at the inquiry with vigour. The document ends up with this categorical statement: Labour says that the award to doctors is too high. I do not know whether or not Transport House consults the right hon. Gentleman before it issues documents on health matters where, after all, the right hon. Gentleman holds a certain responsibility for their policy, but that document was issued, and I can find nowhere in the utterances of the right hon. Gentleman anything to refute that attitude or disclaim in any way that he shared the opinion that the award to doctors was too high.

Throughout the whole of this period, when the matter was being exploited in the constituencies, and when, in my view, many negotiations on wages which might have been taking place were poisoned and embittered by the kind of interpretation which could have been placed upon it, the right hon. Gentleman said nothing at all about his attitude to that award.

I think the best description of his attitude is contained in one of those "Ruthless Rhymes" by Harry Graham which some hon. Members may remember from their earlier years. The particular ditty runs as follows: Nurse who peppered baby's face—She mistook it for a muffin—Held her tongue and kept her place.Lying low and saying nuffin

Photo of Mr Hilary Marquand Mr Hilary Marquand , Middlesbrough East

Might I tell the hon. Gentleman that, in fact, I made many speeches on this subject in many parts of the country? Unfortunately, my words do not always get into the newspapers as they used to do when I was a Minister. Of course, I think the award was too high. I said so, and I have said it here again in the debate, but I did not labour the fact though I feel that the case could have been made with much more vigour, and that the result might have been different.

Photo of Mr John Vaughan-Morgan Mr John Vaughan-Morgan , Reigate

I have quoted from an article in the "Daily Herald" of 27th March in which the right hon. Gentleman does not say that the award was too high, and I was coming back to that point in a minute. I am sorry that the right hon. Gentleman did not "lie low and say nuffin." Perhaps he is not nurse but only the baby whose face was peppered. I still think that he bears a great responsibility for the exploitation of the award in the constituencies, and, if he thinks that the award was too high and that the case was not prosecuted with sufficient vigour, why is it that he and his party allowed the Supplementary Estimate to go through unchallenged, without a vote or a voice being raised against it?

The right hon. Gentleman will remember the subsequent history. He said that the award was conditional on the Working Party's Report. That was published on 5th June. On 24th June the Labour Party had a meeting and announced their equivocal attitude to this award, and then said that they were going to put forward their constructive proposals. We have had to wait from 24th June until today for them. There were 12 Supply Days after that when the right hon. Gentleman and his friends could have raised the matter and discussed it. They could have put down a Motion to reduce the salary of my right hon. Friend, or they could have followed the various forms of procedure which were open to them to debate the question.

They cannot say that it was because business was too crowded. As I have said, we have had 12 Supply Days, and it should go on record that on 14th July, that great day for radicals, progressives and people like hon. Gentlemen opposite, the anniversary of the fall of the Bastille, they chose for a Supply day discussion, first, museums and art galleries, and, secondly, national parks, but not the Danckwerts Award.

The Working Party had reported and discussions were in progress with the B.M.A. Surely that was the moment for the right hon. Gentleman to make his constructive suggestions. As the saying goes, Time marches on, and we are now come to November. The right hon. Gentleman has waited until the last possible moment, until the gong has nearly gone, to raise these matters, and I think he has only done it now to implement a pledge which he gave to the readers of the British Medical Journal in August. I do not think there is any other reason at all.

On the Working Party's Report, I cannot understand why the right hon. Gentleman, who was responsible for that remit to that Working Party, could not find it in his heart to say much more wholeheartedly, without those minor criticisms, how much he welcomed the content of it. Personally, I think they have met every single obligation that was imposed on them in the right hon. Gentleman's remit. It is going to reduce the size of the doctors' lists; it is going—and the right hon. Gentleman did not mention this—to give an incentive to young doctors to set up in the under-doctored areas; and, above all, if taken in conjunction with the award, it is going to restore the status of the general practitioner in the medical service. It is going to put him back where he ought always to have been—the linchpin of the service.

The right hon. Gentleman made his rather disappointing case. He said that it would be hard on the incompetent and on the elderly, and as regards the doctor with the small list, he bases his whole case on one woman doctor. He cited one particular case.

Photo of Mr John Vaughan-Morgan Mr John Vaughan-Morgan , Reigate

If the right hon. Gentleman would let me, I should like to finish this. I realise that he has all the rest of the cases, but the case he cited was that of one woman doctor. He omitted a very important point, and that was the area in which that doctor was practising. Was it an area already fully doctored, or was it an under-doctored area? If it is a fully-doctored area, why should he wish to encourage her to remain there? If it was an under-doctored area, one can only draw the conclusion that she is very incompetent.

Photo of Mr Hilary Marquand Mr Hilary Marquand , Middlesbrough East

The lady would not have been able to practise under the Health Service in a closed area. She entered the Health Service after it was started, and she is, in fact, in one of those intermediate areas. She is not, it is true, in an industrial area, but she is in a fairly thickly populated area.

Photo of Mr John Vaughan-Morgan Mr John Vaughan-Morgan , Reigate

I am not really sure that that disposes of my case. I think it still leaves open the question of the competence of the doctor, and if we are going to subsidise the incompetent or the idle, I can see that we are well on the way to that bugbear of the right hon. Gentleman's newly-found friends, the Fellowship of Freedom in Medicine—a State salaried service. I think, after hearing the right hon. Gentleman's moving plea for the small list doctor and his solution, which is a little difficult to follow, that we can say that that is what is hanging about at the back of his mind. I think we ought to ask him for an unequivocal declaration as to where the party opposite stand on this matter.

Have they abandoned this idea of State medical service? The right hon. Gentleman spoke so much about his new friend, Lord Horder, and the Fellowship for Freedom. He did not tell us so much about his other friends, the Medical Practitioners' Union. They have not entirely abandoned that idea, and I think I may speak on behalf of the authors of all the 80 letters who have not had a reply when I say that they would like an answer to the question I have put.

Photo of Mr Hilary Marquand Mr Hilary Marquand , Middlesbrough East

If they would like an answer, did I not spend the greater part of my speech in an attack on the growth of the numbers of salaried doctors? It is precisely towards that evil that I was drawing the attention of the House.

Photo of Mr John Vaughan-Morgan Mr John Vaughan-Morgan , Reigate

Salaries paid by principals but not by the State.

Photo of Mr Hilary Marquand Mr Hilary Marquand , Middlesbrough East

What difference does it make?

Photo of Mr John Vaughan-Morgan Mr John Vaughan-Morgan , Reigate

What difference does it make? I do not think I will bother to answer that. The doctors in the country will answer it for the right hon. Gentleman.

The right hon. Gentleman referred to what he called group practices, and he was very contemptuous about the proposal for £100,000 to stimulate group practices. He did not offer many suggestions as to how it should be spent. Perhaps my right hon. Friend himself will produce some suggestions as a reply to the right hon. Gentleman the Member for Middlesbrough, East in the role of critic. I think, personally, that group practice is going to grow. We shall be able to see how it grows as a result of the spending of this sum.

I must honestly say, as a layman in these matters, that I have found it a little difficult to know where a partnership ends and a group begins. It sounds like a discussion on the internal politics of the party opposite, but it is a perfectly honest question. This Working Party Report seems to place the whole accent on partnership where it is a partnership and not a group practice.

Finally, for myself may I say that I think this is an admirable Report? There are minor difficulties which can be ironed out, and this proposal is not final. It is flexible, and can be amended. If I might, I should like to quote the words of a doctor friend of mine when I asked him a few days ago what he thought about the Report. He said, "Doctors are beginning to settle down." We have had our debate today and after it I think we might stop interfering in matters which concern doctors. These proposals—and this should not be forgotten—have been supported unanimously by all the appropriate organs of the B.M.A. I think that the general practitioners have been far too involved in politics in the last four or five years and we might now leave them alone to help to make the Service a better one.

