With permission, I will make a statement on the situation as regards the medical profession and the National Health Service.
In the debate on 21st November I gave the House details of the junior doctors' dispute. As I told the House, at the heart of this dispute is the Government's overriding need to sustain the pay policy. The juniors' representatives maintain that they do not wish to breach the policy but that it is being wrongly interpreted in their case. On 20th November the Secretary of State for Employment and I met representatives of the Hospital Junior Staff Committee of the British Medical Association and explained that, as the policy applies to earnings and not just basic rates, their claim for greatly enhanced rates for all hours worked over 80 could not be reconciled with it and that any improvements in the new scheme of pay supplements would have to be contained within the amount of money formerly being paid out in extra duty allowances. I am sorry to say that, despite this, the BMA Council has endorsed this claim by the juniors and officially authorised the industrial action which started last Thursday in support of it.
The juniors are also arguing that the sum of £12 million which is available for redistribution has been wrongly calculated and is an underestimate. Since it is certainly not the Government's desire to deprive the juniors of any money to which they are entitled under the policy, I offered the Hospital Junior Staff Committee an independent audit of the extra duty allowance claim forms on which the figure of £12 million was calculated. This was refused by it on the ground that the underestimate arose from the failure of the Review Body to take certain factors such as underclaiming into account in costing the new contract.
At my request the BMA sent me details of these factors and I forwarded them to the Review Body, which has now commented. The Chairman of the Review Body explains in his letter to me:
I can assure you that the Review Body took account of the kind of factors that Dr. Stevenson refers to in his letter and made due allowance for them within the limits of the evidence available to them.
In the interests of removing possible misunderstanding of the basis on which its recommendations were costed, the Review Body suggests that the Office of Manpower Economics, which serves the Review Body, should discuss this with the BMA's statistical adviser. I am pleased to report that the BMA has accepted this and technical discussions on these points
will take place in the next clay or so. I have placed copies of this correspondence in the Library.
In the meantime, industrial action is continuing. The BMA has recommended juniors to restrict their hours of duty to 40 per week worked flexibly according to local needs. I regret to say that some juniors are restricting their hours to from 9 a.m. to 5 p.m. five days a week. This industrial action has led to the closure of a number of accident and emergency units, which will undoubtedly put some patients at risk. In some hospitals facilities have been closed in order to concentrate manpower and maintain a 24-hour service in other hospitals. The picture varies from region to region and is changing from day to day. It is impossible to give a precise picture at this stage, but I am keeping the situation under close review through the Department's monitoring unit.
It is encouraging that as many as four out of 10 junior doctors who answered the question in the ballot about sustaining industrial action voted "No" and that the endorsement of industrial action by the Hospital Junior Staff Committee of the BMA was carried by only 23 votes to 19. It is also encouraging that the principles of the new contract which we have negotiated received overwhelming support in the recent BMA ballot. As I have explained, it is possible under the pay policy to start phasing in the new contract immediately on a basis which will ensure "no detriment".
But our real aim should be to reduce the long hours which some juniors work. The Government have immense sympathy with the juniors over this. I am willing to enter into immediate talks with the juniors, and with the representatives of the consultants who would, of course, also be involved, to agree a timetable for reducing juniors' hours of duty to a maximum of 80 hours a week. This, of course, cannot be introduced without agreement by consultants as well as the juniors, and without a willingness for juniors in posts which do not involve long hours of duty to shoulder some of the burdens of their colleagues who work long hours.
I now turn to the consultants. The Council of the BMA has recommended that from today doctors in the senior grades in NHS hospitals should limit their work to caring for emergencies and to the care of patients already receiving in-patient treatment. Also, the Council is collecting undated resignations. It says that its grounds for discontinuing this action would be a decision by the Government to refer to the Royal Commission all the matters in our consultative document on private practice, together with the phasing out of pay beds. I hope that the House—the whole House—will deplore this additional industrial action. As my right hon. Friend the Prime Minister has said, the question of separating private practice from NHS hospitals is a matter for Parliament, where no doubt it will be fully and hotly debated.
As for the licensing proposals in the consultative document, the Queen's Speech makes clear that the Government propose to continue consultations on them before finally deciding their policy. I have already held one discussion with the representatives of the medical profession on the document and I have today written to the BMA inviting it to resume discussions with me.
