The House of Commons last discussed the present difficulties between the doctors and the Ministry of Health exactly a month ago, and I should like to congratulate both the right hon. Gentleman and the profession on losing no time after the debate on 17th February in entering negotiations.
I should like to repeat what I said at the beginning of the last debate—that I hope that nothing I say will make more difficult the task of the right hon. Gentleman. I sincerely believe that all of us would like to give him what help and support we can in his search for a solution of the present grave problem.
But I must say that it is exactly for this reason that I hope that he himself will say nothing which will make his own task more difficult. He was reported last week-end as having, denied that the remarks which he made the week-end before constituted any kind of attack on any section of the medical profession. Naturally we accept his disclaimer of any aggressive intentions and we are grateful for it, but the right hon. Gentleman will clearly realise that it is, unfortunately, impossible for remarks of this kind to be made without having any effect on an already difficult situation. Where feeling already runs deep, this is surely not the way to introduce a calm and reasonable climate for negotiation.
In other words, it does not make for the long, cool look which the Minister asked of the medical profession and it has already led to a number of comments far from cool, the most significant being the not very friendly remark of the right hon. Gentleman the Member for Loughborough (Mr. Cronin), who is reported as saying that the right hon. Gentleman was psychologically hostile to the medical profession.
I never quite know how to behave in these rather embarrassing quarrels in the party opposite, but, personally, in this fraternal tiff I find myself on the side of the right hon. Gentleman. I do not think that he is hostile, psychologically or otherwise, but the whole quarrel shows only too clearly what happens in delicate situations when emotion is substituted for patience and common sense.
Earlier this month, the Prime Minister published a letter from the Review Body which contained what he described as the clarification of some points in its recent report. The effect of this was o remove, any conditions which were attached to the recent award. Several of my hon. Friends and my right hon. Friend the Member for Thirsk and Malton (Mr. Turton), during our last debate, expressed disquiet about the imposition of these conditions. My own view is that, however anxious any of us may be to see the introduction of a scheme where the amount of expenditure reimbursed bears a closer relationship to the money actually spent on ancillary help and practice premises—and Lord Kindersley makes no secret of his own feelings—it would be wrong to insist—and I believe that the right hon. Gentleman and his predecessor both undertook not to insist—on a particular method of distribution to which the profession is opposed.
I believe that the right hon. Gentleman, after seeming to take a rather different view a month ago, eventually showed wisdom in recognising this fact. But it remains the case that the question of reimbursing practice expenses has still to be resolved. This is, unfortunately, one of the many matters which still have to be decided.
On 8th March, the British Medical Association issued its "Charter for the Family Doctor Service". Discussion of it so far has turned mainly, but not exclusively, on the question of pay. I shall, therefore, begin by discussing this question, but it would be unfortunate, important as it is, if the problem of remuneration diverted attention from the wealth of other proposals in the charter.
One of the most important questions is the function of the Review Body in relation to the pay proposals of the charter. On the face of it, the present gap between the Minister and the profession seems to be wide. We have the B.M.A. saying:
… the detailed pricing of the new contract we have in mind must be first agreed direct between the Profession and the Government".
We had a statement from the right hon. Gentleman that
the entire question of how much the G.P. should be paid under the terms of the contract
must be left to the independent Review Body for consideration after the contract has been agreed.
If the Review Body were to be bypassed on this occasion, I would find it very difficult to look into the future and see it operating with authority in the years ahead. It seems to me that, wherever the immediate advantage may seem to lie, it is surely in the long-term interests of the medical profession that the prestige of the Review Body should remain high because the arguments which led the Royal Commission to propose it in 1960 and the considerations which inclined the profession towards this form of arbitration have certainly lost none of their cogency during the last five years.
It is important to remind ourselves of what the Royal Commission said:
We are satisfied that the appointment of such a body is the only means of achieving: (1) the settlement of remuneration without public dispute; (2) the provision of some assurance for the professions that their remuneration is not determined by considerations of political convenience; (3) the provision of some safeguard for the community as a whole against medical or dental earnings rising higher than they should".
It may be that some of us would feel that the first objective—the settlement of remuneration without public dispute—may today have a rather optimistic ring about it, but I think that most of us are certain that, on the whole, all these desirable objectives would be very much more difficult to achieve if the authority of the review body were damaged by its exclusion from the present negotiations.
I therefore hope that the B.M.A. will not be too ready to dispense with arbitration in this present dispute, because I believe that by doing so it would almost certainly destroy the effectiveness of that arbitration in the years to come.
I come to the other proposals in the charter. I think that the House as a whole is anxiously awaiting the comments of the Minister on those proposals. He was kind enough, before the debate began, to let me have a copy of his letter to the General Medical Services Council, which we shall certainly study with interest and which, no doubt, he will want to amplify publicly during the debate for the benefit of the House.
We have been assuming that he would give a warm welcome to the many constructive suggestions contained in the charter for such things as the greater availability of diagnostic aids, more ancillary help, the improvement of premises, adequate numbers of G.P. beds, and so on. We hope that he is already discussing some of the proposals, particularly, perhaps, the one about certification and the burden which it places on doctors, with the Minister of Pensions and National Insurance to see in what way this very general widespread burden could be lightened.
I shall be asking the right hon. Gentleman very shortly some questions both about group practice and the supply of doctors, but meanwhile I doubt whether any of us would quarrel in principle with the need to provide family doctors with reasonable leisure, although, as I will try to show, I believe that the charter's proposals on this subject seem to take us to the very heart of the doctors' dilemma. The question which faces all of us, and doctors in particular, is: what should be the shape of general practice in future?
The charter contains the statement that
General Practice must remain a personal family service.
I am sure that we should all like to see it remain so. Although other hon. Members may disagree with me, I believe that the personal nature of this service could be preserved even if doctors were to look more to the State for the provision and modernisation of premises. But I am much less sure whether it could for long survive the introduction of regular working hours and payments for overtime. One newspaper last week drew attention to the simultaneous wish of the doctors for the independence and status of self-employed professional men and for the limited hours and overtime rates normally expected only by salaried employees. There is a real dilemma here.
It is perhaps very easy for us to talk. Most of us here are fortunate enough to enjoy reasonable leisure, and, except for a few rather miserable occasions during the year, we generally have undisturbed nights. For that reason, it would be wrong for us to try to deny what we enjoy to the doctors. It would certainly be shortsighted, because the potential contribution of overworked general practitioners must be seriously and, perhaps, dangerously devalued. Nevertheless, if the family doctor service is to survive in a recognisable form, there are certain features peculiar to it which cannot be ignored.
Most patients, for instance, have the inconvenient habit of preferring to see their personal family doctor rather than any other doctor who happens to be on the rota on any particular day. If they continually saw the rota doctor, they might begin to fail to recognise the personal service which we all want to preserve. In the more populated areas it is perhaps through group practices or partnerships that an increasingly acceptable compromise might be offered. Patients there frequently get their own particular doctor, but, meanwhile, they come to know the other partners whom they accept with a greater or lesser degree of willingness when their doctor is off duty.
Yet I find it remarkable that, in spite of the real contribution which group practices or partnerships are making, and could make, about a quarter of our general practitioners still work either single-handed or in partnership with one other doctor. Real problems will continue to exist in some of the rural areas.
I should, therefore, like to ask—and I think the Charter asks as well—what are the right hon. Gentleman's present proposals to encourage group practice? In the last debate that we had on this subject in the last Parliament he said:
The Government must accept responsibility for providing premises for group practice. A system of loans must be replaced by one of grants. That is what a Labour Governmnt would be prepared to do."—[OFFICIAL REPORT, 27th July, 1964, Vol. 699, c. 1017.]
Now, less than eight months later, are the Labour Government still prepared to do that?
Can the right hon. Gentleman, at the same time, take us further on another promise that was made before the election, the promise to set in hand an increase in the supply of doctors? Last year, again in the debate to which I have referred, the right hon. Gentleman told us that a Labour Government would ensure the setting up of four new medical schools at least. During the debate a month ago I asked whether he had persuaded his right hon. Friend the Chancellor of the Exchequer to provide money not only for the promised new medical schools, but for the expansion of places in the existing schools.
On that occasion he gave no answer, but his right hon. Friend the Secretary of State for Education and Science gave us a flicker of hope last Thursday, when he said:
This matter is under consideration, but I am not yet in a position to make a statement."—[OFFICIAL REPORT, 11th March, 1965; Vol. 708, c. 128.]
When can we expect a statement on this most important matter, and is it too optimistic to hope that this election promise will be fulfilled within the span of this Parliament? We should like the right hon. Gentleman not to forget, if he would be so kind, to give us an answer to that question, because I believe it to be fundamental to the problems that we are discussing.
During the debate last month a certain amount of attention was paid to new methods of remuneration. Just as I had mastered the intricacies of the old pool system, it seems to be near the point of death, and I have not heard a single lament in its honour, and now a vast question mark stands over the system, or systems, of remuneration which are to operate in the future.
The charter suggests that doctors should be given the choice between three methods of payment—capitation fees as at present, item of service, or some form of salary. It seems to me that all these methods have both advantages and disadvantages. The capitation fee gives to the doctor a definite incentive to take on patients although, in its naked form, it makes no allowance for their differing demands. But, to take account of the extra attention which is needed by the old and very young, I suppose that it may be possible to adjust the capitation fee method by a suitable system of weight for age.
Then there is payment by item of service. This would overcome the particular difficulty I last mentioned, but it is clear that many of the services which a doctor performs for his patients are extremely difficult to itemise. It is true that dentists are paid in this way, but I doubt whether itemisation in dentistry presents exactly comparable problems. In the case of doctors, much would have to be covered by the term "consultation", and I would find it hard—and I would be grateful if the right hon. Gentleman would give us his views about this—to decide what the proper reward should be for a long and intricate consultation on the one side, and for a very simple consultation of a few minutes on the other.
The third method, that of a straight salary, would certainly get over many of these problems, but I have no doubt whatsoever that it would produce a great many new ones of its own. Among others, this method of a straight salary raises the most profound and important question whether the personal nature of the service could continue if the present relationship between the patient and his or her doctor ceased to exist.
I think that it would be unwise for any of us, certainly for me, to be dogmatic about any of these different forms of payment. It may be that the right hon. Gentleman has it in mind to experiment with one or more of them. In the case of an experiment with the salaried system, I would be grateful if the right hon. Gentleman would confirm that this would need an amendment to the 1949 Act, because one of the main objects of that Act was to prevent a State salaried medical service being introduced by means of regulation alone.
If I am right in thinking that that experiment could not be introduced without amending legislation, we should naturally examine very carefully any Bill which the right hon. Gentleman introduced, but we should not oppose in principle an experiment with any of the methods which general practitioners believe might be a suitable system of remuneration. We should certainly want to study the results of the experiments, and I assume—and perhaps the right hon. Gentleman will confirm this—that if the experiments were carried out they would take place in different parts of the country in order to take account of widely differing circumstances.
The Charter is rightly and naturally concerned with the status of general practitioners and their proper place in the Health Service of the future. I am concerned, as I imagine and suppose we all are, that the key position of the general practitioner in the Service should not only be recognised, but that it should be made possible for him to occupy it.
The Health Service is "tripartite" in more senses than one. It is not only a unity between the medical services, the hospital services, and the local authority services. It is, or should be, as I see it, a co-operative enterprise between the Government, who determine its structure, everyone, whether skilled or unskilled, who works within the Service, and everyone who benefits from it. All these three, the Government, the doctors who work inside the Health Service, and the patients, have their responsibilities for its success.
The responsibility of the Government, and the right hon. Gentleman in particular, to improve the framework and conditions of the Service is only too clear, and I assume that the right hon. Gentleman willingly accepts that responsibility. The responsibilities of general practitioners, whatever the result of the present negotiations, are bound to remain immense, and, if we spend the time in thinking about them, literally terrifying in their implications. In this House and else-where we are sometimes afraid to talk about the responsibilities of patients, but I believe them to be very real, and I believe that they must be recognised if the Health Service is to survive.
These three partners share the responsibility for the relationship which exists, and will continue to exist, between the patient and his doctor, and it is on that relationship that the whole position and status of general practitioners, both in the Health Service and, I think, in society as well, ultimately depends. We want, today, undertakings from the Government about the ways in which the right hon. Gentleman proposes to discharge his share of this joint responsibility.
With regard to the responsibility of patients, I believe that it is essential that all of us—after all, we are all patients or potential patients—should arrive at a real understanding of, and sympathy with, the problems of doctors—in particular, the appalling difficulty for doctors, who are sometimes almost worn out with work and frustration, to realise how much individual men, women, or children are in need of the care which only they can give. But it is the doctors, finally, who will really determine the kind of relationship that is to exist in the future between them and their patients. I believe that it would be extremely unwise for us to try to hide our heads in the sand.
I believe that today there is a real threat to the relationship between doctors and patients. If that relationship were seriously damaged we would all be the losers, and it is possible that general practitioners would lose most heavily. This is why I believe it to be essential, even if the form and circumstances of the relationship between doctors and patients undergo a change in the future, for the personal nature of this relationship to be held to as long as is conceivably possible.
It is true to say that the Health Service could undergo all kinds of changes and modifications and still preserve its continuity and character, but if we destroy or damage the personal relationship between doctors and patients, which seems to me to lie at the very heart of the Health Service, we may be left with something that went by the name of a National Health Service, but I doubt whether it would be easily recognisable.
I welcome the debate. At the outset, I want once again to express my appreciation at the consistently helpful and constructive tone of the speech of the right hon. Gentleman the Member for Bridlington (Mr. Wood). I was especially glad to hear his observations about the Review Body. I hope that these will be pondered by those who are making decisions elsewhere in this con-nection. As I expected, the right hon. Gentleman devoted the greater part of his speech to the problems of general practice and the situation which the profession and the Government are facing at the moment. I propose to do likewise.
There are one or two points which are slightly extraneous to that, however, but I want to get out of the way at the outset. I was not surprised when the right hon. Gentleman made a brief reference to some remarks that I made about one or two surgeons in a speech about ten days ago. At this stage I will not add to the later speech that I made at Nottingham last Saturday, which the right hon. Gentleman described as a disclaimer. I made my position and intention clear in that speech, and in leaving the matter there I hope that I am responding to the right hon. Gentleman's suggestion that I should say nothing this afternoon which might exacerbate what we all agree remains a delicate situation in respect of general practitioners.
The right hon. Gentleman also asked about medical schools. I recall that in opposition I said that we needed four new medical schools, and not merely the one which was planned and announced by the Government of which the right hon. Gentleman was a member. Responsibility in the departmental sense, as the right hon. Gentleman knows, rests with my right hon. Friend the Secretary of State for Education and Science, although I am vitally interested in this matter, since we must have the doctors to run the National Health Service.
The supply of doctors can be expanded most rapidly by increasing the intake of students into the existing medical schools. That has been done to the extent of a 25 per cent. increase within the last four years. I am told that any substantial further increase into existing schools will need additional facilities at the schools, and these requirements are being urgently examined. The planning of the new medical school in Nottingham is going ahead, and longer-term needs, such as the possibility of future new schools, are also under urgent consideration. I cannot give a time when my right hon. Friend or I shall be able to make a statement; I can only assure the right hon. Gentleman that we are seized of the urgency of this matter, and that there will be no avoidable delay in communicating our conclusions to the House.
I now turn to the main part of the right hon. Gentleman's speech. His questions on the charter and on general practice in general will be answered in the course of my speech. He will forgive me at this stage if I cannot answer in detail questions which he may have posed and which will come up for discussion in the negotiations which we hope will start. It is a mark of the importance and urgency of the problems that we are facing that we should debate them in the House on 17th March as well as 17th February.
I have only one complaint to make about the Opposition—the timing of these debates. We all like to think that what is said is debates here may have an influence on what is going on elsewhere. It so happens that the debate on 17th February took place on the very day of the meeting of the Council of the British Medical Association, which was considering the Review Body award. Again, today, the debate is taking place on the very day when both the General Medical Services Committee and the Council of the B.M.A. are considering my response to the charter. Our chances of influencing those bodies by what is said in the House today are minimal.
I can probably best serve the Committee by tracing as briefly as I can the course of events since the February debate. In so doing I may have to run over some of the ground covered by the right hon. Gentleman. On that occasion the Review Body's recommendations that doctors' remuneration should be increased by £5frac;12 million a year, and also that the bulk of the money should be used to facilitate the schemes for fairer distribution of practice expenses, were under consideration by the Council of the B.M.A.
The Council apparently recorded neither acceptance nor rejection of the recommendations at that stage, but it endorsed the resolution of the General Medical Services Committee that doctors should be asked to send in undated resignations from the Health Service and that there should be immediate negotiation with me on a new contract and new methods of remuneration. It went on to say that as an essential preliminary to the negotiations the £5½ million increase should be used not as the Review Body had recommended but for an all-round increase in capitation fees, leaving the present distribution of practice expenses unchanged.
The Government had accepted the Review Body's recommendations in their entirety, and it was not easy to see how the deadlock which was thus created could be broken. But later in the week the leaders of the profession came to see me in order to discuss the situation. I made it plain at the meeting—as I had to—that I could not agree to make the £5½ million available for a general increase of pay in breach of the recommendation of the Review Body. However, after some hours of discussion it became clear that in the profession's present mood the practice expenses scheme was no longer acceptable to it. I therefore agreed to transmit to the Review Body the profession's request for clarification of the Review Body's intentions regarding the £51 million in the event of the practice expenses scheme not being agreed to by the professison.
The Review Body considered this request a few days later—and here I want to pay my tribute to it for the speed with which it dealt with this matter. It indicated that although, in such an event, its recommendation for the distribution of the money could not be implemented, its other recommendations would nevertheless stand. The Government adhered to their acceptance of these recommendations, and, as a result, the £54 million will be added to the pool for 1965–66.