1.0 p.m.

Photo of Mr Somerville Hastings Mr Somerville Hastings , Barking

I must apologise if I do not follow the hon. Member for Reigate (Mr. Vaughan-Morgan) in the way that he would wish, for I do not know everything that members of the Labour Party have said and thought during the last few months. All that I can say is what I think myself and that is what I propose to tell the House this morning. I, for one, have no quarrel whatever with the Danckwerts Award. I do not think it is too much, because I believe that it is essential to raise the status of the general practitioner who, I believe, is the most important link in the medical chain.

It is he who has to see the cases first and has to make the diagnosis and, if necessary, send the patient on to the specialist. I feel that unless the status of the general practitioner, financial and otherwise, is raised we shall not get the best men in the profession going into general practice. I believe that that is important because, valuable as the discoveries in medical treatment have been in the last few years, in tuberculosis, cancer and in many other branches, very much depends on the early recognition of those cases and that is the function of the general practitioner. So my quarrel is not with the Danckwerts Award but with the Working Party's Report.

My first objection to that Report is that it does not raise the status of the general practitioner sufficiently. Now we find that the salary of the general practitioner at the present time depends entirely on the number of patients on his list, the number of patients who choose him as their doctor. I know that patients can estimate many of the qualities of their doctor, his kindliness, sympathy and readiness to help, but they have but little knowledge as to the quality of the service which he gives.

If I want to know what sort of doctor a man is in any area I do not look at the size of his list. I make inquiries of the medical superintendent of the nearest hospital and ask him what sort of cases the doctor sends into that hospital—whether they have been, as we say, sat on too long, kept waiting before they are recognised and dealt with. I feel that something ought to be done to improve the status of the general practitioner so that when a young man wonders if he should go into general practice or not he can ascertain to what special awards for special merit he can look forward.

In the other branch, the consultant service, we have what are called merit awards. I do not think that they are perfect, but I feel that something more should be done, which it is not suggested in this Working Party's Report, to raise the standard of the general practitioner service and to provide some special rewards at the top of that service to which any young man or woman can look forward if he or she has special ability and capacity. That is one of my objections to the Working Party's Report.

Another one, which was dealt with by my right hon. Friend the Member for Middlesbrough, East (Mr. Marquand) concerns permanent assistantships. I want to see much more done to discourage them. I agree that the Working Party's Report proposes some reduction in the number added to the list for permanent assistants and that goes some way; but I want something further done, because I believe that while it may be useful for a man, when he starts practice, to be an assistant, if he works with a good man for a time, I do not think it is a good thing for him to be an assistant too long. I speak from experience here. I was an assistant to a doctor for a short time when I started practice many years ago. I learned useful things which were valuable to me and I learned some things which it would have been better if I had left unlearned.

In any case, I look upon permanent assistantship as bad for the doctor, the assistant and the patient. In the correspondence in the medical Press a lot has been said against permanent assistants. It has been said that they have been slack and have not been doing their duty well. It may be true, but I suggest that the permanent assistant too often feels that he is exploited and, wrong as it is, tends to respond by not doing as much as he ought to do.

Again, if a doctor takes private patients, and many in the Service do, he will not put those patients under the care of his assistant. He will put his list patients for the assistant to look after. That will give the patients on the list the idea that there is something second-rate in the National Health Service and I believe that to be a very unfortunate thing to suggest. Besides, the assistant too often is sent to deal with emergencies. Surely a time of emergency is the time when a patient feels the need of somebody he knows and can trust.

I regret that though the Working Party's Report does something it does not do more to reduce the number of these permanent assistants. As my right hon. Friend the Member for Middlesbrough, East has suggested, I would allow perhaps only 1,000 or at the most 1,500 patients to be added for a permanent assistant. I would go further and only permit a permanent assistant to be employed by one doctor for a maximum of five years.

My third and last objection to the Working Party's Report is that it does not do enough to encourage partnerships. I admit that it does something and it sets aside £100,000 which it says might be used to stimulate partnerships but it does not suggest in any way how that may be carried out. I feel that much more might be and should be done to stimulate partnerships, because in my view we shall not get the medical service which the Minister of Health wants and which we all want until health centres are developed.

I can only conceive health centres developing when the doctors working in them are in a partnership or, of course, better, are in full-time service. If doctors working in a health centre are in competitive practice it will be very difficult to carry out the legitimate desire of patients to transfer from one doctor to another, for temperamental and other reasons. Such transfers will not make for harmony in the health centres.

Again, if doctors give instructions—as I hope they will—to their patients collectively in the laws of health that will be looked upon as advertising. Unless doctors are working together, we shall not get the development of that minor specialisation which makes general practice so much more interesting.

I suggest that one of the ways of getting the development of health centres is, as a first stage, to get doctors to work together in partnership; then as a next stage, perhaps to get a local authority to build or secure a house into which they can transfer their practices; and then later, when the money is available, to attach to that health centre all the other preventive services.

I realise that I am making a suggestion for the development of group partnership and group practice without giving the House a clear idea of how this could be done. I suggest that it might be possible to add something to the capitation fee of all those practising in registered partnerships, but this is only a suggestion.

My quarrel with the Working Party's Report is that it does not provide sufficient incentives at the top to get people to come into general practice, does not do enough to get rid of what I object to very strongly—permanent assistantships—and does not do enough to develop and encourage partnerships. But though I feel that there are many objections to the Working Party's Report, I admit that there is much good in it, and I myself have no quarrel whatever with the Danckwerts Award.

1.13 p.m.

Photo of Mr Angus Maude Mr Angus Maude , Ealing South

I do not propose to detain the House for very long, but there are one or two points which should be made in this connection. The hon. Member for Barking (Mr. Hastings), speaking from his very great experience, made the point very strongly—and I do not dissent from most of what he said—that this Working Party Report did not go far enough in the very necessary task of raising the general status of general practitioners in this country. I think that is true, though I confess that I find it difficult to see how, within the terms of their remit, they could on a purely financial basis do very much towards it.

In this connection it seems to me that what the right hon. Member for Middlesbrough, East (Mr. Marquand) said was really correct—that in first remitting the question of remuneration to arbitration he had felt very strongly, with his right hon. Friend the Secretary of State for Scotland, that it would never be possible to make substantial progress towards improving the Service until the bone of contention of remuneration, which has frankly embittered the Health Service—certainly the general medical service—for a long time, was got out of the way. That, it seems to me, the Danckwerts Award did, and I find it very difficult to see how the Working Party, which had a pretty substantial remit, was to go very far beyond what it has done.

That is not to say that I think the Working Party's suggestions are perfect. It would, of course, be a miracle if they were. I think the Report was produced in something of a hurry, and I am inclined to think that there is some justice in the complaint of some doctors that they were asked to accept it in too much of a hurry. I think they were given the impression that unless this were rushed through and generally accepted quickly, they would not get the terms of the Danckwerts Award carried through.

I cannot conceive that to have been true, and it seems to me a very great pity that the suggestion was ever made by the doctors' representatives, because it may well have been that, given longer time to discuss this question, the doctors would in fact have decided that this was the best share-out that could possibly be produced. I do not say they would, but they might have done.

The impression that was given by an appearance of haste was that something was being rushed through which was not in the best interests of the minority, at least, of the doctors. I think that was a pity. Looking at these proposals, I think that there are extraordinarily few objections which one can take to them if one looks at them very carefully and re-reads them many times, as I have done.

