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 Dr David Kerr Dr David Kerr , Wandsworth Central 12:00, 17 March 1965

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.