It appeared to be the view of the profession that the money should all go in general distribution. Since I could not introduce a practice expenses scheme against its wishes, the Government have agreed to this. I did not conceal my regret at the loss of this opportunity at any rate to make a start with a fairer distribution of practice expenses in a scheme which everybody—the Government, the profession, as I think, and the Review Body—agree is so desirable in the interests of good family doctoring.
I have heard what has been called the untying of the strings of the £5½ million described as a victory for the doctors. It is hard for a Minister of Health to see as a victory for anyone an outcome which frustrates, even though only for the time being, progress in a direction which all agree is the right direction. However that may be, the way now seemed clear for discussion on the new contract and new methods of remuneration. As I told the House in the debate on 17th February—hon. Members may refer to column 1217–8 of the OFFICIAL REPORT—I have always been willing to discuss these matters, but the profession's representatives did not feel able to do so until the business of the £5½ million had been settled and was out of the way.
Even so, the British Medical Guild—which is, of course, the Council of the B.M.A. with different hats on—sent out letter after letter to family doctors urging them to submit their undated resignations, with fresh forms to fill in in case they had mislaid the first lot. The B.M.A. Council also summoned a meeting of doctors from all over the country for 24th March, a week today. It announced that unless this meeting decided to the contrary, in the light of progress in dis- cussions with me the resignations should go in, presumably on 1st April. I refrained from any comment on these activities, apart from the point I made earlier that I could not continue negotiations if the resignations were actually sent in.
The profession did not open discussions with me immediately. First six doctors were instructed to prepare draft proposals. After a 48-hour conclave they produced a document for presentation to me as the profession's proposals for far-reaching changes in a system that had been in operation for nearly 17 years and really, in basic principle, for about 35 years before that. It was, of course, a formidable task that they had set themselves. There was a great deal of material to work on, from publications over the years, including the material collected by the B.M.A. for presentation to the Working Party on General Practice which my predecessor set up. It was, none the less, a tremendous task to produce a set of firm proposals in a couple of days when for years the profession had been unable to agree on what the answers should be.
Would not the Minister agree that this charter which he is claiming was produced in 48 hours has been largely the policy of the Medical Practitioners' Union over a number of years and this was stated by the Medical Practitioners' Union, which has several influential members on the benches opposite, at a recent meeting in the House?
I certainly should not like to intervene in what may possibly be a disagreement between different bodies representing the profession. I very much doubt whether the B.M.A. would endorse the intervention of the hon. Gentleman
However, I was saying that it was a tremendous task, and one cannot altogether stifle doubts whether six doctors have necessarily hit on the best structure for general practice and the right way to secure it. For example, little is said about group practice, to which the right hon. Member for Bridlington devoted part of his speech, and about which I have spoken very often in this House. Experience has, I think, amply confirmed the value of group practice in removing frustrations and in providing infinitely better working conditions for the doctor. What I should like to do is to bring about a situation in which more doctors will combine voluntarily in groups that match local needs, with due regard to what the hospitals and local authorities are providing, and planning to provide, and indeed with help for the general practitioners from local authority staffs. Obviously, for this purpose there will have to be joint studies of local needs. I should like very much to encourage this in any way I can.
I realise that the question of how premises are provided is important in this context. I have already indicated to the profession that I accept the need to help doctors with the provision of finance for this purpose.
This, in fact, is a matter which comes within the discussions which I shall have. The right hon. Gentleman will have seen from the charter that the profession's representatives have other ideas about financing practice premises. I want to go into these discussions with an open mind. I shall be putting ideas of mine and they will be putting ideas of theirs. I do not want to lay down a fixed policy at this stage.
The document, the family doctor's charter, reached me officially on Monday, 8th March. I did, in fact, receive an advance personal copy of it at the weekend. This, as I think the House will see, left me little more than a week to express my views on it if these were to be considered by the General Medical Services Committee and the Council in time for the meeting on 24th March—next Wednesday.
There were two factors in the document about which I must confess I felt some disappointment. First, that so little emphasis was placed on what has always seemed to me to be the central problem of general practice, the method of organisation of the service and, secondly, that so much emphasis was placed on the cash price of the general practitioner's services. Certainly the G. P. s must be fairly rewarded, but I have always made clear that while I am prepared to discuss anything else with the profession, the quantum of remuneration is a matter for the advice of the independent review body appointed for the purpose. I think that no one could have misunderstood what I said in the House on 17th February—it is reported in column 1281 of the OFFICIAL REPORT, if anyone wishes to refer to it—and I was disturbed that the profession should have paid so little regard to this aspect.
The document was actually published on Monday, 8th March, the same day as I officially received it. Criticism of it in the Press was concentrated on, but not limited to, the size of the pay claim embodied in it. The Secretary of the B.M.A. held a Press conference and appeared on radio and television to expound the proposals with estimates of the cost. He told the public that it was now up to the Minister to make up his mind on the proposals and thus to determine the issue whether the profession would resign.
Again, quite deliberately I refrained from any public statement or any appearance on T.V. or radio until I had had an opportunity to meet the profession for a first exchange of views. That meeting took place on 12th March and afterwards I gave the Press, not an account of the meeting, which at that point had been adjourned until the next day, but my own first reactions to the charter, just as I have conveyed them to the profession.
As soon as I said 12th March I thought that I had got the date wrong. The noble Lord is quite right, it was Wednesday, 10th March. The document was published on Monday, 8th March. I said nothing about it until I had seen the profession on the morning of the 10th and the Press conference followed my first meeting with the profession. I am grateful for the correction.
I held this conference and told the Press, just as I had told the doctors, that the charter seemed to me to provide the framework for negotiations on the contract and on methods of remuneration, and that I was ready to help with the provision of premises, but quantum should be considered by the Review Body. I said that only actual handing in of the resignations collected could frustrate progress.
The Press, I think very correctly, reported my tone as "conciliatory" and that was certainly my intention. I am sorry that the B.M.A. saw fit to issue in quick succession two strongly worded statements charging me with being inflammatory and tendentious; inflammatory because I reminded everybody that I could not negotiate under duress—the House should remember that the British Medical Guild has not felt inhibited about continuing throughout to urge on doctors the sending in of resignations—and tendentious because of the figures I have quoted. These statements were understandably seized on by the Press as a dramatic clash between the Minister and the profession.
Perhaps I could say a word here about the figures. In view of the profession's attack on my Department's estimates, I suggested that the best course was for the experts on the pool on both sides who had worked out the estimates to get together and either agree on what was a fair assessment of the cost or at any rate to define the area of disagreement and the reasons for any disagreement. This procedure was agreed at a meeting with the profession's negotiators the following day, 11th March. I am glad to say that the experts have now agreed on a rough estimate of the increased remuneration implicit in the charter. It is £40½ million, or £35 million over and above the £5½ million recommended by the Review Body. For a given volume of expenses, these are net figures. They relate to about 22,300 doctors, and the arithmetical average per doctor is thus over £1,800 per doctor, or over £1,550 on top of the recent Review Body increase.
The profession took me to task for mentioning an average of £1,800 a doctor. They had suggested a figure of £900 because, so I understand, this was all the increase which they thought would be guaranteed under the charter to a doctor with an average list, whose income derived entirely from capitation fees, in other words, a doctor who was not getting remuneration from weekend work or overtime payments or any of the other things which are outside the capitation fee.
I thought that this was a difficult argument to follow. To me, the average per doctor is the total increase divided by the number of doctors. If there is a large number who would get only an extra £900, there must be many who would get very much larger increases than £1,800. This follows, I think. I know of no way of giving an overall picture except by an arithmetical average. I cannot agree that to quote such an average was in any way misleading. However, I am glad that the B.M.A. and I are now agreed on the global cost of the proposals. Certainly, it is beyond dispute that the charter, as priced by its compilers, implies a very big increase in remuneration for the family doctors. Nevertheless, I have not rejected it out of hand on that account.
There is much in it which seems to offer hope of agreement on changes which will improve general practice and the lot of general practitioners without any necessary implication for amount of remuneration. I want to negotiate on these matters. On quantum, I find it a little ironic that the profession are now pressing for direct negotiation with the Government. The history of the National Health Service has been punctuated with bitter disputes between Government and profession on remuneration, disputes which have had to be resolved in each case by recourse to independent advice, first Mr. Justice Danckwerts in, I think, 1951, then the Royal Commission 1957–60, then the Review Body. The Review Body was set up on the Royal Commission's recommendation and in accordance with a suggestion from the doctors themselves. The right hon. Gentleman quoted from the Royal Commission's Report; let me quote from another part of the Report. In paragraphs 402 and 403, it said:
We have no doubt that some arrangements should be made to keep remuneration under review, and that they should be such as to achieve three aims which we consider to be of great importance.
The first is that avoidance of the recurrent disputes about remuneration which have bedevilled relations between the medical and dental professions and the Government for many years. Whatever the rights or wrongs of these disputes, they do nothing to promote the smooth working of the National Health Service.
I was going on to quote paragraph 429, but the precise words, which are relevant in this context, have already been quoted by the right hon. Gentleman, so I shall not weary the House.
The Review Body was set up with the professions' agreement and steps were taken to make sure that its membership was such as to command their confidence. They expressed that confidence in unequivocal terms only three months ago in the letter which I quoted in the debate on 17th February. To the Government it is inconceivable that this source of advice on general practitioners' remuneration should be ignored in so important an operation as the pricing of a new contract. My right hon. Friend the Secretary of State for Scotland and I note that the profession now wants direct negotiation with us on remuneration, but we must be forgiven if, in the light of history and of happenings in recent months, we have our doubts about the prospects for a satisfactory outcome from such negotiations. I would think that, on reflection, the profession itself might share those doubts.
But I do not want to dwell on the negative side of my response to the charter, particularly as this concerns an aspect which, I made it clear in advance, I could not discuss. On what I understood the charter was going to be about—a new type of contract and new methods of remuneration—I am entirely ready to negotiate within the framework put forward, with a view to the first fundamental change in the structure of general practice in the whole 17 years of the National Health Service. Even on the pricing of the contract, I would have said that willingness to refer to independent advisers is not usually regarded as an unco-operative or oppressive attitude to adopt. Altogether, I cannot see how I could have been more conciliatory in my response to proposals put forward in the circumstances which I have described. I was called upon to commit the Government, at very short notice on proposals to which the profession are not yet committed at all—I should like to emphasise this—and to declare my position before actual negotiations could even start. But because I understand the profession's difficulties and because I am genuinely concerned for the future of general practice, I have not allowed this to deter me from responding positively on all the main points except quantum.
Perhaps I might read to the House one or two paragraphs from the letter which I have sent to the chairman of the profession's negotiating committee.
I shall not weary the House with the whole letter, because it is a long one, but it says in part:
It has been repeatedly stated that what is now needed in general practice more than anything else is a revision of general practitioners' terms of service and methods of remuneration. I have told you that your proposals for a new type of contract and flexibility in methods of remuneration seem to me to provide a perfectly possible framework for negotiation. During the course of negotiation I shall want to inject ideas of my own, but I believe that the Charter offers an opportunity, which we should all do well to seize, to improve the general practitioner service for doctor and patient alike.
I was at first concerned lest the proposal for limited liability for the individual doctor and a review of the Allocation Scheme implied a repudiation of the liability of the profession as a whole for the general medical care of the population as a whole, with continuous cover, but you have assured me that this is not so, subject to reasonable protection of the individual doctor against unreasonable demands on his services. On this basis I am prepared to discuss limitation of individual liability.
Then I go on to deal with the Review Body point, and a little further I write:
My position is that, provided it is understood that I should not be ready to agree to new levels of remuneration except on the recommendation of the Review Body I am prepared to negotiate on all the other matters covered by the Charter, and I believe that it would be in everyone's interest that we should do so.
One of the suggestions in the Charter, for example, is that public finance should be made available for the provision of practice premises. I am interested in any idea likely to improve general practice and I shall be very ready to consider with the profession how premises for practice can be provided in a manner most likely to bring maximum benefit to doctors and patients alike. I accept the need to help doctors with the provision of finance for practice premises, and I am prepared to discuss with you your particular suggestion for a separate publicly financed corporation, though,
as I have explained to you, this would require legislation.
My final paragraph reads:
These discussions are bound to take time, notwithstanding everyone's best endeavours, and I do not see how new arrangements could in any event be brought into effect before the end of the period for which the Review Body's recommendations in 1963 were intended to last.
Broadly, that is, 1st April, 1966, which is just over 12 months from now. I continue:
With good will on both sides I should hope we could have a new and priced contract ready to introduce then. Our joint aim must be to secure for the general practitioner the conditions he requires to give the best care to his patients and the greatest satisfaction to himself.
That is the end of the letter.
The right hon. Gentleman asked me about legislation. I have already mentioned one point of the charter which, in my view, would involve legislation, and I agree with him that the introduction of a salaried general practitioner service would also involve amending legislation in the light of the Section in the 1949 Act. I have quoted from the letter at some length, and I understand that copies of it are now available in the Vote Office. If, as I hope, the profession decide that negotiation is the wiser course, I do not want to pretend that the negotiations will be short or easy. We shall not want to delay them in any way, but they are bound to be long because they cover a very wide area—the whole field, in fact, of general practitioner work.
We shall want to be sure that the changes which we shall be making together—changes which will determine the future of general practice in this country—are the right ones. Negotiation is likely at times, perhaps, to be tough, for it would be unrealistic to expect an identity of view on all, or even perhaps most, of the problems which are bound to come up. But on both sides of the table, I hope, there will be a common interest, because the welfare of the patient, I am sure, will be in our minds throughout. Provided that this is so, I believe that we can achieve a satisfactory conclusion.
It would be miraculous, however, if we could reach the right answer for all time to every question, and what I profoundly hope is that we should not allow any new structure of general practice to ossify, as the 1948 pattern has been allowed to do, causing growing frustration and worry for doctors and often a second-best service for patients. For my part, I should be willing to keep the pattern which emerges under periodical review and to consider with the profession what changes may be needed from time to time to improve it.
As my right hon. Friend has so far described these arrangements, it seems that the negotiations will be fairly narrowly confined to what is in the charter. My understanding is that a very large number of younger doctors would like to see some experiment, some pilot scheme, of a salaried service, connected with health centres, as has been the ideal of the profession for many years. Would it be possible for this to be discussed within these arrangements?
Yes. I can assure my right hon. Friend that I have already told them—I think that I said this in my spech—that I should have ideas of my own which I should want to inject into the discussion. There is no difficulty at the moment about the provision of health centres from the legislative point of view. Local authorities are willing to build them and doctors are willing to work through them. As for the point about a salaried service, my right hon. Friend will be as glad as I am that this is now a subject which the profession itself has said that it wishes to discuss. Of course, it is anybody's guess how many doctors would prefer to be salaried, but there is no doubt that quite a substantial proportion of doctors today would prefer to be on a salary. Certainly we can discuss this matter.
No. What I have said is that I envisage these discussions as being, first of all, discussions direct with me about the terms of the contract—a completely new form of contract—and methods of remuneration. Only when that stage is completed can the Review Body be asked to do its task of, so to speak, setting a price or, if hon. Members prefer, a schedule of prices on what has been agreed. As I said in my letter, and as I have told the profession, taking into account that legislation is also needed, the whole of this operation is likely to take the best part of 12 months. That will take us to about the end of the period for which the Review Body have said the 1963 settlement might be intended to last.
This would be a matter for the Review Body. I have told the profession very many times that I do not want to discuss quantum in any sense at this time for the reasons which I have given, and I must tell the hon. Member the same thing.
There can now be, in my view at least, no conceivable excuse for withdrawal from the service. I cannot think that, in the light of my expressed willingness to negotiate, family doctors will wish to persist in a course which could only amount to, and would be seen by the public as an attempt at, coercion of the Government. Though doctors rightly stand high in public esteem, I do not believe that a doctors' strike—and however much the doctors dislike that word, this is how it would appear to ordinary people—would gain any sympathy or support from the public at large. Because, let us face it, it would be a strike about pay and not about working conditions or the structure of the family doctor service or any of the other matters which I am ready to discuss.
The National Health Service, whatever its defects may be and we can always argue about those—has become part of the British way of life. It is recognised, I think, by all political parties as permanent, and in my view it represents the civilised way of organising medical care. After 17 years' experience of this great service, I think that the people of Britain would not take kindly to any attempt to force them to become private patients.
I could say very much more about the unavoidable consequences both to the doctor and to the patient of mass withdrawal, but I shall refrain because I cannot see such an action as a rational possibility in the light of the Government's initial response to the family doctors' charter. Nor, for the same reason, will I say anything about any plans which I may have to deal with such a contingency. I prefer to believe that commonsense will prevail and that it will not come about.
All hon. Members will feel that the Minister made a most friendly and conciliatory speech, certainly more friendly and conciliatory than his last speech. He rightly showed that he feels real concern for the welfare of the patient and the welfare of the doctor. I hope that before the profession takes any action which has been threatened its members will read and reread the right hon. Gentleman's speech, which showed great hopes of a satisfactory settlement.
The crisis which has arisen is really a manpower crisis. It is not only in the general practitioner service, but in our hospitals, and some people who know better than I believe that it is greater in the hospitals. We have 4,000 Indians and Pakistanis helping to run our hospitals. At the same time, 400 United Kingdom doctors leave this country annually. The Minister will correct me if I am wrong, but I understand that last year, for the first time, the number of doctors in the general practitioner service diminished—and diminished by 70. That is a serious thing. It means that for the first time we have had a running down of the medical manpower in the general practioner service. We must seek ways of putting this right.
I believe that one of the main causes of this were the recommendations of the Willink Committee and that the members of that Committee arrived at the wrongest conclusion it was possible for them to reach on the facts laid before them. If it were possible, I would like the Minister to call that Committee together again—the members of it who are still alive—and ask them to have a look at the situation to ensure that we do not go wrong again, for this could be the beginning of a real drain of manpower in our medical services.