I am going to make the points on which I hope my right hon. Friend will give us a little more information. I am not as worried as the right hon. Gentleman was about the appearance of the title "permanent assistant." I did not take it to mean what he seems to suggest. I thought it was intended rather to distinguish from somebody who was merely a locum in the first place, in which case "permanent assistant" is not a bad description. I did not think it was ever suggested that it should be the same assistant indefinitely. Indeed, assistantship is a very reasonable way of training a young doctor who comes into the Service for the first time.

I also thought that some stipulation of this kind was essential if we were to prevent an unscruplulous principal from getting an advantage over and above the maximum number permitted on his list, by taking on a temporary assistant simply for the purpose of doing it. That was what I took to be the purpose of this insistence on the term "permanent assistant," and it does not really worry me very much. Nevertheless, of course, we recognise that a system which means that large numbers of young and middle-aged doctors have to remain as assistants for the greater part of their lives is quite wrong.

It is also quite wrong that a principal should be getting a considerably larger sum in capitation fees than he pays out as salary to the assistant who enables him to increase his list. I do not think it is quite so serious a problem as the right hon. Gentleman seemed to suggest because, of course, the expenses of the practice do increase and the difference between the principal's salary and capitation fees is to some extent accounted for by additional expenses, though I recognise that expenses do not on the whole go up in proportion to the size of the list.

The right hon. Gentleman talked at some length about the question of group practice which he said was absolutely essential to this Service. I am very far from going all the way with him on this. I think there is a lot to be said for group practice, but I do not regard it as essential to the Service. I very much doubt whether group practice will ever greatly increase or work very well until health centres are built, but I believe that an increase in partnership would be very desirable.

Nevertheless, it seems to me that this problem of partnerships is common to all the professions. It is becoming increasingly difficult to make a partnership work in any profession because of the impact of Death Duties, the difficulty of saving and all sorts of other things. Partnerships in every profession—in law as well as in medicine—are in a very bad way nowadays and they are finding it extremely difficult to survive. Obviously, the more we can do to encourage partnerships, the better. I think that there are quite a few proposals in the Working Party's Report which will have this effect. I do not think we are very clear about how the allocation of a sum, which may or may not be £100,000, is going to help to improve practices, and we should like to know rather more about this.

I welcome the substitution of the initial practice allowance for the fixed annual payment. It seems to me that must be an improvement and that the suggestion is not unreasonable. It gives the doctor a clear picture of his future, and time in which to make up in extra capitation fees the drop in the initial practice allowance year by year during the three-year period.

There is one last point which I want very earnestly to bring to the attention of my right hon. Friend, and on which I should very much value his views. Like the right hon. Member for Middlebrough, East, but not entirely for the same reasons, I am not altogether happy about the doctor with the very small list. I know the objections which are always made by the medical profession to giving any particular consideration to the small list doctor. Nevertheless, I do not believe that they are altogether justified.

There is a great prejudice against small list doctors. We hear about the elderly, incompetent doctors, those who cannot secure patients, and the contemptuously so-called "pin money" doctor. I can only say that I would much rather entrust the health of my family to a "pin money" doctor if he or she were competent—particularly if it were a she—than to a doctor with a list of 3,500 who had not sufficient time for diagnosis and treatment, which is roughly what it amounts to.

I cannot see why, if for any special reason, such as, for example, because the doctor is a married woman or has some private means, but nevertheless wants to practise medicine and is therefore in a position to give much more time to individual cases than if he or she takes on a quite unnecessarily large list, such a doctor should be paid less per patient than one with a list much larger, for that is what the recommendation concerning the capitation fee above 500 implies.

I do not say that there is a very large number of people involved or that among those involved there will not be a great many undesirable doctors whom we should not encourage, but I do say that there are probably enough good doctors deliberately taking great trouble with their patients to make it worth while for the Minister to see whether he cannot go a little further towards meeting their difficulty.

The elderly doctor is, to some extent, taken care of by this £50,000 allotment. We do not think that is enough, but, if it is not, then there is a reasonable chance that something can be done to meet the problem. But if, as the hon. Member for Barking suggests, we want to raise the status of the medical profession, then we must provide every inducement possible to the doctor to keep to a list which will enable him to give the best possible service.

We want adequate time for diagnosis and we do not want a system in which, as the Collins Report reminded us some time ago, a doctor either becomes simply a filter for the hospitals or else has to limit his diagnosis to a sort of intuitive process which might become slick as time goes by, but is not real medicine. So long as there are too many doctors with very large lists in industrial areas, so long will this problem remain. But we shall not make it any better by not giving a fair crack of the whip to the doctor who, for whatever reason, keeps his list small and gives a good service which contrasts so markedly with the behaviour of some doctors with very large lists in industrial areas.

I do not believe that group practice is the ideal at which we should aim; I think we should aim at the return to the ideal of the family doctor giving a good family service, knowing the inside history, the psychological and the economic problems of the family so well that he knows from what the physical ills of the family may spring.

I do not think that ideal is being met. At the moment we are probably going further away from it. I am certain that something ought to be done to get back to it, but that is a matter for the doctors themselves. I am not satisfied that there is not still a minority—it is only a minority—who are not giving a proper service either because their desire for income is greater than their desire to produce a decent service or because some of them are, quite frankly, rather idle.

There are still too many doctors who hurry through a very large list in an incredibly short space of time and manage to do quite well out of it. That, I think, the medical profession can in the end take care of, though one must, as the right hon. Gentleman said, be very careful of a system which provides some inducement to restrictions. Nevertheless, I would much rather see a system where the profession had a reasonable control over the standard of quality than a system where the State had such a firm grip over the Service that it could dilute it as it pleased, lower the quality of its standard, and fiddle the remuneration as it pleased. I think we have nearly the best solution we could possibly have got.

I hope that my right hon. Friend will be able to clear up these one or two points, but I must say that in the end the solution of the troubles of the general medical service is in the hands of the doctors. As the right hon. Gentleman said, this gets the bone of contention out of the way, and I very much hope that in time the doctors will feel that the matter has been adequately discussed and that they have a reasonable solution which can be altered if it proves not to have worked as well as we had hoped.

1.28 p.m.

Photo of Mr William Griffiths Mr William Griffiths , Manchester Exchange

I agree with a very great deal of what the hon. Member for Ealing, South (Mr. Maude) said to the House this morning, but I hope he will forgive me if I do not follow him in his argument because in the very few minutes that I propose to detain the House I want to deal with something rather different. Before doing so, however, I must say that I found the remarks of one of his colleagues who spoke earlier in the debate a little hard to take.

In the first place, I find it a little revolting that an hon. Member should welcome the Danckwerts Report and describe it as a just reward to the general medical practitioners of this country—an award which gives them an average increase in remuneration of £10 a week—and, at the same time, should see something extremely dangerous to the whole of our economy in a wage demand put forward by engineers who, at the moment, are receiving an offer of an increase of 7s. 4d. a week.

I also find it a little much to ask us to leave the National Health Service out of politics, as was suggested by the hon. Member for Reigate (Mr. Vaughan-Morgan). Until last October, hon. Members opposite never lost an opportunity of aggravating the relationship which existed between the Government and Health Service workers. The Tory propagandists and the music-hall comedians spent a number of years making "gags" about many aspects of the Service.

I want to refer to one aspect which puzzles me very much. In the spring of 1951, the Chancellor of the Exchequer advised us that the state of the economy was such that it was impossible to progress further with expenditure on the National Health Service, and he said that further expenditure in other fields of social security also could not be countenanced. Personally, I believe that the Treasury have never had any particular affection for the Health Service. I believe they have sought from time to time to impose limitations on various aspects of the service.