I am glad that the Royal Colleges, although not in agreement with the Government's proposals on pay beds, have said that they cannot associate themselves with their profession's proposals to limit services to patients, and I am glad, too, that consultants in Scotland, as well as a number in England, have publicly announced their refusal to take part in the industrial action. The action proposed by consultants in England, if fully applied, together with the junior doctors' sanctions will give rise to very serious risks to the health and even the lives of patients.
In the Government's view it is indefensible that any patients should remain at risk while the discussions arranged by the Review Body take place and pending the further talks which the Government have offered to both junior doctors and consultants. I can only hope that, even at this late hour, the profession will reconsider this damaging action and resume talks.
I also have to report that the executive committee of NUPE, at its meeting yesterday, recommended its members not to provide services for private patients, except for emergency cases, in hospitals where the consultants are taking industrial action affecting NHS patients. I can only deplore any action from any quarter which damages the needs and interests of patients, and I urge all NHS staff to leave this matter to Parliament.
That is a very serious position, and our urgent need must be to reach an agreed solution. On the junior doctors' dispute, is the right hon. Lady aware that, as the Prime Minister acknowledged on Thursday, the Opposition have made their position absolutely clear? We will not support action to break the Government's counter-inflation policy. Therefore, may I put two points to the right hon. Lady which could bring about a solution within that policy?
First, we know that the crucial figure is the £12 million available for distribution. Will the right hon. Lady allow an independent audit to go one step further than currently envisaged and consider the basis of that figure and, in particular, whether £12 million is the amount now being paid in 1975 in extra duty allowance? Will she therefore agree to an independent examination of the view of many junior doctors that that figure is out of date?
Secondly, with that evidence, which can be collected quickly, will the Government now agree to the Prime Minister convening a conference later this week of all the parties involved with the aim of giving the negotiations a new start and breaking down the atmosphere of mistrust which has surrounded them?
As for the consultants' dispute, the right hon. Lady will again recognise that we have made our position clear and that we do not support industrial action. Does she recognise also that the solution really lies in her own hands? Will she not, even now, agree to a reasonable compromise and refer the whole pay beds and separation policy to the Royal Commission, or does she not understand that she has not only led the National Health Service into crisis but risks leading it to catastrophe?
With regard to the first part of the hon. Gentleman's question, I think I have made it clear by the offers I have made that the last thing the Government want is to deny the doctors any money to which they are entitled under the pay policy. Therefore, we have proceeded on the basis of the claim forms sent to us by health authorities for extra duty allowances during the base period on which the calculations have, by agreement, been based.
In one of his recent letters to me Dr. Stevenson, the Secretary of the BMA, said:
We accept that the arithmetic covering the 24-week period from 1st July to 15th December 1974 is correct.
Those were the figures which were, at the time the calculations were made, the only figures available. That is the kind of base period on which everyone else's salary calculations are made. Since then, more recent figures up to the end of March have come into our hands and they confirm the pattern revealed by the previous figures. Therefore, I must repeat that we are perfectly willing to allow an independent audit of the claim forms which were sent in to us.
At one stage, one of the juniors' representatives said to me "You are the only one who has seen the claim forms." I said "If that is the suspicion, let us clear it up. Let us have an independent audit to check that the claim forms sent to us by the health authorities were correct." From the latest figures available, the pattern is shown to be the same as that during the 24-week period to which I have referred, and at no time in all the discussions about the costing of the contract has any objection been made by the juniors or the BMA to taking this base period, which, as I say, was the only period available at the time.
The purpose of the pay policy is to see that the amount available does not exceed the figure which was available last year. That is the basis of the counter inflation policy. Any other approach is self-defeating.
With regard to the hon. Gentleman's second question that the Prime Minister should convene a conference, that, of course, is a matter for my right hon. Friend. But he has received a request from Sir Rodney Smith, the President of the Royal College of Surgeons, asking for a meeting, and he has agreed. My right hon. Friend is currently abroad, but I understand that the meeting will take place on Wednesday.
Dealing finally with the hon. Gentleman's suggestion about referring the pay beds issue to the Royal Commission, I
put this to the House. Not many years ago this House set up a Select Committee to examine private practice in the National Health Service. That Select Committee was divided, of course, and there is every reason to assume that a fully representative Royal Commission would be divided too. In the end it will be for this House to decide what is, after all, a profound matter of principle—whether it should be possible within a publicly-financed National Health Service to buy privileged treatment. As The Guardian put it in a leading article not many weeks ago,
This is a political matter which ought to be decided by Parliament.