This shortage has thrown an increased load on our general practitioners and we must realise that, with a diminishing number of them and an increasing population, a tremendous increase in the load has been thrown on the medical profession. Not only is the birth rate increasing annually, but people are living to a greater age. These things are throwing an extra burden on the general practitioner service.
I believe that this burden will increase and not diminish. If one looks 10 years ahead one can see that the number of people between 65 and 80 years of age will have increased tremendously. This will mean an added burden on a diminishing general practitioner service. We must, therefore, consider, first, how to retain the general practitioners we have and the doctors in our hospitals and, secondly, how to increase their numbers. I was delighted to hear the Minister say that a new medical school is in the process of formation at Nottingham.
If the right hon. Gentleman looks through the dusty files in his Ministry he will find a memorandum which I laid in 1948 recommending the setting up of a medical school in the City of Bradford, the largest centre of population in the country, which in those days did not have a university. At the end of this year it will have a university, the first chancellor of which will be the present Prime Minister. I suggest that this centre of population would be a suitable place—considering the splendid hospital, which is well staffed—for the establishment of a new medical school.
One must realise that the provision of new medical schools, including the one at Nottingham—and I hope that another will be recommended for establishment in the City of Bradford—will not produce any extra manpower for our medical services for at least eight, and probably 10, years. We must, therefore, consider how we can retain the doctors we already have. What can we do to reduce the workload to prevent 400 doctors yearly leaving this country? We can do much by providing ancillary staff, modernising equipment, providing adequate premises and preventing the wasting of time, as my right hon. Friend suggested, in signing many hundreds of certificates.
I must add—although I realise that hon. Members opposite will not like to hear this—that the removal of prescription charges has added greatly to the doctors' burden. Doctors have had to make out 30 per cent. more prescriptions, and when one realises that each prescription represents a consultation or interview, it is a large increase. In the City of Bradford the additional number of prescriptions has been 50 per cent. I believe that I see the Minister shaking his head in disagreement. Perhaps I might also inform him that the cost of this concession, which was stated by the present Government to have been estimated at £26 million, will be nearer £40 million.
We acknowledge that the number of prescriptions has increased, as they always do in February. Perhaps the hon. and gallant Gentleman could say what is the present rate of prescribing compared with previous years, when the prescription charge was on.
I will drop the Minister a note and inform him.
While the Minister was talking about the increase in the cost of the recommendations in the charter—of —35 million, not taking, into consideration the £5½ million—I thought that he should also be taking into account the additional amount as a result of abolishing prescription charges which, as I say, may be £40 million and not £26 million, the figure which he gave the House three months ago.
If we are to retain the doctors we have we must see that their working day and week is less Victorian than it is at present. Many doctors work seven days a week, many more six days. Many work 10 to 12 hours a day. There is no other profession in which people work so hard and long. We must get this work load reduced by some means or other and the working week fixed at six days at the most, and eight hours a day.
I appreciate that group practice will be one way and I was glad to hear my right hon. Friend and the Minister speak so highly of the importance of group practice. However, it is not possible in the most rural areas to go in for group practice. So we must consider those doctors who practise in the very rural areas and find ways to reduce the work load on them.
Would the Minister confirm that doctors do a lot of work for which they are not paid? For example, when doctors in the Health Service emigrate, and their places are not filled, their work must be done by doctors in neighbouring or surrounding districts. If a doctor doing this work has more than 3,000 people on his panel I understand that he does not receive any extra pay for the extra work he does.
So it is possible that a doctor who takes on extra work and more patients—simply because a nearby doctor has emigrated or his practice has not been filled—does work and does not receive pay for doing it. I hope that the right hon. Gentleman will look into this to ensure that doctors get paid for every bit of work they do.
At the moment, they are grossly underpaid. Over the last 13 years their remuneration has increased by 40 per cent., but in that same period the cost of living has gone up by 50 per cent. and salaries and wages have gone up by 110 per cent. The doctor is at the very end of the queue—others have had salary and wage increases amounting to almost three times as much as his.
The Minister spoke of the panel system that existed before the National Health Service started—about 35 years ago. In those days a doctor got 10s. 6d. capitation fee, but was called upon to treat only the working population, the healthy people—not children or old people. Now he is called on to treat the youngest and oldest—those who demand the most attention—and gets between £1 0s. 6d. and 27s., according to the number of his panel. If we were to translate the former 10s. 6d. into real terms, the doctor should now be getting about 42s. for every patient on his list but, at the most, he gets 27s. We must look at the doctors' pay, although that is not the thing that matters most to them. They have never put money matters first—had they done so, they would have been at the Minister long ago.
The present position is very serious, and I hope that, to retain people in the Service, the right hon. Gentleman will look at the interest paid on the money set aside by the Government when they stopped the buying and selling of practices. A sum of money is paid out to the individual when he retires, or it is paid to his widow, but if the Minister were prepared to pay it out at age 60 we would retain more doctors in the Service, because I am sure that some retire only to get hold of capital that is earning no more than 2¾ per cent. To keep doctors in the Service, the Minister must make this money available earlier, and must see to it that a more realistic rate of interest is paid on it.
The Minister could also help by removing the threat of closing many of our cottage hospitals and what might be called practitioner hospitals. In the great Hospital Plan, many cottage hospitals, where the general practitioner had access to his patients, will fall by the wayside, and that will increase the gap that general practitioners feel exists between themselves and their patients and themselves and the consultants. If they could have access to these small hospitals, they could practise more scientific medicine and go in for more scientific investigation of their patients—
It is in the great Hospital Plan, which comes up for review—or did, before this Government came into office—once a year. There is some doubt now whether it will come up annually for review—
I am glad to hear that, because some of us feared that the plan was being changed and cut, just as the number of universities to be built is being reduced from four to one.
This crisis has been blowing up for many years, and I believe that what has brought it to a head is—[HON. MEMBERS: "A Labour Government."] I do not think that it is the election of a Labour Government. I thought it rather mean, untrue and petty for the Minister to say that some consultants have complained about the hospitals simply because a Labour Government had been elected. I do not think for one moment that that is true.
What I think is true is that the doctors saw that £26 million was going to remove prescription charges while they themselves were getting only £1½ million, out of the last recommendations£[HON. MEMBERS: "£5½ million."] Yes, £5½ million now, but it was £1½ million when the doctors rebelled. I think that the consultants also feel that when £40 million—not £26 million, but £40 million—is likely to go in free prescriptions a little more should be spent on the hospitals. I think that they were very suspicious when they heard that the Hospital Plan might not be reviewed every single year.
We must realise that a free and comprehensive hospital service is very costly. We have had it rather on the cheap in the past. If we want a free comprehensive hospital and health service we will have to pay more for it. It may be too costly for any country to bear. No country except Britain has yet attempted a free comprehensive hospital and health service. Some of us remember how, during the 1945–50 Parliament, Sir Stafford Cripps froze the cost of the Health Service at £400 million a year, saying that the country could not afford more. There was a time in the 1950–51 Parliament when the then Chancellor of the Exchequer, the late Mr. Gaitskell, introduced a Bill to put a charge on prescriptions simply because the cost of the Health Service was mounting.
The Government must make a decision. They must pay the practitioners adequately, but, at the same time, they must decide whether a free, modern, comprehensive Health Service—growing more expensive every year with the advances of medical science, the invention of new drugs and the use of new methods of investigation and treatment—is not too much for any country to support unless prepared to pay a large health tax or make some charges.
I am not against charges, because I think it excellent to have such a great service available. Whether or not there should be a charge on prescriptions I would not like to say—or whether there should be a hospital charge, or a hotel charge in hospitals, or a general practitioner charge. It is something that must be thought about, because in the coming years the cost will be so great that we shall have to make a decision.
I do not think that the salary basis of the general practitioners is the only thing in this crisis and I am glad that the Minister does not take that view either. We must find means whereby general practitioners can have more leisure and their amount of work lessened. We must see how we can improve their professional standing, and give them greater and better access to their patients in hospital. We must also give very earnest consideration to the question of how to increase medical manpower or retain for a longer period the manpower we have in the hospital and health service. These are absolute essentials—
Perhaps the hon. and gallant Member will clear up one point. He said that the nation could not possibly afford such a Service—that it might become too expensive—but I gather that all he suggested was a different way of paying for it, not reducing the Service; that instead of our all subscribing through the Government, we should pay through all sorts of odds and ends of ways. But would that make the Service any less costly?
Not at all—and the right hon. Gentleman knows that it would not make it any more costly. The Service might become so costly, however, that we had to adopt the methods of other countries of having certain charges in a health service available to everyone.
It is essential that the Government should meet the number of demands that doctors have made if we are to maintain both the general practitioners service and a medical service in our hospitals.
I will follow the hon. and gallant Member for Ripon (Sir M. Stodart-Scott) into a number of the rather queer excursions he made into the subject of doctors' pay and the Health Service. The figures he quoted for the increase in the number of prescriptions being issued by doctors were obviously such that he could not substantiate them, at least not to this Committee. Unless the hon. and gallant Gentleman is prepared to stand up now—I will willingly give way—and tell the Committee the source of his information, he should withdraw those remarks. Obviously, he is not prepared to do that.
The hon. and gallant Gentleman said that doctors' salaries had risen by only about 40 per cent. in the last 13 years. He was in the Chamber when my right hon. Friend the Minister said this on 17th February:
… I must put it on record that if this award is included their increases since the Royal Commission was appointed eight years ago have aggregated to around 50 per cent."—[OFFICIAL REPORT, 17th February, 1965; Vol. 706, c. 1214.]
The hon. and gallant Gentleman is again at variance with the facts.
The hon. and gallant Gentleman said that Britain is the only country in the world with something approaching a comprehensive free Health Service. I am very proud that this is so, especially as it was begun by the Labour Government between 1945 and 1950. As my hon. Friend the Member for Halifax (Dr. Summerskill) said on 17th February, hon. Members opposite voted against the Health Service on the Second and Third Reading of the Bill which set it up.
I believe that a tremendous number of tears are being shed on behalf of the G. P. s. We are conscious that there are many hard-working G. P. s who have a very difficult job to do. However, if they persist in their declaration of intent to withdraw their services from the National Health Service, they are in very grave danger of losing the sympathy which exists for them throughout the whole country. A few—more than a few; probably a fair band—of general practitioners are today jumping on the political bandwagon purely because there is a Labour Government in power.
It is important that certain historical facts are borne in mind. Only two years ago the doctors were awarded a 14 per cent. increase which was due to last for three years. The Economist, on 30th March, 1963, speaking of that increase, said this:
What is important, however, is the effect of this 14 per cent. increase on other salary claims. Doctors may now have caught up and overtaken their professional counterparts, but this in itself will give a stimulus to other professions to put in a matching claim. The Higher Civil Service review body will be bound to take the 14 per cent. into account in its current consideration of salaries—so will those sorting out university salaries, especially as Health Service salaries directly influence the salaries of clinical and pre-clinical teachers in universities with medical schools. The three year stability in doctors' pay will certainly not produce stability elsewhere.
It did not even produce stability in doctors' pay, because within a very short time the doctors were asking for, and, indeed, were granted, an independent Review Body to consider their pay and conditions. When that award was made, my right hon. Friend the Minister said in the House of Commons on 17th February that, because this was the nearest thing to an independent arbitration body and tribunal which the profession had had, he was compelled more or less to accept or to reject the Review Body's findings. It was completely to my right hon. Friend's credit that he decided to accept in full the Review Body's recommendations. The recommendations were such as to ensure that those who needed help most to improve facilities and give their patients better service would receive a higher amount. Since then I think that the Minister has perhaps gone a shade too far. He has made considerable concessions.
It should be borne in mind that, including the £5½ million award, the average net salary of a G.P. is in the region of £3,000 a year, with an average gross salary of £4,500. Now, at least part of the profession cries for more. They have become the Oliver Twists of the National Health Service. They cannot make up their minds what they want to do. One minute they wanted to negotiate with the Minister. Then they decided that they did not want to negotiate. Now they have decided that they do. In the charter which they published they want the best of both worlds: they want to negotiate with the Minister and then have a Review Body which will adjust those findings from time to time.
I am prepared to take the hon. Gentleman to my own town of Croydon and show him doctors handling 2,300 patients and earning only £1,800 after expenses, so the figures he quotes are inaccurate.
If that is so, there must be a considerable number of doctors earning far in excess of £4,500. The idea of the Review Body was to ensure that doctors in need of help would receive it. The way the medical profession has been behaving in the last few months has been such that, if they were trade unionists on the shop floor or elsewhere, they would have been denounced as irresponsible. Indeed, trade unionists would not dream of behaving in this manner.
Would not the hon. Gentleman concede that, if the doctors had been trade unionists, this trouble would have occurred a very long time ago and this patience would not have been shown?
If the members of any trade union had received a 14 per cent. increase in pay during the last three years and had violated the agreement within that period, there would have been a tremendous outcry by hon. Members opposite.
Not only are these doctors to whom I have referred the Oliver Twists of the Service. They are almost the Dick Turpins. They are pointing a gun at the Minister's head. They are asking him to stand and deliver some more money. The Minister should not at this moment give way. He should stand fast, because the doctors seem to want their cake and halfpenny at the same time. They are demanding another £40 million. We should ask the profession how much they add to the work that they do and to the salaries that they obtain by taking on the number of private patients that they do. What effect has this on their salaries and, indeed, upon the conditions in which they work?
Having been granted the award of £5½ million, they should immediately remove the threat to withdraw their services from the Service. I implore the Minister to tell them that he is not prepared to negotiate until that threat is removed.
Referring again to the article in the Economist, which spoke of the effect the 14 per cent. increase two years ago would have on other claims, before I came to the House of Commons I was employed in the Service for nine years. I assure hon. Members on both sides that amongst the ancillary workers, clerical and administrative staffs, and others in hospitals and elsewhere, there is a seething cauldron of discontent about the pay and conditions they have to endure. How can we expect them to endure those conditions when the doctors are demanding this £40 million?
The facts—and the House should know them—are to be found in the booklet issued by the Whitley Council which sets out rates of pay in the National Health Service. They are as follows: Group 1, general porter, gross pay £10 5s. 8d. Group 3, ambulance attendant, £10 13s. 8d. Group 8, attendant on aged and infirm, £11 13s. 8d. On that gross pay they are expected to keep a wife and family. The net pay is considerably less. How can we expect these people to accept this kind of wage in the light of the extravagant demands which are being made by members of the medical profession?
If I may now refer to the charter, I agree that the objects of the charter are, in the main, excellent. It is, indeed, the eventual goal towards which we should move in many respects.
I would point out that the time for this debate has already been severely restricted. I hope that hon. Members will not take up too much time with unnecessary interventions.
I accept the charter as it stands as being the eventual goal towards which we should move. Certainly, the abolition of certification is an extremely good thing. The doctors recommend the setting up of an independent corporation to be financed from public sources. They say that we should lend public money for improvements, to acquire surgery premises, to build and lease purpose-built premises and provide medical and practice equipment. All those are wonderful arguments for the real answer to the problem, which is a full-time salaried service by the doctors.
This would not destroy the relationship between doctor and patient. It would mean that with the help of central Government and local authority money, doctors' pay and conditions could be improved, that the Health Service could be built up, surgeries could be made more effective and the clinics that they require could be provided.
And the doctors would be made into a stronger trade union.
The doctors provide a useful and valuable service, and we should try to extend the system of group practices and the rota system. We must ensure that the service they offer is high, and that they have the right facilities with good pay and conditions. But this can only be done on the basis of a salaried service, and I ask the Minister, when he speaks of injecting these new ideas into the negotiating structure, to think in terms of putting forward some ideas which will lead to the creation of a full-time salaried service which will benefit the medical profession, the patients and the National Health Service as a whole.
I thought that the Minister was very conciliatory, and I was Fateful to him for taking the Committee into his confidence and telling us of the developments which have taken place since this matter was last debated. I feel that the Minister will probably say, "Heaven protect me from my friends" after the last speech, for the hon. Member for Huddersfield, West (Mr. Lomas), unfortunately, introduced into the debate a note of heat which has so far been absent.
I should like to go back to a comment which the Minister made in his closing speech in the debate on 17th February. He referred to the fact that one ex-Minister and three ex-Parliamentary Secretaries had contributed to the debate, and that one other ex-Minister and one ex-Parliamentary Secretary had sat through the debate. As the No. 2 silent one on that occasion I should like to make a contribution today. I think that this links with the Minister's comment which I have just mentioned.
If so many of us who have had the honour of serving in the Ministry of Health sit through a debate, whether we take part in it or just listen, it shows our concern for the Service and our desire to ensure that it shall be a good Service. It is a good Service. In all the countries that I have visited I have seen nothing better, and in most cases not as good as we possess in this country. It is also valued by the general public.
Obviously, the National Health Service cannot remain static. Already, comments have been made in the debate on the changes in the pattern of medicine. the demands on the Service, and the new techniques which have been introduced. Therefore, we must expect changes, and I think we face the possibility of a considerable change in the National Health Service from what it was when it began 17 years ago. This is because there are stresses and difficulties. The difficulty which concerns us today is the frustration felt by the family doctor. It is very real and serious, and I was very glad that the Minister said that he was prepared to negotiate. I hope that the profession will be equally co-operative, though I do not want to underestimate the strength of feeling in the profession. This frustration is not new.
I am sorry that the Minister, in chiding some of the consultants, let himself in for the general condemnation that he was suggesting the doctors were taking action because there had been a change in the political complexion of the Government. This is not true, and anyone who refers back to the debate we had in July last year will find that the present Minister, the then Opposition leader in health matters, said that general practice was facing a critical situation, and so did many others of us in that debate. I do not think the Minister is helped by his right hon. Friend the Minister of Technology who, of all people, is the last one who should chide an organised professional body when it attempts to improve the pay and conditions of its members. This difficulty and frustration in the medical profession, and particularly among family doctors, is a compound of several things. Pay certainly plays a large part. So, I think, does status, and, though this is a minority point and has not yet been voiced, some of the family doctors are quite concerned about the claims made on them by a minority of their patients, the less thoughtful patients, who make unreasonable demands.