I am, therefore, genuinely puzzled to understand why they gave their consent to this procedure in 1951. I am puzzled by the glaring inconsistency to be found in their attitude, for at a time when they had been successful in persuading the majority of the Government to impose limitations on the service which created the need for charges in certain parts of it, they gave their consent to this procedure and allowed what is really a wage-dispute, however it is dressed up, to be taken outside the House of Commons to the extent that the Government and the Minister agreed that, whatever the findings of the arbitrator, they would accept them. The result was an award which dealt with the colossal sum of £40 million.

I find this a most extraordinary business, and I hope that in the future, if we again have differences of this kind with Health Service workers or others in the public service, the Government will not permit a matter affecting vast amounts of public money to be taken outside the control of the Executive and of the House of Commons in the way it appears to have been done on this occasion.

I have referred earlier to what I regard as the dislike of the Treasury for the Health Service. In the present Minister, the Treasury have an amenable tool. In a speech which the newspapers told us was instrumental in getting him elevated to the Front Bench, he told us that he "was delighted with" the Danckwerts Award and that he, like the hon. Member for Reigate (Mr. Vaughan-Morgan), saw nothing inconsistent in an attitude which deprecates modest wage demands for working people but sees nothing wrong in giving an average of a £10 a week increase in pay to general practitioners.

While he welcomed the Danckwerts Award, he also told us that he considered charges on sick people to be "socially and ethically desirable"—something which went far beyond anything we had heard from other spokesmen from those benches before. Now I read in at least one newspaper, this morning, that he intends to carry through a further limitation of expenditure on the Health Service, which will mean further reductions in the Service. I see that the Minister, carrying out, as he has indicated, the dictates of the Treasury, will continue on the path on which he has already set his feet—namely, to dismantle and destroy the National Health Service which the first post-war Labour Government created.

I see no hope of putting all these matters on their proper basis, that of the benefit of the people, until the electorate have an opportunity of removing all hon. Members opposite and returning to power people who are motivated by the right spirit—the interests of the people of this country.

1.35 p.m.

Photo of Sir Lionel Heald Sir Lionel Heald , Chertsey

I intervene for a moment or two, but I am sorry that I cannot follow the hon. Member for Manchester, Exchange (Mr. W. Griffiths) in his remarks for I want to acknowledge something which was not said by him. I was responsible for the conduct of the proceedings before Mr. Justice Danckwerts. The right hon. Member for Middlesbrough, East (Mr. Marquand), although he did not refer to the matter at the outset, in a later intervention said that the case ought to have been made with much more vigour. I would describe that in the old words, Willing to wound, and vet afraid to strike In making that comment, in accordance with the very recent policy of unity in his party, he is echoing something which was stated originally by a certain periodical. I was very struck by the fact that the hon. Member for Manchester, Exchange, who speaks with great authority in this field, did not support the allegations which were originally made in that periodical and which were so halfheartedly supported today by the right hon. Member for Middlesbrough, East.

Listening to the right hon. Gentleman, this is what I wondered. Here I am speaking in defence of the team of people who work with me, some of whom are civil servants who cannot speak for them-selves; they were the people who worked under the right hon. Gentleman when he was at the Ministry. If these proceedings were conducted in such an incompetent way, and if there is this case to be made, one wonders where are the legal luminaries today.

Where are those pundits the hon. and learned Members for Hornchurch (Mr. Bing) and Northampton (Mr. Paget); the eminent lawyers the hon. and learned Members for Gloucester (Mr. Turner-Samuels), Aberdeen, North (Mr. Hector Hughes), Kettering (Mr. Mitchison) and Crewe (Mr. Scholefield Allen)? Where are they? Where, above all, is the right hon. and learned Member for St. Helens (Sir H. Shawcross)? Why is he not here? I was wondering whether the reason why they are not here is because, after all, they are no longer the masters. The masters are those in South Wales, or those connected with it.

These things should be brought out into the open. If these accusations are to be made then I, in my position as Attorney-General, responsible for the legal conduct of the proceedings, must consider them; and I treat this sort of allegation, made in a very half-hearted way, with contempt.

1.38 p.m.

Photo of Sir Barnett Stross Sir Barnett Stross , Stoke-on-Trent Central

I am not legally trained and can use that as an excuse, if I may, for not following the Attorney-General. I want to return to the question of whether the terms of reference which the Working Party received have been fully implemented. We have had a number of speakers, and the well-informed, dispassionate and positive contribution made by the hon. Member for Ealing, South (Mr. Maude), in particular, struck me as being valuable.

In opening the debate, my right hon. Friend the Member for Middlesbrough, East (Mr. Marquand) covered the whole field. It is a large field and he could not speak on any one aspect of it at great length. I shall confine myself mainly to one or two points about the terms of reference, but I must first say that I was very disturbed to hear the hon. Member for Reigate (Mr. Vaughan-Morgan) say, not once but more than once, that if a man is not affluent in general practice that proves that he is incompetent. He did not withdraw that statement; in fact, he made it twice.

Photo of Mr John Vaughan-Morgan Mr John Vaughan-Morgan , Reigate

Does the hon Gentleman suggest that I said that unless a man was affluent in general practice he was incompetent?

Photo of Mr John Vaughan-Morgan Mr John Vaughan-Morgan , Reigate

I do not think that the hon. Gentleman either listened to or understood my speech. The right hon. Member for Middlesbrough, East referred to a doctor with, I think, a maximum of 600 patients—a man with considerable experience in an area which was intermediate. Does the hon. Member for Stoke-on-Trent, Central (Dr. Stross), who is a doctor, think that a doctor who, after so many years, and apparently for no other reason, does not attract an adequate number of patients, deserves a subsidy or should be subsidised by the State out of the pool?

Photo of Sir Barnett Stross Sir Barnett Stross , Stoke-on-Trent Central

I think the hon. Member is confounding matters and making it worse for himself. He now admits, with reference to a case which was read out, that a woman doctor who, after many years' service abroad, came back here and set up in practice, and had not more than 600 patients, is to be accused of incompetence. That is quite unjustified.

Photo of Mr John Vaughan-Morgan Mr John Vaughan-Morgan , Reigate

I was asking whether the hon. Gentleman did not agree that either there were other reasons or else she was incompetent.

Photo of Sir Barnett Stross Sir Barnett Stross , Stoke-on-Trent Central

Whether I am correct in interpreting what the hon. Member said we shall see tomorrow. I can leave that point now, having made my protest against insinuations of that type being made against any doctor, man or woman, who merits something better from this House than statements of that sort.

One thing seems quite certain—I hope the Minister will accept this as true—that throughout the country well-informed opinion is dissatisfied about that part of the terms of reference described as seeking to bring about a relative improvement in the position of those practitioners least favourably placed under the present plan of distribution. We have had a rider in the Working Party's recommendations to the effect—if I may quote half a sentence—that in the final settlement … we shall allocate an appropriate portion for the purpose of remedying any obvious defects in the distribution scheme. My right hon. Friend asked the Minister if he could tell us how much money there would be for this particular purpose. I have been informed that it may be a larger sum than was originally considered available—that it may be, perhaps, about £500,000. If so, we should like to know, for it would be consoling to us, and we shall know then what the amount may be and how the money should be allocated. We do want to avoid any question of charity or gift. It could be allocated by a re-arrangement of the size of the capitation fee. If we can in any way avoid the appearance of condescension or patronage, we should be obliged.