We are grateful to the Secretary of State for her statement, in the course of which she said a great deal about the cause of the present situation. Can she also say something about the effect? Is she aware, for example, that in my area health authority the junior doctors have been working from 9 till 5 five days a week for the past four and a half weeks and that we have had to close all the Rochdale area hospitals to all admissions, including emergencies? Will she consider the grouping of hospitals across area health authority boundaries to ensure some kind of long-term coverage of emergency treatment as from, perhaps, the end of this week?
Secondly, does the right hon. Lady agree that all that the doctors are now doing is displaying the militancy which has proved to pay off in all other sections of the community in past years?
I appreciate the position in Rochdale because the hon. Gentleman's constituency is in a militant area, as I am in my constituency, where I have met a number of junior doctors. I well appreciate the difficulties in Rochdale, and the kind of provision that the hon. Gentleman suggests is exactly the kind of cover that we desire to make. We intend to attempt to make it, but it depends on the co-operation and agreement of the doctors themselves. If they are prepared to work 40 hours flexibly in the light of the local situation, as the BMA recommended to them, such arrangements may be possible. However, some juniors are refusing to do even that.
Does my right hon. Friend accept that Government supporters believe that she has been open and conciliatory towards the junior doctors? The offer of an independent audit of the claim was put to them earlier than today. Does my right hon. Friend agree that the fact that doctors, juniors and consultants, are prepared ruthlessly to put the health of patients at risk is despicable, and that it is time we stood up to those people who will put their self-interest first? [HON. MEMBERS: "What about the miners?"] If a patient suffers damage to health as a result of being refused admission to hospital, against whom is redress available? Is it the junior doctor, the consultant or the health board?
I am grateful to my hon. Friend for recognising that throughout the time I have held my present responsibilities I have sought to advance the juniors' cause. I had extremely friendly relationships with them until the past few weeks, as any reading of the joint statement which the juniors' representatives and I issued in January this year will show. We then reached a warm agreement on the principles of the new contract and the date for its introduction—1st October this year. That being so, it is obvious that anyone in my position who wished to defend the pay policy could have done nothing other than I have tried to do.
The matters raised by my hon. Friend in the second part of his question are legal matters which are far too abstruse for me to enter into.
In regard to the juniors, if the figure of £12 million is arithmetically correct does it not show how small the extra duty allowance is in relation to the excessively long hours? What proposals does the right hon. Lady have to implement her policy of reducing and eventually eliminating excessive hours, as to do so obviously requires making the profession attractive to new entrants, which it will not be unless something more constructive is done?
The fixing of the rates for juniors, as for others, is a matter for their independent Review Body. It was not until April this year that the Review Body was free to fix increases for the juniors which it felt were fair. Under our predecessors' statutory policy the Review Body had not been free to do so. In April the doctors received a record increase of 30 per cent. and more, which gave them individual increases of from £13 a week to £30 a week. That is a fact that we should never forget, and it is why it is impossible, if the pay policy is to survive and not collapse in ruins in a matter of weeks, for the Government to exceed the amount which was being paid in extra duty allowances during the current year.
Will my right hon. Friend note that there is wide support, certainly on the Government side of the House, for the view that the principles of our policy on pay beds and private medicine are not subject to negotiation with the BMA or anyone else but are subject only to the consent of Parliament? Does she also agree that during the past 12 months the National Health Service has had a better financial deal in real terms than ever before? Against that background, will she give a firm assurance that there will be no giving way to the kind of politically motivated blackmail to which we are being subjected?
Of course, I agree with my hon. Friend that the principle as to whether or not pay beds should be contained in our National Health Service is a matter which should be decided by the House. That is why I have proposed to put it in the form of legislation to the House. The authorisation of pay beds is within my administrative discretion. If I had wished to play unfairly by the medical profession, I could have so whittled down those authorisations de facto as to abolish pay beds without giving the House an opportunity to vote on the matter. What I propose is, therefore, the most democratic course.
I agree with my hon. Friend that it is very dangerous when industrial action of the kind now being taken by the consultants is taken to prevent a political decision. My hon. Friend is also right when he says that from the pay point of view the National Health Service has had the best deal in the past 12 months that it has had for years. That is why the Government introduced over £700 million-worth of Supplementary Estimates last year to meet the increased pay that we gave to those from the top to the bottom of the Service.