Some of the doctors in Birmingham complain to me that it is the doctor who has to control the demand and that in that respect it is the doctors who are doing the work of the Government. I would say, as I have said to them, that there is another side to that matter. It has always seemed to me that doctors receive a privilege in that nominally they are employed by a Government Department, but are free to practise their profession entirely on their own account. I make this point only briefly and without any wish to give it any major importance; nevertheless, it is one which I hope the Minister has in mind. A number of patients do make excessive demands on the doctors, and that does not help. As one old doctor friend of mine, now dead, used to say "You cannot put your indignation on the bill."
This trouble, with the sense of frustration and criticism, has been brewing for some time. One of the difficulties has been that the profession has not spoken with one voice, despite belonging for the most part to the most tough and hard-bargaining trade union that I have ever had dealings with. The B.M.A. is a very powerful body, but up to now the doctors have not spoken as one profession.
To turn to the charter, one could agree, as the hon. Member for Huddersfield, West said, with most of the points in it, and certainly those in the left-hand column of the first page, which gives the ideal set-up for family doctoring. One of the things which I hope might develop from the negotiations is that the doctor might have more time for his patients. From inquiry in the areas in Birmingham which I know best, I find that the doctors are able to give only five minutes to six minutes, on average, to each patient. Very often that is quite enough. One does not need five minutes to give a certi- ficate but some patients, and especially the elderly, need a longer period of time. I hope that, arising out of any changes made, it will be possible for doctors to give more time to individual patients, because there is another side to the penny. Some of the complaints which one receives from members of the public is that the doctor does not seem to have enough time to deal with their problems.
The doctors' suggestion that they need six weeks' holiday is not unreasonable provided that they take advantage of that longer period to undergo some postgraduate training. Anything that we can do to encourage doctors to keep up-to-date and to undertake refresher courses and post-graduate work is certainly worth while, not only for the doctors themselves and for the National Health Service, but most of all for the patients. Therefore, if six weeks' holiday were practicable and most doctors accepted, as I think most of them do, that part of it should be devoted to refresher and post-graduate work it would be right to concede it.
I appreciate the point they make about diagnostic aids. This has been recognised for some time. In some cases they have been provided, but the provision is patchy and should be widened. Two of my doctor friends in Birmingham say that what they would most like to have for the treatment of patients is an E.C.G. machine. I believe that it costs about £250, and I realise from even my lay knowledge that it would be most valuable to patients.
I understand that the doctors wish to be paid by methods most acceptable to them. The majority want capitation fees, including an items-of-service basis and others want a salaried basis. I differ from my right hon. Friend the Member for Bridlington (Mr. Wood) in that I do not agree with a salaried basis. I do not think that it is to the best interest of either doctors or patients. I believe that it would be going back to something which the doctors themselves opposed vigorously when the Health Service was introduced.
I would remind my hon. Friend that I pointed out that this proposal raised one of the most profound problems of all, that is, how the personal service could be maintained. I hope that there is no disagreement between us on that.
There is no disagreement in that respect with my right hon. Friend. I only make the point that in the negotiations the infinite variety of views are better considered, and I was going to say that there has been a change over the years. I know now that a number of doctors, particularly the younger ones, would favour a salaried service. Therefore, however awkward it may be on the face of it, it seems, to have a triangular system, the Minister ought to consider this.
A matter which is not in the charter, but on which the Minister said that he was prepared to put forward his own view, is the need to consider a seniority award for the older doctors. I regret that a merit award was not found practicable. There is a case for a seniority award, especially when one remembers that, contrary to the position in most professions, the older the doctor gets the less likely he is to be in the top earning bracket.
Practice expenses would mean the end of the pool, and this surprises me because it was something which the doctors were so insistent on in their proposals at the beginning of the Health Service. But the Minister has said that he intends to carry out the promise made in July last year seriously to consider a method of reimbursing practice expenses and also, I gather, his promise on surgery premises.
A point not raised in the charter which might be considered once more is the development of health centres. I have not been very keen on the health centres because I think that they drive the doctors more and more towards a State service. This was the doctors' view at the beginning of the service, and when some local authorities tried to provide health centres we found the utmost reluctance on the part of the doctors. Again, this is one of the changes which have come about in 17 years and ought to be looked at again.
The charter said that the profession sees no need for late evening surgeries. I disagree. I think that there is, and probably will always be, a need for some evening surgeries. I would go as far as to say that I do not think that that need apply to a particular doctor on every night of the week. Some arrangement could be made whereby some doctor would have his surgery open late one night a week. This would be better for the doctors themselves because some prefer to have the little leisure-time they get in the afternoons. What is needed is more flexibility than there is in the present arrangements.
Another point made in the charter was the doctors' feeling of frustration about the disciplinary machinery now in operation. This, also, is a real point. I hope that the Minister is prepared to consider whether anything can be done to apply the disciplinary machinery in a different way. No one suggests that it should be removed, but doctors find it irksome that a number of the smaller complaints are made and they have no redress.
The doctors suggest that the practice of issuing certificates should be altered, but they are quite open about it in saying that they have no method to suggest to the Minister. I have one which the right hon. Gentleman might consider. I have always known that the need to give certificates is irritating to doctors and I said so in our debate in July last year. I wonder whether they would like to be relieved of that need, because, apart from the National Insurance certificate, this is an extra for which they are paid, but I am told firmly by my doctor friends that they would like to be rid as far as possible of the need to give certificates.
Patients need a certificate for National Insurance purposes and the doctor is required to give one every week for the first four weeks, but surely there must be cases, for instance, when a man breaks a leg, or he has a serious heart attack, where it is obvious that he will be away for a month or even longer. If he is in hospital the authorities accept a monthly certificate. Is it not possible for the Minister to discuss with his right hon. Friend the Minister of Pensions and National Insurance some alteration which would require doctors to give weekly certificates only in cases of short-term illness?
If he could discuss with his right hon. Friend the Minister of Labour the other question of the need always to present a certificate to one's employer, this, too, could lead to helpful change. Some industrial companies require from all employees a separate sickness certificate. Not all companies do. Some are sensible enough to have a sight of the National Insurance certificate which is at present required by law; this National Insurance certificate is then sent on so that the employee may claim sickness benefit, and the company has seen all it wants. This arrangement ought to be more widely adopted.
I am not quite sure how one can deal with the certificates required for school purposes, and under the rules of benevolent associations like the Oddfellows, Foresters, and so on. All these certificates the doctor is required to sign. I have asked my doctor friends how much of their time is devoted to the signing of certificates, and I can tell the Minister that their estimates vary between 10 per cent. and 40 per cent. If we could cut out the 10 per cent., how much more valuably that time could be devoted to attention to the sick, and what a relief it would be for the doctors, too.
I should like to go on, but this is a short debate and I realise that there are still several hon. Members who wish to take part. I wished to intervene because of my concern about the present situation in family doctoring. I am sure that the majority of doctors are not prepared to carry on under the present contract. The Minister has a remarkable opportunity in the negotiations now going on to try to deal with the frustration which exists, to try to re-establish good relations with the general practitioner, and to fulfil something which he himself said on 27th July last year, when he ended his speech with these words:
The G. P. s are demanding, above all, the tools with which to do a better job for the patient and for the nation, and by now they know that only a Labour Government are likely to provide them."—[OFFICIAL REPORT, 27th July, 1964; Vol. 699, c. 1023.]
This is a chance for a Labour Government to do something. I beg the Minister to take it very seriously. His opportunity is not only to carry out his own promise, but to restore family doctoring to what it should be and make it possible for the profession to contribute as it can to our national life.
I think that everyone is probably as tired and irritated as I am by the constant repetition of the phrase "the doctor's dilemma". It would not hurt if we thought for a moment of what Shaw's doctor's dilemma originally was. He had a treatment which he could make available either to the husband of a woman he coveted or to a poor doctor. If there were any parallel with that situation today, no one, I hope, would expect me to pursue it in the House.
The very charming and seductive hon. Lady the Member for Birmingham, Edgbaston (Dame Edith Pitt) was clearly the voice of the siren. She will forgive me if I take issue with her at once, and I preface what I have to say with this. There can be no doubt about the compelling nature of the doctors' case. There can be no doubt about their frustration and irritation. What there can be doubt about is the way that irritation and their years of deprivation are being misused.
The hon. Lady saw fit to take issue on with my hon. Friend the Member for Huddersfield West (Mr. Lomas) on the small amount of heat which he engendered. I go a long way with my hon. Friend but he makes one mistake which many of us continually make. He confuses the doctors with the doctors' leaders. This is the mistake which the doctors themselves make and it is a cause of much of the trouble.
My hon. Friend the Member for Huddersfield, West made a number of points, but I wish, first, to comment on some of the observations and suggestions made by the hon. Lady the Member for Edgbaston. Towards the end of her speech, she raised the vexed question of certification. I am sure that she is aware that the subject of long-case certification has been discussed over and over again by the National Insurance Advisory Committee and by the medical profession. In fact, the majority of certification work undertaken by the general practitioner is not for the long cases, the broken leg, the heart attack, pneumonia, perhaps, or tuberculosis. The great bulk of such work arises from the need to have a few days off.
These short periods off work are quite well merited and I am not suggesting that people misuse the certificate system, but it does represent the great bulk of the work involved. Someone comes in on the Monday, he wants a few days off, he goes back the following Monday, and he has to have two or more certificates in one week. I do not think that the hon. Lady ought to speak about reducing the burden or private certification. For many general practitioners it is a valuable source of income, and a source of income which the Income Tax inspector has the greatest difficulty in assessing.
The hon. Lady said that the medical profession was not talking with one voice. Of course we are not talking with one voice, and this is the nub of the problem in the present situation. On this side of the House there are several doctors, and a word with any one of us would show that each speaks with a different voice about it. The reason is that every doctor has his own problems. In my practice, we have our problems, the man down the road has his, the man out in the countryside has very different problems, and in the Black country, the Welsh mining valleys, and the northern industrial districts, places for which we on this side claim to have a special concern, the problems are probably at their most acute. It is in these latter places that doctors find the work-load heaviest, the illness-load the highest, the demand the greatest, and the hope of relief the least.
Our problems differ greatly, and this fact exposes the failure of the British Medical Association when it repudiated that first faltering step recommended by the Review Body which would have differentiated a tiny bit between different practice problems by providing a solution which was not applicable as a national blanket solution. But the B.M.A. has chosen to draw the blanket up tightly round its chin, and we are left now exactly where we were before, with a frustrated profession and little immediate prospect, until the charter has been negotiated, of an improvement in the services offered to the patient.
The National Health Service was created for the patient. It was not created for doctors. Those of us who serve in the Health Service and are proud to do so enjoy widely differing rewards for the services we give. My hon. Friend the Member for Huddersfield, West reminded us that there are ancillary people in the Health Service who were also affected by pay claims. This was brought home to me very forcibly the other day when I met a young sister from the ward of a local hospital. She looked me very straight in the eye and said, "I understand that the doctors are hungry today". I acknowledged that they were, and she said very pointedly, "We are hungry, too".
It is impossible to invite a Government to accept the representations made by one section of one profession in a large concern like the National Health Service and, at the same time, invite them to ignore the position of all the other people working similarly in the Service.
Apropos diagnostic aids—I am sorry to deal with these things in grasshopper fashion, but this is how the points came out—the hon. Lady referred to the provision of the E.C.G. machines, and I heard the whispered comment from one of my hon. Friends, "Heaven forbid". There is a great deal in both points of view. I confess that, if anyone presented me with a E.C.G. machine, I could use it only as decoration on my grand piano, if I had a grand piano. In fact, the expertise involved in taking, recording and reading electrocardiograms would require of the overworked doctor a degree of skill and time consumption which would make his whole case, that he is overworked, fall to the ground.
There is a small medical journal that is, perhaps, not seen by many hon. Members. It is the journal of the College of General Practitioners. Most opportunely—perhaps there has been a little co-ordination—someone this month has written an article on the use of these machines in general practice. One of the points made is precisely the difficulty of the non-specialist reading electrocardiograms in dealing with this sort of service in the normal course of general practice.
The vexed question is: what precisely is general practice and what are we to do to help it develop? Of course, there are many different points of view, and I am expressing my own. It seems to me that general practice is developing as a form of practical social medicine, that it is being forced away from the rather conventional clinical type of medicine which involves hospital beds and facilities. Of course, these things are essential but the emphasis is changing.
When we talk of the development of general practice, dare we talk about it as though it were in a vacuum? How can we begin to talk about changes as though they concern only general practitioners? Changes are occurring in the behaviour of the users of the Health Service and in the other professions and other methods of practice in it. The whole problem lies in the fact that nowhere, in any British university or technical centre or Government Department, is there a professor charged with the study of the organisation of medical care.
I contrast this with the situation, for example, in the Soviet Union, or in Australia. A year or two ago, we lost one of our best men, who took up a professorship of the organisation of health care in Australia. In the Soviet Union, there are large institutes in every State studying how to bring the best and most effective medicine to bear on the point of contact with the patient so that he can have the maximum benefit from the advances which are changing the face of medicine.
In this country, we have taken—rightly, I hope—the view that the most important point of contact is through the general practitioner. But can anyone believe that a compelling and sensible answer can be contrived in 48 hours to the years of shilly-shallying in which we have never begun to discuss the problem in depth, profundity and with knowledge of the facts? Is this the sort of catchpenny idea about which we can talk?
Let us look at the charter. Of course, the hon. Member for Birmingham, Perry Barr (Dr. Wyndham Davies) was right in saying that much of the charter turns upon the campaign conducted so vigorously by one of the smallest of the doctors' organisations—the Medical Practitioners' Union. Indeed, when a few of us met representatives of the union here a few days ago, they were somewhat hot under the collar at seeing their clothes stolen while they bathed. However, perhaps it does not matter as long as the answer is right. Some of the framework that the charter provides for the Minister to enter negotiations hopefully is acceptable to many of us. But it seems to me that to tie it so closely to the question of the quantum of remuneration is cutting the throat of the hope that might be held out for proper negotiations.
Let us look at one or two points. First, there is the proposal for a five and a half day week. Where does that fit in with the much vaunted idea that we have to have continual personal service? The two are paradoxical and opposed.
The idea of personal service was thought very much of by the hon. and gallant Member for Ripon (Sir M. Stoddart-Scott). Incidentally, in parenthesis, I think that if we are to have equality of status for doctors there should be some way in the House of Commons of calling a doctor M.P. something like "honourable and qualified Member". However that may be for the moment, the hon. and gallant Gentleman was very "hot under the collar" about the question of personal service. If the charter is acceptable as the framework, with a five and a half day week, and if the hon. Lady the Member for Edgbaston is right about her ideas of one or two evening surgeries with patients rotating between doctors, where is the idea of personal service?
In fact, of course, we and the consumers in the National Health Service have long since abandoned the idea of personal service when it applies to the emergency in medicine. The consumers retain it, and quite rightly, when their contact with the doctor involves the exploration in depth of their particular problems. But the person who suffers a heart attack or falls under a bus does not have a personal problem immediately. He has an emergency problem and it does not matter to him whether it is Dr. Jones or Dr. Smith who comes to his aid as long as the doctor is a skilled and qualified man.
The conflict in general practice today is between providing continual emergency service and providing exploration in depth—the time consuming, psychosomatic type of consultation. Today, that sort of general practice is no longer the Victorian medicine of our forefathers. It is more than merely family medicine. It is environmental social medicine, a question not only of knowing the individual and his job but of knowing also his family and its fate, his background and anxieties, his housing situation. Above all, it is knowing the full range and panoply of social service that the general practitioner can call on to meet the needs of his individual patient.
We are not dealing with one problem, topographical, demographical or medicinal, but with an absorbing, colourful variety of problems and to suggest, as the doctors' leaders are trying to suggest, that we can provide one solution in a four-page leaflet thought up in a country house over the weekend is the opposite of intelligent negotiation and good planning.
This is our grumble about the way in which the medical profession is being led at the moment. But let no one confuse our attack on the leadership with any lack of sympathy for the lot of those doctors who are genuinely working a long week, have little relief and inadequate reward. Our hope and faith are with them, just as they have always been with them.
I now turn to the sort of ideas that we should be looking at. Of course, the spread, the availability, of doctors is cardinal. We cannot accept the urgings of a leadership which overlooks the position in which the country and the profession is placed by the lack of medical manpower. What is the use of urging upon us a charter which, if it were to be satisfied, would demand more medical manpower than we have or can hope to have for the next five years? It is true that we must do something to stop the loss. We should be doing the same as my right hon. Friend the Secretary of State for Education and Science is doing in re-recruiting married women teachers. We should be re-recruiting married women doctors.
The Medical Women's Federation has made great play with the lack of opportunity available to married women doctors. In my own practice we have made it a cardinal point to employ at least one woman for the last six or seven years. Our difficulty has always been to make contact with those available to do this sort of work. Is there not some means by which we can explore their availability and assist them to come back not merely to general practice, but into part-time hospital practice?
I take the point made by the hon. and gallant Member for Ripon—that the crisis of manpower will be in general practice tomorrow but that it is in the hospital service today. One of the distressing smaller aspects of the present crisis is that it is distracting our attention from the less dramatic, but far more immediate crisis in hospital manpower. In talking of the hospital service I must beg, very tactfully, to differ a little from my right hon. Friend the Minister of Health.
I welcome the explosion among hospital surgeons. I do not think that even the most ardent member of the Fellowship for Freedom in Medicine could really expect anybody to believe that the ceilings fall down in our university college hospitals because of the vile machinations and neglect of my right hon. Friend. I do not think that this was the point the surgeons were making. I think that they were trying to hide the point of what they were saying, but they did not manage to hide it from me or from any other people.