There are two specific points, closely related to each other, that I want to mention and about which I want to ask a few questions. The first is that aspect of the Report which states what would enable us to give the best possible medical service to the public, and which has been touched on by so many hon. Members on both sides, and the other is how to stimulate group practice. We have talked a good deal about the medical profession in this debate, but we have also to remember the taxpayer has to be considered. The public is very intimately and deeply involved, and it is the public that finds the money, and from the public's point of view these two aspects on which I want to say a few words are the important ones.

Indeed, the Minister will have noted, in discussing the financial matter, that the central pool is linked, of course, to the number of doctors in the service as principals and, that, therefore, the central pool will increase as more medical men pass into partnership and become principals. The Danckwerts Award did present a warning note on that by stating that unless the number becomes unreasonably large then the pool should increase automatically as the number of principals increases, so that as assistants become principals the global sum for remuneration becomes larger.

If the Minister feels I am wrong in this I should be grateful if he would check me. I did not know that the number of assistants today was 2,300; I know that last year it was put at about 1,724; in 1950, at 1,187; and, in 1948, it was 562. If it be 2,300 this year, as my right hon. Friend suggested, it means we may well get a large number of these becoming principals within the next year or two.

Photo of Mr Iain Macleod Mr Iain Macleod , Enfield West

I wonder whether the hon. Gentleman would like confidentially to give me the source of his figures, because they differ very considerably from the figure I gave some time ago, and for the earlier years we have no official figures at all.

Photo of Sir Barnett Stross Sir Barnett Stross , Stoke-on-Trent Central

Certainly. The figure of 2,300 was given by my right hon. Friend, and I did not get it; and the other figures I have given are from a memorandum sent out to us by the unestablished practitioners group, who are, of course, concerned with their specific problems. If for argument's sake, purely as a hypothesis, 2,000 practitioners at present unestablished become principals within the next two years, would the Minister agree with me that the global sum available for distribution will increase very considerably?

It has been put to me that the average remuneration of the practitioners under the Danckwerts Award, if our present proposals are implemented, will be about £2,240 net at the end of the year or in The spring. That means about £3,240 gross. If that figure be correct—and it seems a simple matter to divide the total amount available by the 19,000 established practitioners—then we can see the possibility of large increases in the amount to be distributed in future—perhaps, if 2,000 further medical men are established, approximately a £6 million increase.

If that be the case we have to remember the implications. It means that, whereas on the one hand those who have small lists or who are elderly are worth, as it were, to their colleagues £3,000 because of their presence as principals, they themselves, if their lists are small, will get no specific benefit, or very little benefit, from the global sum, unless special attention is paid to their particular case. I think we may leave that point, but I think it is going to disturb the Minister sooner or later.

If I am right so far, will he agree, further, that it becomes an incentive to my colleagues in my profession not to let anyone retire at all and not to let anyone die—and I hope they never will—because, obviously, the central pool tends to shrink if there are fewer people working in the service? This could create some embarrassment in this way—on the one hand, by keeping men at work, perhaps, too long, but certainly, if men do remain at work, too long, it makes it difficult for new people to come into the profession and to take partnerships.

If the Minister is seized on that point I think I may leave it. I may, however, add that if we do not encourage men when they are, say for the sake of argument, 70, to give way to younger men, it means that they will tend to restrict the possibility of new men setting up at all in allegedly restricted areas.

The question of group practice is much more important than anything I have dealt with so far. I am one of those who believe that this is our own essentially British way of trying out a new form of giving service to the public, and, if not ideal, certainly one of the best methods by means of which the general practitioner service can move forward. There has been a difference—and the Minister will agree with me—between the improvement in the service offered by the family doctors as compared with the rather spectacular improvement recently offered by the hospital service.

Everyone is anxious to assist the general practitioner service to play a notable, and perhaps the most important part of all in the Health Service. What is the good of £100,000 a year? How is it proposed to use it? If it is to be doled out in the form of gifts I would find that objectionable. Many medical men working in isolation in the countryside will ask why money is to be given as gifts to people who happen to be working in a city or large town while they, who are working just as hard in the countryside and possibly a good deal harder, with longer hours because they are always on call, are not to get it. So there will be jealousy and embarrassment.

Moreover, public money given in this way tends to be in small amounts which do not do anyone any good. The least it will cost those forming a group practice to buy a house and alter it completely to meet their needs will be £5,000 in terms of present day values. That means that in any one year we might get 20 group practices assisted. Therefore, it is a mistake to limit the sum to £100,000 or award it as a free gift in small sums.

The Minister has some experience of group practice. There is one experiment at Skipton, which I am sure he remembers quite well. There is one at St. Paul's Cray, there are one or two in Kentish Town, one in South London and some in the West Country. Recently, in Northern Ireland, an attempt was made by 12 men to join together in a group practice. That would be quite a large group. They needed a loan from the bank of £25,000 with which to buy a large house and alter it. That would have cost each doctor £2,000. They could not get that loan because banks are not lending money easily these days so the scheme has fallen through, which is a pity.

Our view, therefore, is that it should not be £100,000 but at least £500,000, and not awarded as gifts but in the form of a loan at a half of 1 per cent. or possibly 1 per cent. merely to pay for the administration of the money. It could be loaned out for 10, 15 or 20 years. Obviously, in 10 or 15 years there would be a large amount of money circulating and fructifying all this field. I hope, therefore, that the Minister will use his influence on this point.

Certain principles have emerged already from our investigation and inspection of group practice. For example, we know that it is the quality of the personnel of group practice which matters much more than the quality or convenience of the building. We know that general practitioner specialisation is possible within the group, is desirable, and happens. We know that the standard of service which can be given in group practice is higher than can be given by a similar number of men working alone and in isolation.

We also know that the hospital service tends to be less used—I almost said, less imposed upon—by a good group of this kind than when it is used by a number of people who are content to work separately, again in isolation. That is because the men working together and tending to specialise are able to do more work and with more confidence, than if they work alone.

Photo of Mr Richard Fort Mr Richard Fort , Clitheroe

I want to clear up the difference between partnerships and group practice.

Photo of Sir Barnett Stross Sir Barnett Stross , Stoke-on-Trent Central

Partnerships can be purely commercial, with the men working in different parts of the town and in different houses. They are in isolation except for helping each other in holiday time. Group practice men work in one place together.

Photo of Mr Richard Fort Mr Richard Fort , Clitheroe

But many partnerships approximate to group practice.

Photo of Sir Barnett Stross Sir Barnett Stross , Stoke-on-Trent Central

Yes, many of them do. One other principle that can emerge from group practice when successful is that we can get true research work on the relation between society and the individual. This cannot be obtained in a hospital.

I have already said that we want £500,000 and we would like it as a loan so that it grows and has a snowball effect. If that amount of money were available in this way, some of it could be used to help people setting up in practice for the first time—again as a loan and virtually interest free.

The mechanism should be something like this: when a group is formed by free association it should notify the local executive which, after examination, either agree or disagree. If they agree, the local authority will be notified to give whatever assistance is necessary by way of licences and so on. Lastly, there should be no difficulty in getting the finance required.

If, of course, the local authority in its discussions with the group puts other proposals to them, that is another matter. The local authority may say, "We have a building which we will lend to you and prepare for you. Later we would like to add to it our local authority services." In that way it becomes a health centre and that is all to the good. The Minister has already been asked to keep his eye on agreements formed between partners in order to make sure that people are not exploited, so I will not touch on that point.

I want to appeal to the Minister to do something else. The Minister knows that local executives have power over general practitioners to superintend their premises and make suggestions to them. The Minister knows that the quality of accommodation available to the public varies greatly from the very best to something which is not satisfactory. In view of this Award, which allows medical men a standard of life which might be termed now not ungenerous, has not the time come when the Minister should ask the local executives to look at this matter and assist medical practitioners, by advice and precept, to see that their standard of accommodation for the public is improved?