May I bring the right hon. Lady back to the real problem, which is not a question of the doctors and herself but a question of the patients? In the past 10 minutes we have wandered away from consideration of the great risks being run as a result of the impasse that has been reached. As a member of the South-East Thames Hospital Authority I received a report half an hour ago that King's College, Guy's and St. Thomas's Hospitals in London are now at grave risk and that at the end of the week the risk will be severe. Other hospitals in the region—[HON. MEMBERS: "Ask a question."] I am asking a question. I will not be prevented from completing a question involving people's lives. The Secretary of State is not complaining about the way in which I am putting the question.
I deplore industrial action by both junior doctors and consultants. We have reached a state of impasse. It is the Secretary of State's duty to lead us out of that impasse now. I hope that she will recognise the mood of the House and the country and give us a lead.
I believe that the mood of the House and of the country is that it would be wrong for the Government to approve a breach of the pay policy, because in the end the pay policy would collapse, inflation would resume its appalling upward course and the first people to suffer would be the patients in the National Health Service that we should no longer be able to sustain. I am deeply concerned about the well-being of patients. That is why I am monitoring the situation daily through my Department's unit and why we shall make whatever arrangements we can to safeguard the interests of patients, which their doctors are so wantonly flouting.
Does my right hon. Friend accept that part of the trouble with the junior doctors is that many of them genuinely do not understand the pay policy? For example, they believe that overtime payments pro rata can be taken by ancillary workers and they therefore think that overtime is negotiable for themselves. Will my right hon. Friend take every possible step to ensure that the two associations do what every responsible trade union has done, and make clear to their members what the pay policy is all about?
I entirely agree with my hon. Friend that there is a great deal of genuine confusion among juniors. Many of them genuinely believe that they can have almost a doubling of their earnings from overtime—that is what they are asking for in their latest demand—and still be within the pay policy. This is where the House as a whole can help.
I explained in some detail in our debate on 21st November how the pay policy applied to juniors. My right hon. Friend the Secretary of State for Employment and I spent four hours with their representatives, going over every detail and query and pointing out that we were not asking of juniors anything that we were not asking of other workers. My hon. Friend is right to say that the juniors believe that overtime rates are somehow outside the policy, whereas it is earnings and not basic rates to which the £6 limit applies. It is only extra work, not additional overtime rates, which is authorisable.
I hope that the right hon. Lady will not fall into the trap of believing that the consultants who are not joining in industrial action may agree with her views and her actions. The position is that they do not. Secondly, was it not settled that the provision for consultants to treat their own private patients within the National Health Service was a condition of their joining the NHS in 1947? In the interests of sick people, will the right hon. Lady cease her intention of breaking Aneurin Bevan's promise?
First, I accept that the consultants who are refusing to take industrial action are not thereby necessarily accepting the policy that I have put before the House—and all the more honour to them for putting their patients first and allowing their battles to be fought on the Floor of the House when the legislation comes before us. That is the true medical ethic as I understand it.
I can assure the hon. Lady that she is wrong in her reference to Aneurin Bevan. There was no understanding of the kind to which she has referred. Aneurin Bevan made it clear in "In Place of Fear" that he considered that the retaining of pay beds had been a fault in the Service which had been there from the start. He was in favour of abolishing pay beds in due course.
Is my right hon. Friend aware that at the past two General Elections the nation gave a mandate to the Labour Government to abolish private practice in the NHS hospitals? Is she aware that a junior doctors' representative at St. Helens approached me only a few days ago about having to work 156 hours in one week? Will she make it clear to the country whether junior doctors are actually working 156 hours or whether they are on call for those hours? What is the maximum number of hours that doctors actually work in a hospital?
My hon. Friend is right to say that the intention to phase out pay beds from within the National Health Service hospitals was contained in both our election manifestos. As any honourable Government would, we are trying to implement our manifesto policy.
My hon. Friend is right in querying whether all juniors work the kind of extravagant hours that we sometimes hear quoted. The Review Body carried out a special survey on juniors' hours and found that on average whole-time juniors were on duty for 85·6 hours a week, of which 43·2 hours were spent on normal duty and 42·4 hours on standby or on call.
When we talk about juniors' hours we are not always talking about hours of work as commonly understood but about hours on duty, some of which may be spent at home where they can be entertaining or studying. I still maintain that the average is excessive. That is why I believe that our first duty is to work out a plan of action for reducing the excessive hours in the Health Service.