It is that the hospital service and the operating theatres are in a mucky state. Of course, it is right and proper that they should express the hope that a Labour Government will do something about it, because this is precisely what will happen. They may have erred a little on the side of dramatic expression, but we are glad to have them on our side. They have been on the other side too long. Perhaps this has something to do with the more pressing attitudes which are now being expressed.
The hon. and gallant Member for Ripon made great play with the question of prescriptions and prescription charges. We remain quite uncompromised in this embarrassment. The numbers of prescriptions which appear in chemists' shops are a manifestation of many more social factors than how much they are charged to the patient. They are a manifestation, as I suggested to the hon. and gallant Gentleman, of the normal rise in illness rates.
They are also a manifestation of the prescribing habits of doctors and it is not unknown—and I make this as no charge of malignancy—that if one happens to be feeling a certain resentment towards a certain institution, one may not be too inhibited about doing something to bring that institution into a little disrepute and to express one's resentment in that way. I do not mind confessing, even in so august an institution as the House of Commons, that I myself have sometimes been guilty of that sort of frustration when I have been pressed and when patients have been harrowing. These things are done not because the patients do not have a right to their prescriptions and not to damage the Health Service, but so that we can get on with more work.
But the most important manifestation is that which we do not hear mentioned by hon. Members opposite. Is it not at least a possibility—and I put it no higher—that if there is an upsurge in the demand for prescriptions, it is because there are many people who have not been able to afford them over the last few years and who are coming at last? Just as the demand in 1948 led to a great upsurge, so there is now a demand at a particular time precisely because people have been denied prescriptions which they have required.
Would it not be far better, if only doctors were provided with the necessary facilities, for everybody to feel free to go to his doctor even with a cold in the nose? Let me be technical for a moment and remind hon. Members that to many people a cold in the nose seems a much more serious illness than it is generally thought to be and is best treated early rather than neglected. I am not one of those who believe that everybody with a cold should be sent home to bed with a glass of whisky—unless it is available on the Health Service. It would be a far better scheme for anybody with a minor ailment of that sort to be able to receive proper medical advice and treatment.
We have said time and again that what we aim at, not for tomorrow or for next year, but in the course of time, is a health scheme so that people can go to the doctor to make sure that they are staying well and not to find out why they are ill. That is what we are aiming for in the Health Service and that was what was intended to be its structure when it first came into being. That is what we want to return to—not merely more time for the doctors, not merely the more facilities which they need and which many of them have acquired out of their own pockets. What we also need are incentives to doctors to serve in areas where the problems of morbidity, illness and mortality are greatest and most challenging.
We also need—and this is beginning to occur, thanks to the statesmanlike attitude of my right hon. Friend the Minister—medicine to be a discipline and a justification for a man's life and a fulfilment for him. I am sorry to be a little poetic and vague, but somehow I cannot phrase this correctly. If we are to ask doctors to work in the Rhondda and in the Potteries and in Middlesbrough, we have to give them something more than money. We have to give them a justification for devoting their lives and asking their families to devote their lives to areas which are often very unattractive and where the work is often hard and unrewarding.
This is the sort of background and climate which we have to provide. We cannot provide it when we are bogged down on vexatious items of remuneration. I hope that this charter, wherever it springs from and whatever its defects, will provide the new gateway for us to go through with the medical profession.
I am most grateful to the hon. Member for Wandsworth, Central (Dr. David Kerr) for allowing me to rise as an hon. and qualified Member. I am not so grateful for some of his suggestions, such as that these things are done so much better in the Soviet Union. His remarks, which were addressed to the leaders of the British Medical Association, showed that his long contact with the Socialist Medical Association has taken him completely out of touch with his colleagues, who have felt so deeply about this issue that they have forced the leadership of the British Medical Association to produce this charter and to negotiate it on their behalf.
This is an example of the rank and file forcing their leaders into doing something effective. The leaders of the British Medical Association are highly responsible individuals and, for years, have negotiated with Governments. It is most unfortunate that time after time we should have had these attacks on that leadership from Ministers and hon. Members opposite.
We have had some interesting suggestions this afternoon. My hon. Friend the Member for Birmingham, Edgbaston (Dame Edith Pitt) made many valuable suggestions, and I hope that the Minister of Health will take them into account. I disagree with the acceptance of the Minister's statement by my hon. and gallant Friend the Member for Ripon (Sir M. Stoddart-Scott), because I believe that the statement will be received with great dismay throughout the medical profession. The right hon. Gentleman has suggested merely a delaying operation, and that is not what the profession wants at this stage. It wants him to state his principles clearly so that by the end of the debate it will know what its position is.
Can my hon. Friend tell me why these proposals, on which a strike has been threatened, have not been put before Ministers before? Why has the profession waited all these years and then said that if these proposals are not implemented doctors will withdraw their services?
I am afraid that I cannot answer on behalf of the profession. During the course of my argument I will try to show why this situation has arisen.
The right hon. Gentleman said that the charter did not deal very much with method and organisation, and he, like others, has constantly stressed the question of remuneration. There are eight items in the charter and some hon. Members may not have had the chance to look through them. It is the seventh which deals with money, and it may be worth mentioning the others.
They are: first, the doctors want adequate time for each patient; secondly, they want to be able to keep up to date; thirdly, they want to have complete clinical freedom; fourthly, they want to have adequate, well-equipped premises; fifthly, they want to have at their disposal all the diagnostic aids, the social services and ancillary help which they need; sixthly, they want to be encouraged to acquire additional skills and experience in special fields; seventhly, they ask to be adequately paid by a method acceptable to them and which encourages them to do the best for their patients; eighthly, they do not ask for a 5½ day week, but they want a working day which leaves them time for some leisure. These are perfectly reasonable suggestions. All members of the profession particularly reject the idea that it is pay entirely in which they are interested.
Today we are having a further discussion on the problem of the National Health Service which has been under discussion for 17 years. No one envisaged, least of all Beveridge in his scheme, that it would be necessary to meet more than the need revealed in a wartime survey. At that time, medicine was in turmoil. Doctors came back from the war to reconstruct their practices. They had no idea how many patients they were likely to have. Hospital reconstruction and building had been neglected during the war. A revered Member of the House of strong-minded views upset the general practitioners and skilfully out-manæuvred leaders of the medical profession in 1947 and 1948. I am afraid that later Ministers of Health, and not least the present Minister of Health, have suffered from those early days when the profession was out-manæuvred in its negotiations.
Many people are asking why the dispute today is more serious than ever before. I think that the answer is that 17 years of effort have seen a deterioration in the general practitioners' position. I am afraid that certain hon. Members opposite—my hon. Friend the Member far Edgbaston quoted from the speech of the Minister of Health last year—have been fostering discontent for two years for political ends, and now the chickens have come home to roost.
The Minister has given two long articles to the publication Medical News in the past 12 months. The last, a few weeks ago, was very non-committal, apart from some thoughts on Wilkie Collins. When he was challenged on the abuse of general practice by inconsiderate patients, he said:
People only go to the doctor when they have to. I don't think any good G. P. will want to bring about that situation.
This shows how much the right hon. Gentleman is out of touch with the profession.
I thank the Minister for the correction.
I will go on with this interview in which the Minister, discussing the distress caused to older doctors by the loss of the capital value of their practices, said:
Do you really want to go into that? It is a complicated problem.
In his earlier article—
I am sorry to keep interrupting the hon. Gentleman, but he must not traduce this piece in the way that he is doing. This was an interview which was conducted against the clock. This is a complicated matter. The editor had told me that he had a number of questions which he wanted to ask me. The interview was being taped and therefore he reproduced the taped answer which I gave to his question.
I thank the Minister for that information. Perhaps I may be allowed to quote from the article which the Minister wrote for the Medical News on 24th January, 1964, when, presumably, he was not working against the clock. He said that he did not want to go into detail about what would happen if the Labour Party came to power and he became Minister of Health, but that there would be a new deal for doctors in the National Health Service in the event of a Labour victory. I know at least one Conservative doctor who voted Labour as a result. Now they want to see the promises fulfilled. This is one reason why the right hon. Gentleman is in trouble today.
In the General Election in Birmingham, the hon. Member for Birmingham, Small Heath (Mr. Denis Howell), who had been having a clandestine discussion with leaders of the Birmingham Action Group of doctors, when he wished to embarrass a Conservative medical officer of health, made the following statement which appeared in the Birmingham Post:
Mr. Denis Howell, Labour candidate for Small Heath and a member of the Labour Party's Parliamentary Health Committee, said: 'The G.P. has to utilise the services of his wife in the practice for secretarial help, for which he receives no remuneration, and he has to provide a stand-in when he is away on holiday'.
On a point of order. I thought that I heard the hon. Gentleman refer to a Conservative medical officer of health. I suggest that that is a most improper appellation.
I should like to continue with the quotation:
Mr. Howell added that while the Labour Party had 'sympathy' with the point of view of the doctors and the need to extend the health and hospital service and provide proper conditions under which professional men can work, this should not be done at the expense of people who were ill.
This is fine. The only point that I am making is that in previous speeches made by hon. Members opposite it has been suggested that the trouble has arisen only since the Labour Party came to power, but that the discussion had been going on in the past.
Some of the trouble has arisen because, although the Minister of Health has claimed that, since he is a doctor's son, he is very sympathetic to the medical profession, the hon. Member for Loughborough (Mr. Cronin), in particular, has indicated—and here I should like to quote from a news item in the Observer of 7th March this year. It said:
Mr. Robinson, the Minister of Health, a doctor's son, was psychologically hostile to the medical profession.
I am sure that we will be very grateful for that explanation. I hope that not all hon. Members opposite agree with the hon. Gentleman.
Why is trouble still going on? Let us consider the rather peculiar statement of a member of the Cabinet, the Minister of Technology, who in a Press report in The Times criticised the doctors, who, he said,
had accepted arbitration and when the result went against them held a pistol at the head of the Government by threatening to leave the
National Health Service. … The Government were not going to be bludgeoned into making pay awards so that doctors' remuneration was out of relation to other wages and salaries.
We have the background of the present dispute—years of frustration, more recent disappointments and unhelpful speeches by the Minister, some of his Cabinet colleagues and his hon. Friends.
What is the solution? First, I should like to ask what we are discussing. Are we discussing the whole problem of the middle-class squeeze which is going on? Are we discussing the whole problem of professional men in British life? Are we discussing the problem of keeping up with modern medical advances? Are we discussing the deficiencies of a State service, which are well-known to many of those who have to serve in the Services, in the Civil Service or any nationalised industry; or are we discussing the sheer impossibility of financing such a scheme from the public sector?
What many sincere Socialists should bear in mind is that in dealing with a highly trained body of men who have only their personal skill to sell, we are dealing with a skill which has international value, and unless hon. Gentlemen opposite propose to conscript the medical profession in a totalitarian system, the conditions under which doctors work must bear international and national comparison, otherwise they risk destroying a noble concept for the needy.
We hear a great deal from the hon. Gentleman and his hon. Friend about migration and international attraction. What they overlook is that the international attraction was taking doctors away from this country when there was not a Socialist Administration. What was the hon. Gentleman saying then to attract doctors back to this country? Would he care to give us some indication of that?
I do not think that is entirely relevant to what I was saying, because, first, I was not in the House at the time, and, secondly, I made statements which were reported in the Birmingham Press and for which I was continually attacked not only by certain members of the party opposite, but by some of my own party who thought that the National Health Service was a splendid thing.
No. There are criticisms to be made of it, and I should like to make them now.
What are the irrefutable facts about the Health Service? First, we have to bear in mind the whole question of cost. The cost of the Service to the nation this year is about £1,000 million. This compares with an estimate of £268 million for the first year in Beveridge's plan, and an actual expenditure of £373 million. Aneurin Bevan once said:
Little men do silly little sums.
Is this such a little sum? I have been doing a little totting up, and I have worked out the cost of the Health Service since its inception has been about £10,000 million, which is an excess of £8,000 million on the original costing done by Beveridge. [Laughter.] Hon. Gentlemen may laugh, but this is an extremely serious matter.
During the war years a highly responsible inter-Departmental committee worked out a comprehensive scheme for the social services. It was supposed to be costed, but, because it was incorrectly costed, it was costing the nation more and more each year, so much so that, as has been mentioned, Sir Stafford Cripps had to impose a ceiling of £400 million on the National Health Service. This has to be considered responsibly by any Government, whether Labour or Conservative. Some control must be exercised over cost.
These are very interesting figures. Perhaps the hon. Gentleman will want to enlarge and elaborate on them. It would be interesting, from an economist's point of view, if he could say whether his calculations include the influence of the prescription charges, the hospital boarding charges, the change in the value of the stamp, whether there was—
Obviously, there is not time to develop this theme, but I hope that there will be an opportunity for a full debate on this matter later.
The second problem which faces us today is that of priorities in the Health Service, and the right hon. Gentleman and his Department know that there is a problem of inter-Health Service priorities.
The third problem facing the Service is that of monopoly. We know what hon. Gentlemen opposite think about monopolies. There is a virtual monopoly of medical care in this country and there is an absence of substitutes for the patient and for the employment of dissenting workers, which means that if a doctor does not like the Health Service he has but a tiny chance of gaining a private practice here. Private practice accounts for only about 3 per cent. of the total medical care provided in this country. This was never intended in Beveridge's scheme, and this has led to a State monopoly.
Fourthly, there is a shortage of personnel—of doctors, nurses, and many other medical workers. I think that we must go back to the Willink Committee. This was an example of a group of experts being brought together by a Government Department to make a report to a Minister, and then to plan ahead for the future. Having laid their splendid plans, they considered the whole question of the future supply of doctors during the period 1961 to 1971. That is the period which we are considering. They reckoned that by 1961 the supply of doctors would be sufficient to enable the intake of medical students to be cut by 10 per cent.
We can argue whether it was right for the Minister of Health to accept the Willink Committee Report, but we are going to base many of our plans for the future on this type of Committee and its Report. In fact, I have no doubt that the Minister of Health will set up a Working Party to advise him on the Health Service, and I must remind him, therefore, that the Willink Committee made three fundamental errors.
First, it said that between 1955 and 1971 the population would increase by 4½ per cent. This underestimated fertility, because the population increase is actually about 7 per cent. Secondly, it reckoned that the retirement rate among doctors would not be significantly affected by the commencement in 1958 of payments under the National Health Service Pension Scheme. In practice, a large number of doctors retired in 1958. Thirdly, it suggested the migration of doctors was small and would decline. In practice migration is much greater than expected, and when Dr. John Seale, who took part in the original research, said that 25 per cent. of the output of our medical schools was going overseas, he was not received with any graciousness by the then Minister of Health, who I have to admit came from these benches.
Our next problem is the lack of status in the medical profession. This is a particular problem for the key worker, the general practitioner. Another problem is that of rapid change. A general practitioner requires freedom to change and freedom to adapt to keep pace with the increase in medical knowledge and it is here that the State sometimes tends to prevent this happening.
One of the great problems that is now arising, and which will shortly be of interest to us in the House, is that from the end of the 'forties there has been a tremendous growth in the number of valuable drugs which have been produced by the pharmaceutical industry, and a considerable rise in the use of antibiotics which have saved countless lives. These drugs have changed the whole face of medicine and have made it extremely important to make an accurate diagnosis and provide effective treatment.
A further problem is that of centralisation. Far too many decisions in the Health Service are centralised in the Ministry in London. This causes delay, with all the problems involved in dealing with correspondence flowing backwards and forwards between the central Ministry and the periphery.
Then there is the problem of communications. Communications throughout the Health Service are bad. They are bad between the Ministry and the medical profession, and the present Minister has done well to send a letter round to general practitioners explaining some of the things that he has been trying to do. The Ministry needs to be more in touch with the profession. There has been a lack of communication between doctors, nurses and patients, and we all know of the development of the Patients' Association, which is keenly interested in everything that is going on in the Health Service today.
There has been a breakdown in communications between the Ministry and private enterprise, such as the pharmaceutical industry. These two bodies have clashed in past years. Last but not least, there has been a clash between the public health service and general practitioners. It is only in certain areas that the public health service is co-operating with general practitioners and vice versa. Far greater co-operation of this sort is needed.
I want to sketch some broad outlines of a possible Conservative solution for the future. I hope that some of my ideas will be acceptable to hon. Members opposite. In our rethinking of the general practitioner service and the Health Service we must cater for maximum individuality, by which I mean that the Health Service should cater for the individual needs of the doctor and the patient. It is undesirable that either should be forced to conform to a pattern which does not suit his individual personality or requirements.
It has been suggested that many younger doctors would prefer a salaried service. That may be so, but that would not be acceptable to many older doctors, who fear that it might mean a return to the type of salaried service that they experienced in certain medical services of the Crown. They know that this type of service sometimes does not lead to the greatest efficiency or to the attraction of the best type of man to the job.
Therefore, let us have a little individuality, remembering that some doctors would like a salaried service, others would like to be paid per item of service, while the remainder would prefer to engage in private practice. Let the patients, too, have a choice. Some would prefer to go to health centre clinics which employed a salaried doctor, where they would benefit from all the modern advances in medicine. Some would prefer to have the personal service which can be provided in a doctor's surgery or consulting room. Some would like to have the time and convenience which is available in private practice.
Any such scheme must promote the maximum amount of social justice. The general practitioner service should provide standards of medical care for all members of the community irrespective of income or other personal circumstances. On the other hand, it would be undesirable to prevent those who wish to do so from paying for a better standard of medical care than it is possible to provide for everybody. Choice is available in almost every field of life. We have choice in our transport system and in our entertainment. We can choose to travel by car or by public transport. If we choose public transport, we can then choose whether to go first-class or second-class. We can choose what theatre or cinema to go to, as far as our pockets will stretch. Cannot we apply this sort of thinking to the National Health Service?