To sum up, first, the conclusions of the Working Party have been more favourable to established practitioners than to any other section. Secondly, the taxpayer is not likely to obtain great benefit immediately as the proposal stands, with the exception that there may be a better distribution of doctors as a result, and there will be some curtailment of excessively long lists. We want more than that. We ask the Minister to intervene, particularly on the point of better accommodation for the public in surgeries and waiting rooms. We feel that the problem needs further study, and I am sure that the medical profession will agree to that. Lastly, we think there is ample evidence that the position of the assistants is not satisfactory and we hope it will be possible to get some remedy for them.

I appeal to the right hon. Gentleman to see that we get a quid pro quo for the public, in the best possible way, for the money that is to be spent. We ask that the Government should encourage one of the noblest professions in the world, which has played its part quite as well in this country as in any other part of the world, to do its best in co-operation with the Minister to get what we all need, the finest possible Health Service.

Photo of Mr Arthur Bottomley Mr Arthur Bottomley , Rochester and Chatham

I thank the Minister for giving me an opportunity for a few moments in order to make a comment. I would not have intervened if it had not been for the remarks made by the Attorney-General, who I am glad to see in his place. His remarks showed that he is more concerned with personalities than with legal arguments, which are, after all, his function in Her Majesty's Government.

I take very strong exception to what he said about my right hon. Friend the Member for Middlesbrough, East (Mr. Marquand) who, he implied, had criticised civil servants. My right hon. Friend always took complete responsibility. So far as he was concerned, civil servants were advisers. Once he had accepted their advice, what was done was his responsibility. The Attorney-General showed a cowardly attitude in what he said about civil servants, and I hope that we shall never again have such an intervention by the Attorney-General.

2.2 p.m.

Photo of Mr Iain Macleod Mr Iain Macleod , Enfield West

I shall not at the moment refer to—although I shall say a word or two on it before I finish—the quite irrelevant intervention to which we have just listened from the right hon. Member for Rochester and Chatham (Mr. Bottomley). There are only two points which have arisen in the debate which can reasonably be called political, and I think my reply would be following the spirit which has been displayed today if I got rid of those two points first.

The first is on the question of loading or weighting. We have heard nothing today in disapproval of the theory of loading, although we have heard suggestions, to which I will refer, that another method should have been chosen. It is quite remarkable to have converted the Labour Party to the theory of the loaded capitation fee which, from this side of the House, we have been putting forward for something like three years. Nobody should be surprised that it has taken so long.

Three years is bogey for our points of view on health to be accepted by the party opposite. It took three years for our criticisms of the 1946 Act to appear as the 1949 amending Act. It took three years for our criticisms on the theory of charges to be accepted, from 1948 to 1951. The process is always the same: one year's denunciation, one year's cogitation and one year's affirmation. We, who have devoted a good deal of our time to educating the Socialist Party in a proper Tory approach to the social services, are entitled to chuckle a little bit when we see our ideas returned to us.

The second point is this: I must make some comment on the form of this debate. No one thought, for a second, least of all the medical profession, when the Socialist Opposition put forward a diatribe against the Working Party at the end of June, that this was how it was going to end. My hon. Friend the Member for Reigate (Mr. Vaughan-Morgan) pointed out that a Supply Day could have been taken and he could not understand why it was not taken. I could have enlightened him. The right hon. Member for Middlesbrough, East (Mr. Marquand), writing to the "British Medical Journal" on 9th August, gave the reason. Briefly, the reason was: We seek an improvement in the general medical service within the Health Service, rather than party advantage. I entirely agree with the first part of the sentence, but I must be excused if I take the second part with a small piece of salt.

It was no doubt similar reasons which led the Opposition for the first time for many years not to have a Supply Day on housing. They could not bear to make party capital out of it. When the right hon. Gentleman said he hoped that his numerous correspondents in the profession would read this debate, I echoed it. I hope they will note, too, that for long periods of this debate it has not been possible, as it normally is, for a Scottish Minister to intervene, or for there to be a Government statement at the beginning of the debate. I genuinely hope, after all the froth there has been, that the right hon. Gentleman will find it possible to explain to his correspondents and to everyone else that this half-hearted debate in a half empty House is the answer to everything that he has said.

I want now to turn to the problem of the maximum size of lists, partly because too little attention has been paid to the principles involved. I need not outline the proposals. They are given in the fourth paragraph of the Report. As I said in an intervention, this is a most important point. We calculate that something like two million people will have to be shuffled in one way or another on the doctors' lists. The point has not been made, and I make it particularly to hon. and right hon. Gentlemen on the Opposition side of the House, that to ask two million people to change their doctors is a most serious interference with the ordinary liberty of the subject. This is a factor that we should not ignore.

The size of the ideal list cannot be settled by rule of thumb. If one doctor has a bigger list in one catchment area than another doctor, we do not get a better service to the people by bringing the size of the lists more closely together. We have to know whether Dr. A is abler, more conscientious and more hardworking than Dr. B. If their qualifications are precisely the same, there still may be a very real reason for one man having a much bigger list. It may be that Mr. and Mrs. Smith and Mr. Jones or Mrs. Jones like that doctor with them when they are ill, and they do not like the other doctor. These factors should not be ignored.

I deplore the attacks that have been made in the columns of professional journals on the big list man—we did not hear it today, and I am delighted to acknowledge this—just as much as I deplore the sneers at the small list man. I see no justification whatever for them. It is true beyond doubt, as can be seen from the figures in paragraph 25, that the big list man will suffer a very considerable decrease of income next year as compared with this year, and that his ordinary percentage increase post-scheme in comparison with pre-scheme will be a great deal less than in the case of a man in the middle part of the list. I think it unrealistic to suggest that we could have moved faster in this particular field, and could have brought down the figure to—shall we say—3,000 at the present time.

It is clear that to do that we would need more doctors in the industrial areas, where the big lists are concentrated. In my view, there will be quite enough difficulty and quite enough social upheaval—and I can mention as a footnote that hon. Members will find quite enough letters to Members of Parliament—as a result of the interference that is being proposed in these arrangements by the Working Party.

Now I come to easily the most important part of this debate, the problem of the small list. The right hon. Gentleman said that the greatest volume, 64 out of 80, of his letters were concerned with this problem.

We have read in the "British Medical Journal" and elsewhere most ill-tempered arguments against what has been achieved by the Working Party and in all of these the assumption is that it was a term of reference of the Working Party to help those with a small list. This is the central point of the debate, and I declare this quite categorically. The terms of reference do not say that. The right hon. Gentleman, as I will quote from a letter, did not mean that and the Working Party on both sides of the House never took the terms of reference—which I will read to the House—to mean a special case for the small list. The important part of the terms of reference is this: to bring about a relative improvement in the position of those practitioners least favourably placed under the present plan of distribution. Most people who have studied this problem would probably claim that those people who were "least favourably placed" were not only the people with small lists but, most particularly, with medium-sized lists, who are not in industrial areas and who, perhaps, previously had a measure of private practice and are now doing a full job in the National Health Service. I think that two quotations make this point absolutely clear. The first is from a leader in the "British Medical Journal" of 27th September, 1952: The Working Party tried to help the un-established young practitioner and did give the greatest encouragement to a middle group with lists of average size. It is quite clear how that was interpreted, but there is more cogent evidence than that. This letter, also, was published in the "British Medical Journal" on 16th June, 1951, when, of course, the right hon. Gentleman was Minister of Health. This is the official letter written to the British Medical Association—of course it is pre-Danckwerts—suggesting to them the formation of a working party to go into the very matters which, only a few weeks after this letter was written, were crystallised in these terms of reference: The Ministers accordingly propose that a Working Party composed of … should be asked to suggest methods … with special reference to (a) the need to make it easier for new doctors to enter general practice especially in under-doctored areas by providing an assured income for genuine new entrants …; and(b) improving the position of practitioners with lists of the order of 1,000 to 2,500. That is what was in the mind of the right hon. Gentleman. That was what was in the mind, if we like, of the Department as a whole when the Working Party's proposals were put forward, and that makes two things absolutely clear. It makes it absolutely clear that, for all the attacks—unworthy as they are—that have been made on the motives of the medical profession, it was their influence in favour of the small list man that produced the sort of figures that we have got in the Working Party's Report because the figures that were originally in the mind of the right hon. Gentleman were 1,000 to 2,500 as the point at which special reference should be placed.

