Orders of the Day — National Health Service (Doctors' Pay and Conditions

Part of the debate – in the House of Commons at 12:00 am on 17 March 1965.

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Photo of Mr Kenneth Robinson Mr Kenneth Robinson , St Pancras North 12:00, 17 March 1965

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.