Two other points should be remembered in our rethinking. As far as possible, expenditure should be individually controlled. This principle is based on the belief that it is undesirable to incur expenditure from public funds on items which can be financed equally well by the individual. It is desirable to reduce public expenditure and taxation to a minimum. In this connection, we should bear in mind the cost of the National Health Service. Any scheme that we have for the future should allow for the growth of medical science. This should be encouraged, and the National Health Service should provide fully for medical advances.
This is not a new problem. The Labour Party has identified itself with a comprehensive, free-at-the-time National Health Service, but I believe that the Prime Minister has already shown that he is capable of jettisoning what we thought to be Socialist holy writ in seeking realistic policies in defence and foreign affairs. He and the right hon. Gentleman will have difficulties with the Socialist blowhards, but cannot hon. Members opposite see that the National Health Service is in great danger unless the doctors' charter is accepted and an entirely new relationship is created between the State, the medical services and the general public?
The hon. Member for Birmingham, Perry Barr (Dr. Wyndham Davies) has made a very wide-ranging and historical speech covering everything that was possible to mention on this subject. His was the first speech in this debate which, in my view, was very unconstructive. In these health debates speeches from both sides of the House tend to conform to a pattern, because we have a mutual interest in the subject. The hon. and gallant Member for Ripon (Sir M. Stoddart-Scott) and the hon. Member for Birmingham, Edgbaston (Dame Edith Pitt) made contributions of a type which enabled us to get to grips with the problem.
The hon. Member for Perry Barr surprised me when he appeared to accept the diagnosis of a consultant surgeon on matters of psychology and motivation. This was a surprising change from normal medical practice. He wanted to know why this was the first time that doctors had threatened to withdraw on the question of salaries. I would tell him that the same thing happened in 1956 and 1957. In those days, however, there was an elder statesman of the B.M.A.—Dr. Solly Wand—who was able to make various moves to prevent a withdrawal of doctors' services. When the British Medical Guild was re-established it was just for that purpose, for the B.M.A. itself cannot act with legality in this way.
The hon. Member has gone over all the past history. I would remind him that in considering the Health Service the Conservative Government, during their 13 years of office, established two committees to study the N.H.S.—the Guillebaud Committee and the Willink Committee—and those two committees came to different conclusions. The purpose of Guillebaud was to find the N.H.S. too expensive; and the purpose of Willink was to find economies on the number of doctors needed. The Willink Committee found that there was a surfeit of manpower, but the Guillebaud Committee, which considered the problem objectively, came to the right answer, which was that we were not spending enough. The Willink Committee came to a wrong conclusion. Hon. Members on both sides had bemoaned the fact ever since.
One of the main reasons for the increase in cost in the whole of the general practitioner service was the adherence to the recommendation of the Spens Committee, which reckoned that the total income of a general practitioner from all sources before the war was about £850 and that when the National Health Service started it should be raised to £1,111. Do not ask me why the figure of £1,111 was chosen. This was subsequently doubled, after the Danckwerts Award, to £2,222, and subsequently again, to £2,765, after various other awards. So as the total cost of the Service has trebled from its original estimate, so has doctors' pay.
But the hon. Member cannot get away with his method of costing without taking into account as a general background the rise in the cost of living and in prices generally, not to mention the fall in the value of the £ sterling. The Spens Committee first reported as a background to the Beveridge Report, and it came to conclusions about the future which were entirely outpaced by the way in which the economy has developed.
Turning to the charter that we have been discussing, I was reminded of a report of the B.M.A. annual conference last year, which appeared in The Guardian. That newspaper said:
Two voices are there
One is of a sage
The other of a harpy in a rage.
When I look at the charter this quotation would seem to be apt. The voice of the sage is certainly there.
Hon. Members who have spoken have pointed to the various things about which there is common agreement, the things that we want for the general practitioner. There is the whole question of adequate time and a reduction of lists. He should have the right kind of premises and equipment and co-relation and co-ordination with the social services. He should have time for refresher courses so that he can keep up to date, and ancillary help, so that, as a qualified man, he is not spending his time acting as a filing clerk or typing letters with one finger to hospital authorities.
My right hon. Friend has said that he would be only too pleased to discuss these things and here he is being consistent in that he made the offer since he has been Minister, especially in the letter sent to every general practitioner on 1st January, and in the speech on 27th July, which has been quoted by hon. Members opposite as well in speeches year after year when we were in opposition.
The difficulty is that the other voice is also there. It seems to me that the voice of the harpy says only one thing, "Money, money, money." This is the problem. When we want to discuss the shape of a reorganised general practice to achieve the kind of service we desire, the discussions are drowned by raucous squeals that, first, we must discuss money. We should not forget that when the matter was examined by the Pilkington Committee against the background of other professions the general practitioners came fourth in the list of professions and other people who had to have a long period of training in order to qualify.
In the present argument doctors are making two points. One is that a good deal of their work is trivial in that they have to minister to the Monday morning malingerers, and so have to do a lot which is unnecessary. The other point is that they are of vital importance to the Health Service. I do not think that the doctors can have it both ways. If the work they do is something which anyone could do then they are not worth more pay. If, as I believe, the Health Service needs the general practitioner as its basic and focal point, then the reorganisation of the practice and the increase in the amount of remuneration become relevant issues.
I should make it abundantly clear that I have no interest in this matter. It may be recalled that before I became a Member of Parliament I was the national organiser of the Medical Practitioners' Union, one of the bodies which has been mentioned in this debate. I ceased that employment on 8th October, 1959, because it was a condition of my appointment that I should no longer remain a member of the staff on becoming a Member of Parliament, because the organisation is non-political. I have received no brief from the union at any time during the last five years. When I have contributed to such debates as this, what I have said has been all my own work, or perhaps I should say all my own homework.
I wish to make clear that I am not speaking from the point of view of the union when I say that I believe that the general practitioner is right to demand his proper place in the Health Service. It is a conclusion at which one must arrive if one considers how, constructively, the Health Service could be improved.
In the redevelopment of general practice there must be the investment of large capital sums and this, I think, is a prob- lem which the Government will have to face. We shall not be able to improve the shape of general practice unless we improve the surroundings in which the general practitioner works. This and the previous Government were committed to a capital expenditure of £750 million for hospitals. I believe that if a financial arrangement could be secured where about £150 million could be scheduled for the improvement of practice premises, either on the lines suggested in the charter or in other ways, to give the doctors the right tools to do the job, that would prove a more significant contribution than any talk about the doctors' income.
A good deal of the answer to the problem lies in capital investment, in forecasting the shape of general practice in the next five or 10 years and seeing that we put in the right kind of foundation upon which a reorganised practice can be built, rather than giving the doctors a bit of money from time to time to calm them down until the next time.
The fantastic thing about the B.M.A. negotiations—the B.M.A. was described by the hon. Lady the Member for Edgbaston as a tough negotiating body, and I agree—is that since 1948 nearly every demand which it has made it has eventually secured, but once the demand has been granted it has turned out that the doctors are not satisfied and this has lead to further problems. I look back to the whole history of the Pilkington Committee and the way it worked, and the independent Review Body. All these things resulted from the way in which doctors wished their pay to be dealt with. Even since we had the last debate in the House there has been the question of "strings" on the £5½ million and, once again, the doctors have had their way.
I agree with my right hon. Friend, I think it would have been a break-through if in this award we could have shown the way in which this terrible anomaly could be overcome where a doctor's expenses are paid in such a way as to give a direct incentive for him to give bad service. That could have been altered had the doctors accepted the recommendation of the Review Body in that respect and it would have been a step in the right direction.
We have talked of the way in which we could encourage group practice and I hope that this part of my right hon. Friend's discussions will be fruitful. From the figures I find that in 1963 only 95 loans were made in respect of group practice, amounting to £608,000.
One problem which we have to fact is that doctors are inclined to over-state their case when discussing the problems of emigration and population. It was, I think, the right hon. Member for Wolverhampton, South-West (Mr. Powell) who analysed some of the figures which showed that out of 223 doctors recorded by Dr. Seale as having settled in Australia in the final analysis the figure worked out at 114. In the report made in 1964 from a paper by Brian Abel Smith it was shown that only 24 per cent. of doctors who emigrated came from general practice. A specific result of that study was that the generally held view that emigration resulted from dissatisfaction with general practice is not true.
The whole career structure of all doctors needs examination. A doctor may go into hospital service and even after being a registrar for four years wish to change. It is most difficult then to transfer from one section of the Health Service to another, and career prospects are such that it makes for frustration when the doctor cannot see how much further up the ladder he will get in the hospital service yet cannot see an alternative. This is more than a question of general practice
I believe that it is true that in the present general practitioner service people go via this chain, from registrar or the hospital service, into general practice. Therefore, although they may not be a direct loss to general practice, they are, in fact, a loss, because they would have become general practitioners had they not gone abroad
I accept what the hon. Gentleman says. The point is that there is no real way in which he can become a general practitioner, other than by getting in as an assistant with a view. The whole question of entry into general practice is a vital point. The point made by the hon. Gentleman touches on this. This will surely be a matter which my right hon. Friend discussed with the doctors.
The total average increase in the number of patients last year for each general practitioner was 22. The estimated increase for this year is 36. If that is multiplied by the 23,000 doctors, this means an additional work load of about the same amount as the number of patients—now about 640,000—who are on two doctors' lists. In view of the possible maximum of 3,500, and the present average of 2,300, this increase could be absorbed.
Bearing in mind the fact that in London the average list is still only 1,500 per doctor, I am not convinced that the addition of an extra 36 people is such an additional work-load that the doctors cannot cope with it. I accept the fact that, as people get older, and live longer this gives more work for the doctor. I think that it would be wrong, however, if the doctors overstated their case on these issues.
I hope that, when the Minister is discussing the other voice—the voice of pay—he will consider the other sectors in the Health Service. If there is to be a large increase in G. P. s' pay, the other people who serve the Health Service should also be considered. Occupational therapists and physiotherapists have a three-year training period, during which they get no pay at all. When they start practice, they get £623 a year, rising to £829 after seven years. A radiographer also trains for three years—not for the seven years which a doctor does—and he also gets £623 when he starts and £829 at the end of seven years. A staff nurse also trains for three years and receives only £773 per annum after she has been a staff nurse for five years.
If the Chancellor of the Exchequer allows my right hon. Friend any more money for the G. P. s, he should at the same time consider some of the other sectors of the Health Service if equity is to be maintained and the Health Service is to be fully staffed in all sectors.
I suggest that the present situation is not helped by the Press. I can recall the last debate, in which, in my view, my right hon. Friend made a most conciliatory speech. The right hon. Member for Bridlington (Mr. Wood) was most helpful, and the debate was constructive. Yet the headlines the next day would have led people to believe that my right hon. Friend was one of the most adamant members of the Government Front Bench, who had been throwing everything at the Opposition and the doctors on which he could lay his hands.
During the brief interval in which I have been out of the Chamber, I have seen an evening paper, and the headlines indicate a great clash with the doctors. Yet we know, from the points of view expressed by the B.M.A. and by hon. Members opposite, that there is a large measure of agreement, and there is room in which we may be able to achieve a really good settlement. The Press are not being helpful in trying to represent this situation as a kind of contest between two heavyweights, a blow-for-blow battle between the Ministry and the doctors.
The point was raised by my right hon. Friend that, on 3rd March, the Daily Telegraph said, in a front-page story:
It was a considerable victory for the doctors. The independent Review Body had recommended that most of the increase should be used to encourage good medical practice. The British Medical Association would have none of this".
With this kind of approach, making this into a contest, it is very difficult to see how we shall get the best for the doctors.
We need to reorganise general practice. We need, in that reorganisation, not to impose anything on the doctors but to carry them with us. The only way in which we shall get preventive medicine is by an improved general practitioner service. This will mean the employment of all kinds of auxiliaries if the medical manpower is to remain at its present level—as it must—for the next seven years. It means adaptation by the doctor to the new circumstances. I believe that rather than an arbitration battle this must be a combined operation between the Ministry and the doctors, in which, I hope, success will eventually accrue.
One of my hon. Friends said that we are often inclined to lose sight of the fact that the Health Service is basically for the patient. There has only been one point of difference between the two sides of the Committee this afternoon, but it is a fundamental point. Hon. Members opposite consider that health is a commodity which can be bought and sold. Members on this side believe that health is something in which there should be no cash barrier between the prevention of illness and the person concerned. We do not regard health as a commodity, nor as being subject to the law of the market place.
I believe that a good doctor has a vocation and that payment for service is not his main consideration. Of course he wants the right pay for the job, but I do not believe that it will be found by suddenly asking for a terrific increase on the scale mentioned today. I believe that his satisfaction will be found in an orderly, reorganised system of general practice
I look upon the speech of the hon. Member for Willesden, West (Mr. Pavitt) as being extraordinarily objective, in view of his antecedents. I accept the view that we have to preserve the National Health Service, and that the doctor has to play a more important part in it than he has hitherto. I admit that the development of medicine and the development of the Health Service has given rise to a considerable amount of discord among doctors, but I cannot accept much of what the doctors say about their own conditions.
I certainly cannot accept the way in which they have behaved in this dispute. It is distressing to me that professional men should behave in a manner which would be considered unsuited to the toughest of artisans. If we are to improve the standard of the medical profession, the medical profession must do something to improve its own standards.
There is, in the medical profession, an extraordinarily unsatisfactory situation. If one looks at the attitude of one part of the profession to another part, one sees in some sense the cause of the present difficulties. Take the relationship between the medical auxiliaries and the general practitioner. The auxiliary thinks that the medical practitioner is a man who does not know very much anyhow about some things and is overpaid. The medical practitioner tends to resent the efforts of the auxiliary, who, he thinks, does not know much about anything. The consultant looks upon the practitioner as a man who does not know much about medicine. The attitude of the general medical practitioner to the consultant is that the consultant is overpaid and enjoys advantages which he does not deserve.
If we were to relate this sort of attitude of mind to, say, the legal profession, if the managing clerk took the view of a solicitor or the solicitor of the barrister which is taken in the medical profession, that would be an unsatisfactory state of affairs
May I turn to some of the proposals which have been made? The first thing which we must try to do is to get training speeded up, because this is a manpower problem. The Minister, who has been extraordinarily conciliatory here today, would not be facing this demand but for the cut-back by the Willink Committee. He would not be facing this situation. The urgent problem is to get more men trained for medicine. After all, at £3,000 a year net one cannot claim that the medical profession is underpaid.
Indeed, if one looks at all other professions one sees that, on the whole, the medical profession is the highest paid of all professions. I agree that there is a tendency, because of a large demand in developing countries for medical men, for emigration to take place on a considerable scale. But this should not blind us to the fact that at £3,000 a year net we cannot say that the medical profession is underpaid.
Nor is it possible to be quite certain that all elements of the medical profession are overworked. I know of a general medical practitioner with over 2,000 patients who takes a part-time job four afternoons a week. I realise that hon. Gentlemen may be able to find other medical practitioners with the same number of patients who find it very difficult to meet all the demands made upon them when giving their full time, but it is not necessarily the case that all medical practitioners are overworked, or that they enjoy no leisure.
I think that general medical practitioners enjoy more leisure than ever before, because 75 per cent. of all medical practitioners in general medicine are either grouped under partnerships or in group practices, and in modern conditions this provides much more leisure for medical practitioners than ever before.
The real reason for discontent, apart from bad leadership and the fact that no section of the medical profession can agree with another section, is that the doctor's position in general medical practice has deteriorated. He knows that probably 50 or 60 per cent. of his work could be done by people much less skilled and trained than he is. It is this lack of status which is the basic cause of the discontent—leaving out the question of bad leadership and confusion of ideas.
We should try to give the doctor a better position in medical society, because until we solve the problem of the medical practitioner having more status and doing more worthwhile things we shall never achieve the contentment which we want to see in the medical profession and which is essential to a good National Health Service.
I have hurried over these remarks because I know that a number of hon. Members opposite wish to take part in the debate. I hope that we shall not bow to any threat by the medical practitioners. I hope that the right hon. Gentleman will stand firm, knowing that the majority of people will be behind him in resisting any pistol at his head. This determination should not prevent our trying to take a realistic view of the Health Service after 17 years of experience. We must be flexible. We must look at the possibilities of change. We must try to upgrade the status of the medical profession. But let us not be stampeded by excessive demands which are not related either to the need of the profession or to the capacity of the public purse
May I first express my entire agreement with my hon. Friend the Member for Wandsworth, Central (Dr. David Kerr) in his view that medical practitioners should be given an additional appellation when speaking and being referred to in Parliament. He referred to them as honourable and qualified Members. May I suggest that such a Member should be referred to as an honourable and Hippocratic Member.
May I endorse what my hon. Friend said about the reasons for this vast increase in applications for prescriptions since the prescription charges were abolished. He said that this was due to the fact that previously many people could not afford a prescription. In my peregrinations around my constituency I have many times been told by poor constituents, "We cannot afford the prescription charges". It has been said that people who live differently think differently, arid I can only suggest that hon. Members opposite have no idea of the straits in which some people live—people who cannot even afford two shillings for a prescription charge.
May I draw my right hon. Friend the Minister's attention to the situation of young resident doctors in hospitals? Already we have difficulties in staffing our hospitals with doctors. The output of the medical schools lags behind the increase in population. We have had a decline in the number of medical students in training from just over 14,000 in 1950 to just over 12,000 fairly recently. This situation has been aggravated by emigration. The hon. and Gallant Member for Ripon (Sir M. Stoddart-Scott) said that about 400 doctors a year were going abroad. I gather from Dr. Seale's writings that about 600 doctors a year are going abroad, which is five times as many as in the 1930's. Whereas in our country there is one doctor per thousand of population, one out of every 200 emigrants is a doctor. In the last 10 years, as was stated by the hon. Member for Birmingham, Perry Barr (Dr. Wyndham Davies)—accurately, too, this time—a quarter of the yearly output of the medical schools has gone abroad.