The other conclusion which I think must fairly be drawn is that those small list doctors who have thought as a result of correspondence that they have discovered a rather unlikely St. George with whom to ally themselves in the person of the right hon. Gentleman will have discovered again that they have teamed up with the dragon. I should have thought that particular lesson had been learned before by medical practitioners.

Photo of Mr Hilary Marquand Mr Hilary Marquand , Middlesbrough East

I hope that the right hon. Gentleman is not suggesting that category (a) included in the letter we sent was not intended to be helped. I hope he is not suggesting that the one example I quoted and criticised was not an example drawn precisely from that group. I raised no objection whatever in anything I said this morning to the improvements which have been made for the medium lists. I did try very carefully not to overstate the case. I said there was bitterness and indignation and I think it is the duty of the Opposition at least to voice it, even if they do not always entirely agree with the whole of the emphasis put forward, but I did not lay my case on that. As the right hon. Gentleman must be aware, I drew attention to the fact that in category (a) there were clear examples where I felt the terms had not been fulfilled.

Photo of Mr Iain Macleod Mr Iain Macleod , Enfield West

That is a very shrewd bit of back-pedalling. The only point I am emphasising, and which I say again, is that the right hon. Gentleman told the profession quite categorically that the people he thought special reference should be paid to were those with lists of the order of 1,000 to 2,500 and it is that that the terms of reference met. Indeed, there is perhaps an even simpler argument. If the right hon. Gentleman meant those with the small lists, why did he not say so? The justification that has been put forward is the claim for the small list. The view of the right hon. Gentleman was that there were people with a prior claim to the small list. That has been faithfully implemented by the Working Party.

Let us look to see whether there has been such a relative improvement, accepting the fact—which I think one must accept—that the Working Party looked, as I know they did, to the middle groups first. I am not arguing for the moment whether they were right to do that, but I am merely saying that the terms of reference were implemented. If we look at paragraph 25, we find that the largest percentage increases are those with the 1,500 list, with an increase of 42.6, and the award tapers off both upwards and downwards from that figure. So there has been a relative, not just an overall, improvement in the position of these groups.

I wish to say a brief word about the other possibilities, some of which have been canvassed today. It has been suggested that we should have a flat rate and that the amount should be something like £1. But if we had a flat rate, that would mean giving more money both to the small groups and large groups at the expense of the middle groups, and clearly that is inconsistent with the terms of reference.

Secondly, it has been suggested that we should load the first 1,000, or some suitable figure. Again, although not so obviously, that is to some extent inconsistent—for the reasons I have given—with the terms of reference. It would, of course, inevitably mean that a smaller loading would have to be made. But, thirdly, and I think this is the important point, it would tend to perpetuate mal-distribution of doctors. It would make it more difficult for the Minister of Health to get the doctors in the designated areas, where they must be if we are to have a really good Service.

I have seen many calculations which have been made about the effects of these new proposals on the small list and the medium list doctors. Every calculation I have seen omits either one or more of the three following factors, any one of which in my view would vitiate the whole calculation. First, they forget that up to two million patients will have, either under the notional list arrangements or by changing their doctor, to find another doctor. That is bound to make it very much easier, particularly in the designated areas, for small list doctors to increase their practices or, alternatively, to be taken into partnership by someone who has already a big list.

Secondly, they forget—and this I think is the answer to a direct point which was made—the payment of £200 transitional payment which can be claimed during this year while the re-distribution is taking place.

Thirdly, they make the depressing assumption of a static position in their practices and indeed in the whole of medical practice. Of course, some people cannot increase their practice—I will say a word in a moment about the special provision. But I must say that I hope that younger doctors will not make the assumption that because they have a small list now they will always have a small list, and that it is the duty of the State to subsidise them for ever.

Frankly, I do not intend to take competition out of medical practice. I believe that we should try, as fairly as we can, to match rewards with effort and achievement. It is not now and never has been part of the policy of this Government to have a salaried service in the medical profession, although I am bound to say I found less clear the statement made on this point in an intervention by the right hon. Gentleman.

Let us take the question of hardship cases. Of course, they can exist and they will exist, though I think that the numbers are considerably smaller than hon. and right hon. Gentlemen have suggested. A sum of £50,000 is to be set aside—I think paragraph 19 deals with this matter—to deal with special cases of hardship, as yet indefinite. There is additionally the rider passed at the meeting of the profession to the effect that an appropriate portion of the final settlement moneys should be put aside to remedy any particular difficulties.

It is important to notice that that rider is not limited to elderly doctors. The provision made in paragraph 19 of the Working Party's Report is, but the rider passed by the profession is not and can include any hardship cases, on terms which I admit are still to be defined, which may arise in the future.

It has been said that this is charity. If that were so, I am bound to say I should find that a cogent objection to it. But I do not see the argument. This is money voted by Parliament to the doctors, to be distributed by the Health Ministers in agreement with the profession. It is a first charge—I am talking for the moment about the reserve for elderly doctors—upon the central fund; and it is given in recognition of the special difficulties—personal, geographical or whatever they may be, of one particular doctor.

I cannot see why a doctor should find this to be in some way supposed to be coming from a charitable source when he does not object to getting, shall we say, a payment from the mileage fund, which is equally a recognition in its own way of the special circumstances, geographical or whatever they may be, of his own particular practice. I believe that, faced with this difficult problem—it is perhaps the most difficult of all—the Working Party has, on the whole, tackled it the right way.

The giving of an increased capitation fee to the small-list doctor would mean taking money from the middle-list doctors, and it would make more difficult my task of getting an adequate distribution of doctors. I have every sympathy for the small-list man, and indeed with private practice as well, but the duty laid on me as Minister of Health by Parliament is concerned with the National Health Service; and it is my duty, above all else, to encourage doctors to go where they are needed in the Service.

I turn from that to take up the most important point made by the right hon. Gentleman and other Members as to whether this will on the whole make it easier to enter practice. It seems to me beyond dispute—at all events we had no adverse comment on it—that the initial practice allowance is an improvement on the fixed annual payment. The figures are worth looking at. The I.P.A. produces £1,250 plus full basic capitation fee in three years, and the fixed annual payment produces £900 plus capitation fees reduced by one-seventh. That is surely an important inducement.

The second important inducement is the reduction in the maximum lists, which, coupled with the notional arrangements that have been made, is bound to help, particularly in the heavily populated areas. I detect, quite rightly I think, some apprehension amongst doctors as to how this notional list system is to work. I recognise that there are dangers of abuse in it, that there are dangers of what one might call straw partnerships being set up solely in order to get the value of loading of additional numbers or partners' lists. It is a matter we must watch and are watching very closely with executive councils, on whom the main burden must lie for deciding whether there is a genuine new partnership or not.