Does the right hon. Lady accept that it would not be fair to blame her for all the troubles in the National Health Service? Equally, she must accept that it must be more than coincidence that there is now almost civil war in the hospital service. As my hon. Friend the Member for Canterbury (Mr. Crouch) has said, what action does she intend to take? Is she aware that it is no good giving glib answers? Does she recognise the important point that the availability of first-class consultants in 70 per cent. of the country outside the large city areas depends on the consultants having pay beds available at those hospitals?
That is the reason for the consultants forgoing 25 per cent. of their salary so as to be able to do a small amount of private practice. Will the right hon. Lady recognise that point as being crucial?
I am grateful for the gesture of courtesy which the hon. Gentleman has extended to me. It makes a refreshing change. He said that it is no good giving glib answers and that action should be taken, but I would point out to him that the action I am taking in standing by the Government's pay policy has been endorsed by the hon. Member for Sutton Coldfield (Mr. Fowler), the Opposition Front Bench spokesman on these matters. Indeed, we have heard that again from the hon. Gentleman. He says that he deplores industrial action to defeat the pay policy. Presumably he condones my refusal to breach the pay policy.
Let us be clear that if the House is to run away from difficult decisions every time we reach this sort of situation, we shall not have a pay policy or a counter-inflation policy. I would point out that in our debate on 21st November the hon. Member for Sutton Coldfield condemned the consultants' action against our pay bed policy. He said:
We shall fight that policy in Parliament with every legitimate weapon at our disposal."—[Official Report, 21st November 1975; Vol. 901, c. 362.]
The hon. Gentleman was right to say that.
It would seem that there is no disagreement on principle. Of course, there is disagreement about policy on pay beds and about the way in which the situation should be handled. I think it would help the conciliation of these disputes if that message could go out loud and clear from the House.
The right hon. Lady must be aware that her pleas on pay policy would carry far more weight if the country did not remember her previous attitude on these matters. I stand by exactly what I have said both on the pay policy and on the consultants' action, but does the right hon. Lady recognise that neither the pay policy nor anything else excludes her from sensible, reasonable acts of conciliation and compromise? It is such action that we press upon the right hon. Lady.
I should find that intervention easier to follow if any detailed suggestions had been made for any further acts of conciliation or compromise by myself. I think the House accepts that I cannot compromise on the money for the juniors unless and until our joint examination with them or the examination by them and the Office of Manpower Economics of the Review Body's calculations produces a basis which is legitimate. If it does, I shall welcome it. If it does not, I should be letting the country down if I were to invent a calculation which would patently be at odds with the pay policy.
All that we have had this afternoon in the form of suggestions from the hon. Gentleman is that we should allow an audit of the earlier figures. In other words, he seems to want to alter the base rate. I can assure him—and I shall send him copies of the March figures, which are the latest available—that that would make no difference.
Will my right hon. Friend say whether it is a fact, as some junior hospital doctors allege, that some doctors will earn less money as a result of the latest Government proposal?
No, because it depends on how the new contract is introduced. It is true that, if the contract had been introduced in its entirety on 1st October, within the same amount of money, as it must be, that is being spent on those working only over 80 hours a week, some doctors would have been worse off. However, we appreciate that the principle of "no detriment" is a very good trade union principle, and we suggested a way out whereby we could phase in the new contract in such a way that no one would go on to it until he changed his job. That would have meant that in April of next year the option would have been available, with the help of the additional money becoming available to the juniors under the pay policy, for everybody to switch and for money to be available with a "no detriment" safeguard. We got over that part of the problem, but the argument has now changed completely and is now on an entirely different basis which challenges the foundation of the pay policy.
Is the right hon. Lady aware that many of us who deplore industrial action in the Health Service do so not in the interests of the pay policy but in the interests of the patient, and that that is the case whether the industrial action is taken by doctors, COHSE, NUPE or anyone else? May I ask the right hon. Lady, in considering the long-term solution to these problems, to recognise that there is an urgent need for a total job evaluation exercise on all hospital jobs and not only doctors or nurses or cooks? A hospital is a team. Having done that, the right hon. Lady can reasonably ask all the unions and workers involved to reach a voluntary agreement never to strike in the National Health Service.
I agree with the hon. Member that it is the interests of the patients that we must put first. This is why the House must unitedly condemn this industrial action which threatens lives as well as everything else. As for the hon. Gentleman's point about job evaluation, in a sense the independent Review Body is conducting a continual job evaluation exercise in that it has to look at the relative gains and losses of different groups that come under its control. I am not clear what the hon. Gentleman has in mind about anything wider and more comprehensive. If he would like to write to me and put specific details, I should be glad to consider them.