We might ask why this is? In my view the answer is not far to seek. I have gained my information from various young resident hospital doctors with whom I have discussed the problem. The conditions in which they work are hard—almost impossibly hard—and destroy the incentive to work. First of all, the living facilities are not adequate. If a doctor has a family, he cannot find living accommodation for them in the hospital, but has to board his family out and live in himself. What more natural than that these young doctors should seek to go abroad where they will have somewhere to live with their families?
A young resident doctor has no time off whatever. He works literally 24 hours a day, seven days a week. I am informed that he has his full duties during the day and is on call all night. Sometimes he is called out a number of times during the night. At 8 p.m. the casualty officers go off duty, but the casualty department is open all night, and the young resident hospital doctors then have to do casualty duty in addition to looking after the beds in their own wards. In this way, very often a doctor has to work all night. They have no rest next day to help them get over the long hours they worked during the night. We, as Members of Parliament, feel—and, I may add, quite justifiably feel—that we are often kept here much too long into the night, but our plight is nothing compared with the plight of these young house doctors, who work day and night. Their living conditions are often appalling. I was informed that in one hospital the resident doctors lived in a tall building which had no lift. They were called out many times during the night. They had to come down from the top of this tall building and then return to the top again. One young doctor burst an important blood vessel in the heart because of the strain which he was undergoing in his medical duties, and he had to go to the United States to have it repaired.
I am sure that the majority of hon. Members would regard the money that these doctors earn as quite inadequate. During the first appointment, for six months, they receive £770 a year, less £175 for living in. That works out, based on the hours they have to work at l0d. an hour. Is it any wonder that they seek to go abroad? The only way that they can make ends meet may not be known to the House. If a patient dies and is cremated then apparently the young house doctor receives 2 guineas from the undertaker. Indeed, I understand that most of their income is derived that way, especially if they work in geriatrics. What a system to offer. Imagine putting a premium on death so that the more deaths there are the more money the young house surgeon gets and the better he is thereby able to make ends meet. I suggest this system be altered, and the sooner the better. Remedying the shortage of doctors will not be enough. It is imperative that we make the conditions in medical practice attractive enough to retain doctors after they have completed their training.
Without wishing to take issue with my right hon. Friend the Minister, I would place a slightly different slant on the reason why doctors have kept quiet for so long and why they have suddenly come out and are vociferously objecting to their conditions. If I dared to give the reason, it would be that they have known for the last 13 years that it would be no use at all if they complained. They knew that they would get no hearing whatever from a Tory Government. It is only now, when we have a humanitarian Labour Government in power, that they feel that they will get a sympathetic hearing. It is not surprising that they should have waited for 13 years to make their cry heard
Unfortunately, time does not permit me to comment on the last remarks of the hon. Member for Watford (Mr. Raphael Tuck), except to say that we did not have the threat of a doctors' strike during the 13 years of Conservative Administration.
In his remarks today the Minister was much more moderate than he was on the last occasion that he spoke. I welcome that tremendously, having taken a close interest in both debates. I was, however, concerned when he said, in effect, that whilst he was prepared to consider discussions on terms and conditions, apart from the injection of £5½ million there could not be any pay adjustment in answer to the doctors' request until 1st April, 1966. That was the impression I got from his remarks, although I asked in an intervention whether it would be possible to have any pay award subsequently backdated.
This aspect of the matter will cause tremendous concern among doctors, particularly doctors in Croydon. I naturally have a parochial interest in this matter. I want to make sure that the people of Croydon have doctors to whom to turn and I also want to ensure that Croydon's doctors will get a square deal which, in my opinion—having looked into this matter closely and spoken with many doctors in my constituency—I do not believe they are now getting.
All through these discussions Croydon's doctors have felt very strongly indeed about this matter and there is real concern about the present situation. I confess that I felt that, from the moderate way the Minister put his case, that he might still be under-estimating the concern and anxiety that is felt by the doctors today. It is all very well trying to keep the atmosphere cool and calm. That is a good thing to do, but no hon. Member should under-estimate the problem we are up against. The anxiety among doctors now is that the impending negotiations should proceed on the basis of the charter. I stress the word "basis" in relation to the charter because no one in his wildest dreams expects that everything in the charter will be achieved. The doctors' further anxiety is that progress should be got under way as speedily as possible. They were hoping that the pay aspect would likewise be dealt with at a very early date, but it now looks as if they will have to wait until the details are settled before the pricing of their work can be undertaken; and this will, as the Minister confessed, take a long time indeed.
I appreciate the remarks made by hon. Members opposite that the Press have in some respects exaggerated the situation and that there have been some unfortunate reports. That has even happened in regard to the reception given to the charter. I can only say, however, that having looked into this closely in Croydon there is an overwhelming feeling there that the charter is a most sound basis for negotiation.
Speaking personally, I think that the reference in the charter to a five and a half day week is a little misleading. I think that the doctors were only trying to overcome the difficulty of wanting to compare their earnings with the money earned by those in other professions and to relate their hours of work to the hours of other workers. After all, are these not fair points to make?
All hon. Members will, I am sure, agree that the ceiling of 2,000 patients mentioned in the charter could not possibly be realised for a considerable number of years. The adverse comments sometimes made by the Government and certainly by Cabinet Ministers—including particularly the right hon. Member for Nuneaton (Mr. Cousins) the other day—will only harden the attitude of the doctors. It was a disturbing, silly, foolish and almost idiotic comment which he made the other day, if the reports in the Press were accurate. It is disturbing to think that what is a proper and justifiable grievance by doctors on so many matters should have been subjected to some of these attempts to smear doctors by moralising at them. That should never have been done.
Not only is that not an effective way of dealing with the present situation but it should be remembered that we are at a time when delicate negotiations are taking place. I believe that so far about 70 per cent. of our doctors have handed in their resignations to be used, if necessary, by the British Medical Association. Presumably that number might yet be raised to about 75 per cent. That is a disturbingly high percentage of our total number of doctors and we must face the facts involved here. I cannot imagine the doctors easily deserting their leaders now, for if anything, they will prod them on to further efforts. The number of resignations in Croydon handed in is even higher than the national figure. I understand that it is about 80 per cent.
If these negotiations break down, and resignations are unfortunately advised by the B.M.A., I am convinced that the doctors are prepared to accept the consequences, both personally and in attending to their patients. Undoubtedly an insurance scheme for patients would soon be implemented. There would, of course, be a tremendous amount of hardship and concern, but in my opinion the doctors—certainly the doctors of Croydon—are prepared for this. They are concerned that if, unfortunately, they are pushed into taking this line of action, out of the ashes of the National Health Service an attractive family doctor service will eventually emerge. Everyone of us must, therefore, be most anxious that the negotiations ahead should prove successful, and not be protracted.
Many misleading statements have also been made about doctors' remuneration. Figures have been bandied about all over the place even in this debate. One gets the impression that doctors get about £80 or £90 a week. I have never heard such nonsense. There may be certain doctors who are particularly fortunate, but I know that most doctors in Croydon—very hard-working doctors, most energetic, with no spare time—are desperately worried financially at the present time.
I can give an instance that I can prove to the hilt. I have seen the figures relating to the partnership of two doctors in Croydon. Between them they have 4,600 patients and, quite rightly, they find that they can find no time for anything else but looking after those 4,600 people. They do not have time to do hospital work, and they cannot take on separate private patients. For all this, they get a gross figure, between them, of £7,000—I have seen these figures myself—per annum. Of that £7,000, they are allowed £ £3,000 for expense purposes, but as their expenses are more like £3,400-odd it means that they must pay the other £400 from their taxed remuneration. The ultimate result is that, at the moment, they get about £1,800 a year, and then have to pay their own tax on that. That is a very difficult situation, especially for men working such hours.
I stress that that is typical of many doctors, certainly in the Croydon area, and it is something that we have to face up to. I therefore hope that these misleading statements about remuneration will be sat on once and for all—it is just not fair to the doctors. I also know, personally, of doctors in Croydon who are working on substantial overdrafts. They cannot go on getting these overdrafts, particularly when there is no early future increase to come along to help them out of their present difficulties. The situation is very worrying for them, and it is just not good enough. I sincerely hope that the Government will quickly put the matter right, because our doctors are a most vtial element in our National Health Service
Unlike my hon. Friend the Member for Willesden, West (Mr. Pavitt), who declared that he had no interest in this mater now, I declare that I have an interest, and that is the interest of the medical profession in general—a profession of which I am a member. I usually leave the solution of medical problems to people more competent than I to deal with. I agree that the health of the nation is much too important to be left to doctors, but something is clearly wrong. We must find a solution based not on political advantage but on the advantage that will accrue to patient and to doctor alike.
I believe that the present crisis, if it is a crisis, is a complete indictment of previous Governments. The stand which the doctors are taking and the action which they threaten are an indictment of previous Tory Governments who, in 13 years, did nothing to improve the fundamental structure of the general practitioner part of the Health Service.
For many years I have not seen eye to eye with many of my fellow general practitioners. I have regarded them as often being ill-informed about—even uninterested in—public matters, narrow in their outlook, confined almost entirely to their own sphere and conservative in attitude. But I must admit that they do a good job. Since the inception of the National Health Service 17 years ago our general practitioners have done credit to the whole structure of the medical profession, and if today they are coming forward with ideas that would, if carried to their logical conclusion, be disastrous to the National Health Service, there must he a good reason for it.
As I said, I did not see eye to eye very often with the members of my profession—indeed, I resigned from the British Medical Association and am not at present a member of that august body. I also agree that, to a very large extent at any rate, the doctors have themselves to blame for their present position. I do not disagree with this, but it must be remembered that many years have passed since the foundation of the Health Service was laid. It was only a foundation. A new generation of doctors is now taking over. They demand that fundamental changes be made.
I have made a few quick calculations of the cost of the latest demands or requests by doctors. On these calculations, it appears to me that the general practitioners are asking that the 9 per cent. of the total cost of the Health Service which at the moment is devoted to the general practitioner part of it should be increased to 12 per cent. Because the point of contact which most people have with the Service is with their general practitioner, I do not think that it is too much to ask that the country should devote 12 per cent. of the amount spent on the Service to the general practitioner part of it.
I do not think that comparisons are very helpful. To ask if one's doctor is worth £90 a week is just as irrational a question as to ask if the Beatles are worth £1 million per year or, indeed, if a Member of Parliament is worth the salary he is paid. One can make comparisons with various professions. I take issue with hon. Members who bandy figures about which do not bear relation to the truth. The average practitioner under the National Health Service has a net remuneration, not of £3,000 a year but of nearer £2,000 a year, once the essential deductions are taken from his salary.
It is fatuous to talk about "the average practitioner", in any case. I would agree that there is such a thing as a statistical average practitioner, but he is just as fictitious as the average person. If a study were made of what the so-called average practitioner earned and from what sources he derived his income, it would be found that the majority of practitioners derive their income from only two or three sources of the pool—capitation fees, loading fees and maternity work. The majority of practitioners do not do private work, in spite of the facetious talk about the amount of money they can get from prescriptions. They do not do private work. The majority of practitioners do not get money from any mileage fund. They have nothing in addition to the three items I have mentioned.
On Sunday the Observer stated that the medical profession, by using its monopolistic position, was in danger of damaging its most valuable asset, public respect. I maintain that a good doctor will always command public respect. For him to receive adequate remuneration for the work he does can surely do nothing to damage this.
I was very pleased indeed to hear what my right hon. Friend said this afternoon. This will keep the door open for negotiations, which I believe will lead to fundamental changes being made in the structure of the Service. Whether we like it or not, we can no longer depend to such a great extent as we do at the moment on the doctor's sense of vocation. The doctor now sees himself as a worker, working for the good of the community, and he wishes, I think rightly, to obtain some of the fruits of development that other workers have.
We need a reshaping of the Service, for the benefit of both doctor and patient. No service can be good if those who supply it are disgruntled, disillusioned or overworked. On the basis of the charter which the British Medical Association, of which I am not even a member, has put forward, I believe that the way is open for fundamental changes to be made which will indeed be for the benefit of everyone concerned
I think the Committee will agree that this debate has taken place at an important moment in the history of the National Health Service and has proved very worth while. During the course of it we have had a series of constructive and temperate speeches which, I believe, the right hon. Gentleman the Minister of Health will appreciate as having contributed towards a happy solution of the unhappy dispute which exists at the moment
It has been valuable if only because it has given the right hon. Gentleman, to judge by the tone of his speech today, an opportunity of repudiating the assertion made by his hon. Friend the Member for Loughborough (Mr. Cronin) that he is psychologically ill disposed towards the medical profession. I can assure him that we on these benches have never believed that he is psychologically ill disposed towards the medical profession. We have felt that the rather provocative remarks which he has made during the course of the past month were no more than a mere façade and that behind the façade remained the old good will towards and interest in the National Health Service which he so long displayed when he was in opposition.
We on these benches are most anxious to contribute to a successful outcome of these negotiations. Of course, we are anxious not to say anything which could hinder such an outcome. But I think it would be wrong of us to mute criticisms where we feel criticisms are necessary, and I am bound to comment that we have some criticisms of the way in which these negotiations have been handled. Also we feel that some of the statements made by Ministers during the course of these negotiations have not contributed to the improving atmosphere which we should like to see develop. On the other hand, we certainly accept that errors and faults of overstatement exist not only on one side in these negotiations.
Above all, what is needed is calm negotiation, quiet study of the complex, deep-seated and fundamental issues which are at stake and which are affecting the family doctor service. Calm negotiation is not assisted by the Minister of Technology choosing a party political platform in the middle of a by-election campaign declaring that the doctors are holding a pistol at the head of the Government by threatening to leave the National Health Service, and also saying that the doctors are doing their best to pull down the hospitals by this latest withdrawal threat. I can only say that I can think of no person in the entirety of the country less qualified than that particular right hon. Gentleman to criticise others who are discussing the possibility of withdrawing their labour from the service.
Nor do I feel that calm is developed by the Minister's remarks at Tiverton charging those members of the medical profession who complain about their working conditions with playing party politics
We are glad that his subsequent speech, and, indeed, his speech today, have done much to redress the damage which was caused originally. Inevitably when statements of this kind are made the Press headline the event with—"Minister clashes with doctors" or, subsequently, "Doctors repudiate the Minister's charge." We would have liked to see reports of negotiations proceeding quietly ad constructively
We also have some criticisms of the way in which the right hon. Gentleman has handled these negotiations. The Review Body reported recommending an increase in remuneration of £5½ million, but it tied the greater part of this £5½ million to the reimbursement of practice expenses. The Government immediately, without consulting the profession, or without seeing whether this recommendation was in any way agreeable to the profession, accepted the recommendation. The Prime Minister, on the very selfsame day as the publication of the Review Body's Report, announced his acceptance and said that he would forthwith open discussions to implement the recommendations.
It seemed to us from that very moment that the Government were heading straight towards a deadlock with the doctors' representatives. When in the last debate a month ago I queried the wisdom of the Government in taking this step, the Minister leapt to his feet and asked:
Is the hon. Gentleman really saying that one party to an arbitration ought to decide, before accepting, that the award is acceptable to the other side? This is a totally new doctrine. I have never heard it expressed before."—[OFFICIAL REPORT, 17th February, 1965; Vol. 706, c. 1274.]
In the special circumstances of this Review Body's Report, I certainly think that the right hon. Gentleman would have been wise to consult the profession. He ought to have said, "We as a Government are perfectly prepared to accept the overall sum of money recommended, but we are prepared to consult with the profession about the system of reimbursing expenses. It would have been wise to have done this from the first day, for two reasons.
The first reason is that it has always been assumed by previous Ministers of Health and the profession that the Review Body would handle only overall remuneration and would not recommend detailed systems of distribution. Even more important, the right hon. Gentleman would have been well advised to enter into negotiations right from the beginning, because his predecessor as Minister of Health gave on 17th September, 1964, a clear pledge to the profession that he would not impose a system of reimbursing expenses without their agreement. He said:
It has never been my intention to impose this new method of reimbursing expenses, which would cost the taxpayer several millions of pounds, if the profession does not like it.
In the event, the right hon. Gentleman, the present Minister, after a certain amount of ill will had been created, has taken our advice and withdrawn the strings. He has done what, when we debated the matter last month, he said was not open to him to do
The noble Lord, of course, is giving rather a traversity of what has happened. The Government accepted the Review Body's award and
accepted an amended form, if hon. Members like, of the same award after the amendment had been made by the Review Body. What the Government did in the first place was not to impose anything on anybody. We accepted the recommendation of the Review Body and we did exactly what we were asked to do by the profession before that award was made. The profession said:
We are equally confident in assuming that the Government will accept and act promptly upon any recommendation which the independent Review Body may make.
Is the noble Lord complaining that we did precisely that?
To deal with the other point about the scope of the Review Body, what the noble Lord said about its being limited in terms to quantum of remuneration is in contradiction with the profession's evidence to the Review Body, which asked the Review Body to change the nature of the pool, and also said on the ancillary services that if they could not make progress with the Government they would have no alternative but to refer the matter to the Review Body
My main point was to express pleasure that the right hon. Gentleman had withdrawn the strings, which we asked him to do and which he had refused in the last debate. When the profession said that it was anxious for the Minister to accept any recommendations made by the Review Body, it was not then within its comprehension that the Review Body was likely to make a recommendation involving a distribution of the overall sums of money which it would propose. But we do not wish to argue too long on the details of negotiation. The important fact, which we welcome, is that the right hon. Gentleman has now withdrawn the strings from the recommendation and the possibility of fruitful negotiations is now before him.