Lastly, on this point, comes the question of assistants. First, the term "permanent assistant," used in paragraph 5 of the Working Party's Report, has no sinister meaning. It is the term which has been used ever since the 1948 Regulations to describe the type of assistant whom a practitioner is permitted by the executive council permanently to employ as an assistant. So any misapprehension there may be on that point is misconceived. All the same, it is an important point, and it is as well that it should be stated publicly in the OFFICIAL REPORT, but it has no sinister significance.

The numbers which a doctor is entitled to count have been reduced from 2,400 to 2,000. That is bound to help. It makes it less attractive to employ an assistant. More important than that is the fact that these 2,000 do not qualify for loading. There is, therefore, a very considerable inducement given to a principal with a big list to end an assistantship and take the young man or young woman into partnership. I very much hope that that will happen. I entirely agree with everything that has been said about our not wanting to see an interminable period of assistantship going on and on and on.

It would be premature as yet to take further steps, perhaps along the lines of limiting the length of time a man can employ an assistant, but it is a point which we shall particularly watch as the scheme goes forward from April next year. It is my belief that it will lead to a drastic reduction in the period of time a man spends being an assistant.

Lastly, of the main points that have been raised in today's debate, there is the problem of the group practice. The declaration by the Parliamentary Labour Party was very firm in its words. These proposals were stated to be grossly inadequate to encourage group practice. I am bound to point out that the right hon. Gentleman took a very much milder attitude on 25th March, when tilt Leader of the House, the then Minister of Health, put these proposals before the House. The right hon. Gentleman, after asking my right hon. Friend to confirm the principle of the Working Party Report, said: including some reduction in the size of the larger lists, and a better opportunity for young men to enter into practice—possibly also some encouragement of the establishment of group practices."—[OFFICIAL REPORT, 25th March, 1952; Vol. 498, c. 210.] And the word "possibly" is significant, because nobody knows, first of all, what is a group practice. There has never been a definition of it, and I think that the hon. Member for Stoke-on-Trent, Central (Dr. Stross) gave a definition off the cuff this afternoon which was as good as any I have heard.

That is really the fundamental difficulty we are up against at the moment, that there is no agreement about what is a group practice. Some people think it means a partnership of three, four or five people. Some people think of it as a development on the lines that the hon. Member suggested. I have little doubt that the attitude of the party opposite towards group practice is to some extent a hang-over—if I may use that term—of the health centre scheme. I remember very well in 1946 the London Labour Party fighting the L.C.C. elections on an undertaking to supply 163 health centres in London. I went to the opening of the first one about 10 days ago.

I think it might be helpful on this issue if we made our first step towards implementing this paragraph 29 on group practice by making an effort to find out what is group practice. As I have said, that is the difficulty which the Working Party has run up against, and I therefore propose to invite Sir Henry Cohen's Committee on general practice to consider whether the evidence before them at the moment is sufficient to enable them to express a view on what is group practice. It seems to me that that is the best body to which we can go. We shall get, I am sure, a helpful answer, and it may be that it will clarify our ideas.

I have only one or two other points to make. The first is on the question of whether or not it is too late—assuming the case was made out, and frankly I do not think it has been—to put into reverse the machine which my right hon. Friend the Secretary of State for Scotland and myself have started. What is called the Danckwerts Award was passed without comment and without debate by this House in the last day or so before the Summer Recess. There was no sign of any proposals from the Opposition, and I naturally went forward then with the plan. Areas have been re-classified by the Medical Practices Committee and they have been published in the "British Medical Journal." We are in the process of notifying the general practitioners of the arrangements, because they have the most complicated calculations to make to decide whether they can, or should, take advantage of, for example, the notional list arrangements.

The new rates are being paid as from the end of September and the arrears are being paid as from the end of November. Frankly, I think I would have been judged negligent by the House if we had not taken that sort of action when, as I have said, the House passed these proposals without comment. It seems to me that much which has been said today rests on a misrepresenting either of the terms of reference or on what has been said in the to-ing and fro-ing which has been going on in the correspondence columns of the "British Medical Journal."

After all, the position of the Working Party is this; that it has reached agreement within its own meetings, and of course the right hon. Gentleman knows that the people who advised me are exactly the same people as advised him and took part in these discussions, anxious, of course, to implement as fully and as honourably as they could what they knew to be in the mind of the right hon. Gentleman. These proposals were then put before a series of local meetings, and finally before the conference of the profession. They were approved by that conference and later approved by the representative body.

I have read a number of suggestions, and have heard it echoed today, that there was some form of pressure brought to bear on those meetings. I cannot and do not attempt to speak for the profession, but I am sure I can say that I do not believe a single doctor can ever have thought for a moment that the Government, because of a criticism of the Working Party, would run away from the implementation of the Danckwerts Award. I am on record, as indeed has been quoted today, as much as any other hon. Member of this House, considering the short time I have been a member of it, in saying that the doctors had in my view in these years an unanswerable case for higher remuneration. I am quite certain that no doctor who paused to think would have been for a moment in any doubt at all that the Government would try to implement as speedily as possible an undertaking which we were in honour bound to do, in spite of the fact that minor points of criticism might have been raised.

It is true, of course, that the Working Party Report and the Danckwerts Award hang together, as the right hon. Gentleman said. It is true that if very heavy objections had been made, and if the whole scheme had been rejected, of course we would have had to think again. But there never was, and it has never been hinted or suggested, so far as I know, that the Government might go back in this way.

On this question of approval, it is important to notice that it has been approved by the Assistants and Young Practitioners Sub-Committee, as a letter from their Chairman in the "British Medical Journal" says: The Assistants and Young Practitioners Sub-Committee were consulted at every step in the deliberations which culminated in the Report of the Working Party. Before the proposals were formulated the Sub-Committee were consulted in December and in January, and in February they gave a specific preference for the loading arranged on £500 and £1,500. It has been suggested since that that was merely a preference for that figure as against a higher figure. But as I understand the minutes, as quoted in the "British Medical Journal," as I understand what I have read, no rider to that effect was ever put forward.

The point of view I should like to express in the last minute or two before we are interrupted is perfectly summed up in a leading article in the "Times" of 13th August this year: Mr. Marquand needs to explain why, if he was still Minister of Health, he would apparently wish to repudiate what has been agreed by officials of the Ministry (not presumably unaware of the Minister's mind) with representatives of the doctors. If he does not wish to impose a system of payment to which a majority of doctors are likely to object, what does he wish to do? If the Opposition have a practicable alternative to the agreed scheme of payment, why wait till the autumn to disclose it? If they have not, why not agree that the new system is an advance that deserves a fair trial? That is all I am claiming, that this is an advance that deserves a fair trial.

I wish to make my attitude quite plain. I have listened patiently to everything which has been said today, but it is my view that this scheme should go forward as it stands. I make no extravagant claims for it. I would not even attempt to say that there is no hardship here and there. If one is scheming for 20,000 doctors, it is quite likely that any scheme, however carefully drawn, may have flaws in it, and I do not doubt for a second that this scheme has. What I do claim is that in all honour and good will, the Working Party representing the Health Department and the profession strove to implement the terms of reference given to them by the right hon. Gentleman the Minister of Health in the Socialist Party and the right hon. Gentleman who was at that time Secretary of State for Scotland.

It is my view that, on the whole, they have succeeded in those aims. I think we have discussed this problem today in admirable good temper and that many of the suggestions that have been made deserve the most searching examination. But it is my view that this scheme should go forward, and all I ask of all sides of the House is that it should go forward with good will.

Message to attend the Lords Commissioners.

The House went; and, having returned