If I may say so, the right hon. Gentleman, immediately after the stage to which I have just referred, put himself quite unnecessarily in a further difficulty. On 8th March, the general practitioners' representatives published their charter for the future of general practice. This charter covers the fees which the British Medical Association considered desirable. The Minister considers that its calculations are unsound. On 10th March, only two days after publication of the charter, he held a Press conference contradicting the doctors' figures and giving what he considered was the cost of implementing the charter. At once, the right hon. Gentleman was accused, I think too harshly, by the doctors of issuing a tendentious and inaccurate statement.
Surely if he is engaged in serious complex negotiations of great importance for the future of general practice, and if there is a disagreement on the facts, the Minister would have been well advised, instead of rushing into a Press conference and publicly contradicting the doctors' representatives, to set up a working party to agree on the facts. Then, if no agreement were forthcoming, he could have held a Press conference subsequently. In fact, his action was, within two days of publication of the charter, to hold a Press conference and only subsequently to establish a working party to reach agreement on the facts. We were glad to hear from him today that agreement has now been reached on what would be the cost of implementing the charter.
I turn now from what I regard as the unhappy past. We very much welcome the willingness which the right hon. Gentleman is showing in discussing the various fundamental suggestions put forward in the charter. I echo the words of my right hon. Friend the Member for Bridlington (Mr. Wood), that we hope that the medical profession will take heed of the Minister's words and ponder long before urging their representatives to bypass the Review Body. Although we can understand the sense of frustration in the medical profession today, we believe that, in the long term, the existence of a Review Body, independent of the Government, is a source of great strength to the profession.
Obviously, we hope that, on the purely financial side, the Minister will manage to reach a settlement. If he can generate mutual good will—and I believe that he can by demonstrating beyond a peradventure his positive determination to seek a new satisfactory contract of service—we can be optimistic that he will reach a satisfactory financial arrangement. The fact that he has withdrawn the strings from the £5½ million might well prove to be the basis of an interim financial settlement. Then he can turn his attention to the drawing up of a new contract of service.
But, whatever financial settlement is reached, it must not be allowed to mask the fact that the present discontent centring around remuneration is only a symptom of a far more serious illness afflicting general practice. The focal point of discontent today is remuneration, but if treatment is only given to this symptom, if the right hon. Gentleman only reaches a financial settlement, he may truly be securing a temporary improvement in the well-being of general practice, but it will only be a matter of time before the real illness breaks out again.
The surge of discontent and disenchantment among doctors with the National Health Service reflect two things other than remuneration. They reflect a deep-seated failure to develop proper terms of service and conditions for family doctors. They also reflect, admittedly a very longstanding, failure to integrate the family doctor service into other parts of the National Health Service—the hospital service and the local authority health service. The Minister will be able to stave off a massive withdrawal of doctors from the National Health Service only if he can indicate that these two other matters will receive urgent and positive study. I believe that his speech today will have gone a long way towards reassuring doctors that he is urgently studying these other aspects of their problem.
Now I come to the integration of the family doctor service with the other parts of the National Health Service. Every report of significance—be it the Hospital Plan or the Health and Welfare Ten-Year Plan, or the extremely important Gillie Report—has stressed the need for closer integration of the three parts of the National Health Service. Following the Gillie Report, in October last year, the Ministry and the profession set up under Professor Butterfield at Guy's Hospital a general practice research unit. I want to quote words which appear in an article, written by Dr. Robert Smith, who is now head of the unit, which appears in the Guy's Hospital Gazette this month:
The future of general practice cannot be planned in isolation. Tripartite medicine belongs to the past and has little place in the future health arrangements of new developing areas.
With this categoric statement that tripartite medicine belongs to the past, I
find myself in complete agreement. None the less the framework of the National Health Service is based on tripartite structure. I hasten to say that this is not an argument for centralisation but an argument for integration of the three parts of the Service. The danger is, however, that whilst tripartite medicine belongs to the past, the family doctor service, instead of being integrated with the other two parts, may be squeezed out of existence altogether in a medical world of increasing specialisation and of astonishing advance in medical science and technology.
It is this uncertainty about the future of general practice which lies at the heart of the worries of general practitioners. Already in the United States the family doctor service has virtually disappeared. It would be tragic were that to happen here. I do not want to elaborate on this theme of integration now, except to say that integration, on the one hand, should take the form of the family doctor, perhaps working in a group practice, supervising a team of midwife, health visitor, home nurse and welfare worker. On the other hand, it should take the form of general practitioners being given proper access to hospital beds, to hospital diagnostic facilities and to hospital X-ray facilities. It could also take the form of general practitioners being given a proper place in psychiatric hospitals.
I should like briefly to refer to terms of service. The right hon. Gentleman has the task not merely of finding a solution to the pay dispute but of tackling the fundamental wrongs in our family doctor service. This means that he must evolve a new contract of service. In his search for a new contract of service, the time is right for him. The doctors are anxious for such a contract. The interest of patients demand it. It is, therefore, incumbent on the right hon. Gentleman positively to search for such a new contract.
Although we hope that a massive withdrawal of general practitioners can be avoided, if the right hon. Gentleman cannot find a new contract of service there will inevitably be a continued splintering away of doctors from the general practitioner service, some emigrating, others going into private practice. Most important, these will be the youngest and the most enterprising doctors. Also the most acute problems will arise in industrial areas.
In seeking a new contract of service, the right hon. Gentleman should try to achieve a greater flexibility than now exists, greater flexibility in methods of payment and greater flexibility in methods of financing practice premises. The family doctor service in Belgravia is very different from the family doctor service in some industrial areas. The family doctor service in industrial areas is far removed from the quiet rural practices in which other family doctors undertake their tasks.
It would be a bold person who could point with any certainty to what method of payment we should try to lay down for the long term future. We should try to give doctors the security which they have under the present pooling system. It is essential that we give them clinical independence; we must reward their energies and ability and industry, and the contract of service must be financially feasible and professionally satisfying.
What we from these benches ask is that the Minister should consider putting into practice a series of alternative pilot schemes. One scheme could be based on a capitation system and another on an item of service basis. The Minister should also perhaps consider a contract of service based upon salaries, although in saying that we from these benches would like to emphasise that there are profound disadvantages for the medical profession in deciding in favour of a salaried service.
We also want to see a flexible approach to the financing of practice premises. We believe that there is a great deal of merit in the independent corporation which is suggested in the charter. Such an independent corporation could lend money to doctors to be repaid at fixed rates of interest so as to enable them to purchase modern practice premises. It could itself purchase premises to lease or sell to groups of doctors. Alternatively, such an independent corporation could actually build modern practice premises and sell or lease them to groups of doctors.
I should like to end by reiterating the theme which I have tried to develop. This dispute is most certainly not only about remuneration, vital though remuneration is. It is not only about financing practice premises. It is a question of restoring the professional status which should attach to the family doctor service and which is not provided for by the existing contract of service between doctors and the National Health Service.
I should like to end by quoting from a letter written to me by a doctor in my constituency—a doctor in Welwyn Garden City. I quote from it because I think it emphasises that money and buildings, although important, are by no means the core of the problem facing the Minister. This doctor writes to me as follows:
Reading the debate"—
that is, last month's debate—
in full, it was most interesting to see how many points of view were mentioned. I could add much more, but the only point I would make is that even in a town such as this"—
Welwyn Garden City—
where we have group practice with full rota arrangements, ancillary help, first class liaison with hospital staff and facilities for carrying out our own investigations so that probably there is not a better place to practise in Great Britain, the feeling of desperation is such as to produce a practically unanimous vote last Thursday evening
that is, a vote to hand undated resignations to the doctor's representatives.
May we all hope that sufficient progress tray be made in the negotiations with the Minister that this crisis may be turned to the advantage of everyone rather than bring such a service to an end".
This constructive attitude is, I believe, echoed by doctors throughout the country. We on this side certainly echo what he says and express the hope that this crisis may be turned to the advantage of a service of which this country can be truly proud
This House is indeed a strange place. We have had debates when the House was crowded with Members shouting at one another and outside the people were not the slightest bit concerned about what was going on; we were out of touch with the people. But I think that the sober, quiet and constructive tone of this debate shows that certainly on this occasion the House is reflecting the concern which the nation feels for the future of the National Health Service, and particularly for the future of the family medical service.
The tone was set by the right hon. Member for Bridlington (Mr. Wood). He made a speech that was typical of him. It was constructive, thoughtful and generous to my right hon. Friend the Minister of Health. I think that he got right to the nub of the frustrations and, from that, to the dangerous consequences which might arise from impatient and ill-considered actions. There is a dilemma for doctors. While tremendous changes have taken place over the years, not just in the medical service but within the National Health Service as a whole, in treatment, in drugs and in the appliances which are available, there have been an unchanging contract and terms of service which have given the general practitioner the feeling that he is being squeezed out and that his valuable training, ability and skills are not being properly used.
It is these changes which lead us all to believe that it is not really money that matters. The trouble is that we all say it is not money that matters and then start talking about money. I thought that the hon. Member for Hertford (Lord Balniel) was most unfair to my right hon. Friend, particularly in his criticisms of our attitude to the Review Body. The whole purpose of the Review Body was to get an authoritative and independent consideration of what was involved in relation to remuneration, which would be accepted. To suggest that before it is accepted the Minister should see whether the profession wants it is disgraceful
Just a minute. The hon. Gentleman had a little more than his time.
Paragraph 436 of the Royal Commission's Report which gave rise to the Review Body says:
But we believe that seven people such as we have in mind will make recommendations of such weight and authority that the Government will be able, and indeed feel bound, to accept them. This procedure will in fact, therefore, give the professions a valuable safeguard. Their remuneration will be determined, in practice, by a group of independent persons of standing and authority not committed to the Government's point of view.
It goes on to say that in the interests of all concerned the Government should give their decision on the recommendations very quickly.
I think I am right in saying that there have been five reports from this Review Body. It is the Prime Minister to whom this body reports. Did the previous Prime Minister refer these matters to the profession?
The hon. Gentleman must realise that one cannot adopt a procedure like that without destroying the authority of the Review Body, which the right hon. Gentleman said was one of the things which must be retained. I thought that the right hon. Gentleman was very wise when he counselled the profession that in the long term it would not be to its advantage if the Review Body was by-passed.
Even worse than by-passing the Review Body is to send something to it and then to say "It does not matter what you say. Your authority does not count for anything". We cannot make progress on those lines. We all appreciate the difficulties. We all appreciate the dangers that are inherent in this, because we might easily destroy something which has been built up and accepted by the people of this country, and virtually taken for granted, namely, the worth of the Health Service.
Only one hon. Member today has criticised the Health Service lock, stock and barrel. He is the hon. Member for Birmingham, Perry Barr (Dr. Wyndham Davies). I am sorry that he is not here. He is a brave man. I think that his majority is about 300. However, there is plenty of time—four years—before the next election, so perhaps he can work his passage back. The hon. Member for Croydon, North-West (Mr. Frederic Harris) was another doleful pessimist, but he took it for granted that the negotiations would go on.
The negotiations can go on only if we get the feeling of harmony—and this was appreciated by the right hon. Gentleman and by most hon. Members who took part in the debate—which can come from the letter sent yesterday by my right hon. Friend. This is not merely a question of money. Many other aspects of the problem must be considered. We must consider how to make the best use of the valuable service given by general practitioners. Reference has been made to migration, to overwork, to the conditions in which they work and to how best to use them. Surely these are matters for negotiation.
We have not been entirely idle in these matters. We have been pressing the question of group practice for a long time. We have been pressing the question of health centres and diagnostic centres, such as we have in Edinburgh. I wish that it was better used. We have one in Stranraer, which was built at the request of the general practitioners. This is the point about the acceptance of the principle of negotiation, because in Stranraer—a town with which most people will be familiar, if only because it is the place from which the Irish boat sails from Scotland—this health centre is used to the great advantage and general satisfaction both of the profession and the patient.
We are building a new town at Livingston and are already working out the basis for a district hospital with a series of district health centres.
I am not, but I could quite well tell my right hon. Friend that. I want to remind him that since the inception of the National Health Service it has been the responsibility of succeeding Secretaries of State for Scotland to provide health centres throughout Scotland. In that respect the relevant Scottish Act differs from that which applies to England, under which this task is the responsibility of local authorities. In many areas of Scotland, however, local authorities have been compelled to build clinics for the doctors—which they use at a very low rental— simply because succeeding Secretaries of State have not carried out their duties
I can assure my hon. Friend that we are now actively discussing progress along these lines with the doctors. I was glad to hear the speech of my hon. Friend the Member for Glasgow, Kelvingrove (Dr. Miller), who has great experience not only of medicine but, as a Member of Parliament, of an area that has been extensively redeveloped. In that connection I would point out that in the redevelopment areas in Glasgow we are discussing this question with the profession on the basis of providing a series of health centres from which general practitioners can work much more effectively.
The hon. Member for Birmingham, Edgbaston (Dame Edith Pitt) has experience of this subject in relation to both of the Departments to which she referred. She talked about the question of registration. As she knows from her own experience, it is not the simplest of matters to get this right, but I can assure her that my right hon. Friend has already had discussions with my right hon. Friend the Minister of Pensions and National Insurance on this very matter, and in relation to her suggestions. The hon. Lady's contribution was one of the valuable ones we have had today. I do not know whether I like her better when she is speaking on these matters or when she is decorating the Chair.
The hon. Member for Cheadle (Mr. Shepherd)—and he has gone, too—suggested that we should speed up training—my right hon. Friend covered this matter—and rightly referred to the fact that we are now paying for mistakes that were made in the past. It is amazing how every one agrees that the acceptance of the Willink Report was something for which we are now paying. I hope that hon. Members opposite will be a little more patient with my right hon. Friend. Since the mistake was made by another Government in 1957 the blame should not all be laid upon my right hon. Friend's shoulders a few months after he has accepted responsibility.
I was interested in the point the hon. Member made about status. This is something that the doctors do have with the public. Indeed, they have more than status, more than just confidence, for the public rely more than ever on their family doctor. They rely on him more than on anyone in the medical profession, and so it is desirable to advance the family doctor as far forward into the hospital as possible. It may well be that lack of status comes from the change, to which I and others have referred earlier, within the medical profession—the change of emphasis taking place with the development of the Service. Surely in our negotiations we could come to satisfactory arrangements over this. But we can do so only if we start the negotiations. Arising out of what has been said today by my right hon. Friend, I hope that we shall reach that position.
The hon. Member for Croydon, West, I think it is—
The hon. Member for Croydon, North-West—why should I forget the North?—seemed to suggest that because he spoke quietly, because he spoke in such a way that no one could take offence at anything he said—it is difficult for a politician to do that, we get into trouble even by keeping quiet, just by a twitch of the eyebrows—my right hon. Friend underestimated the concern that there is in the country. Far from it. It is because he appreciates that concern that my right hon. Friend spoke as he did. Because he appreciates the concern, he has taken the opportunity today—thanks to the decision of the Opposition to use this day in this way—to make a progress report. I think it desirable that the public should know all the facts and figures and I am surprised that the hon. Member for Hertford should have taken my right hon. Friend to task because he held a Press conference. What had happened before that conference? There had been days of continuous Press conferences and statements made by the doctors. Surely my right hon. Friend was entitled, if only because of the right of the public to accurate information, to draw attention to the fact that there was a discrepancy of between £5 million and £10 million—an underestimate—in relation to the cost. I am surprised at the hon. Member. He must have written his speech before he heard the speech made today by my right hon. Friend. This point was covered—
No, I cannot give way. The hon. Gentleman had four extra minutes and he knows it. The chances are that, if I give way, by the time he sits down the time will be gone.
My right hon. Friend covered this matter and pointed out that as a result of the two sides getting together in quiet negotiation in the past few days they had agreed the figure of the cost. Let us forget the water that has gone under the bridge. Let us appreciate exactly what is at stake for the doctors, for the public and particularly for the patients. It is desirable that we should have these negotiations. It is desirable that the profession should know the extent to which these negotiations can go forward from now, and that it should appreciate exactly that point which my right hon. Friend has made with a firmness which has been appreciated on both sides of the committee, that the quantum, the aggregate in relation to remuneration, is something which should be referred to a body as authoritative as the Review Body.
I think that the advice of the House would be that the doctors would do well to study the letter which has been sent to them by my right hon. Friend, and to appreciate that there is therein the opportunity not only to settle the immediate difference but to go ahead and create a structure within which we can draw from the lessons of the past and which we will be able to mould properly in the future without waiting for crises to come to boiling point.
I have been reading something to which I think the attention of the Committee should be drawn. It is the Lancet for 28th July, and it says:
The eyes of the public are on the movements of the profession, and duly ought they to appreciate any exertions made by medical men to benefit mankind. Those who are aware how badly rewarded, in a pecuniary point of view, are the hardworking general practitioners will do so.
That is from the Lancet of 28th July, 1849. With the passing of a century the position of complaint has not changed. I think, however, that we may well have the opportunity now to put this right, and not merely to put it right for a day but to put it right for, I hope, a generation. We should remember that the generation which is now getting the benefits of the Health Service is a genera-
tion which has never known the kind of unequal service which we had before the war. When I hear a Member of Parliament suggesting that we should compare the provision of health and treatment with the provision of entertainment, I begin to wonder how he got here at all.
The Health Service is part of our heritage. It is part of the challenge that we should, in the negotiations which will come, ensure that the Health Service will stay and will flourish
The CHAIRMAN then proceeded, pursuant to the Order of the House this day, to put severally the Questions, That the total amounts outstanding in such Estimates for the Defence (Royal Ordnance Factories), Defence (Army) Purchasing (Repayment) Services and the Defence (Air) Services for the coming financial year as have been put down on at least one previous day for consideration on an allotted day, and the total amounts of all outstanding Estimates supplementary to those of the current financial year as have been presented seven clear days and of all outstanding Excess Votes be granted for the Services defined in those Estimates, Supplementary Estimates and Statements of Excess.