The Minister of Health (Mr. Aneurin Bevan)
I beg to move:
The House will recollect that this Debate was requested from this side of the House, and not by the Opposition. There is some significance in that fact. During the last six months to a year there has been a sustained propaganda in the newspapers supporting the party opposite, which has resulted in grave misrepresentation of the nature of the Health Service and of the conditions under which the medical profession are asked to enter the Health Service. There has been even worse misrepresentation, sustained by a campaign of personal abuse, from a small body of spokesmen who have consistently misled the great profession to which they are supposed to belong. I make a distinction, and I hope that distinction will be maintained throughout the Debate, between the hard-working doctors who have little or no time to give to these matters, and the small body of raucous voiced people who are alleged to represent the profession as a whole. So much misrepresentation has been engaged in by the B.M.A. that the doctors who have voted or are voting in the plebiscite are doing so under a complete misapprehension of what the Health Service is. It has been frightening to speak to some doctors and to learn the extent to which their representatives have failed to inform them about the facts of the case. I have even spoken to representatives of the doctors who have attended the various conferences which have been held in London, and at which the members of the negotiating committee were supposed to have reported their discussions with me, and they themselves did not and do not understand what the facts are. From the very beginning, this small body of politically poisoned people have decided to fight the Health Act itself and to stir up as much emotion as they can in the profession. I have before me a letter written to the "Scotsman":"That this House takes note that the appointed clay for the National Health Service has been fixed for July 5th; welcomes the coming into force on that date of this measure which offers to all sections of the community comprehensive medical care and treatment and lays for the first time a sound foundation for the health of the people; and is satisfied that the conditions under which all the professions concerned are invited to participate are generous and fully in accord with their traditional freedom and dignity."
I have quoted from one of the more modest of the letters, because I am not anxious to raise the temperature just now. No doubt, hon. Members have seen letters which are even more virulent than that one. The history of the Health Service Act is a very long one. It started with the National Insurance Act in 1911–12. Then in 1920 there was the report of a committee under Lord Dawson. Then in 1943 it was revived, and in 1944 there was a Coalition White Paper. Then there were protracted discussions with my predecessor. Then there was a Government White Paper in 1945 and the National Health Service Act, which took 32 days in the Commons and 10 days in the Lords. I would like to make one personal reference. It has been suggested that one of the reasons why the medical profession are so stirred up at the moment is because of personal deficiencies of my own. I am very conscious of these. They are very great. Absence of introspection was never regarded as part of a Celtic equipment; therefore, I am very conscious of my limitations. But it can hardly be suggested that conflict between the British Medical Association and the Minister of the day is a consequence of any deficiencies that I possess, because we have never been able yet to appoint a Minister of Health with whom the B.M.A. agreed. My distinguished fellow countryman had quite a little difficulty with them. He was a Liberal, and they found him an anathema. Then there was Mr. Ernest Brown who was a Liberal National, whatever that might mean, representing a Scottish constituency. They found him abominable. As for Mr. Willink, a Conservative representing an English constituency, they found him intolerable. I am a Welshman, a Socialist representing a Welsh constituency, and they find me even more impossible. Yet we are to assume that one of the reasons why the doctors are taking up this attitude is because of unreasonableness on my part. It is a quality which I appear to share in common with every Minister of Health whom the British Medical Association have met. If I may be allowed to make a facetious transgression, they remind me of a famous argument between Chesterton and Belloc. They were arguing about the cause of drunkenness, and they decided to apply the principles of pure logic. They met one night and they drank nothing but whisky and water, and they got drunk. They met the next evening and drank nothing but brandy and water, and they got drunk. They met the third night and drank nothing but gin and water, and again they got drunk. They decided that as the constant factor was water it was obviously responsible—a conclusion which was probably most agreeable to Bacchic circles. I think we can dismiss at once the suggestion that the disagreements with the medical profession are a consequence of the personal qualification or disqualification of the Minister concerned, and I have made reference to it now only in order that I might call attention to the sort of propaganda which seems to be recurrent in British politics where issues of principle are vulgarly personalised. It is becoming almost impossible for the citizens of Great Britain to see the differences of political principle through the smoke of personal misrepresentation. That is one of the reasons, but the least important reason, why the Government thought it necessary to have this Debate this afternoon. It has been suggested by the spokesmen of the B.M.A. that we have not negotiated with them sufficiently, that if we had only been more approachable things would have been different. But there were long negotiations with Mr. Brown and long negotiations with Mr. Willink, and on every occasion the B.M.A. rejected the advances made. I have met them on numerous occasions. I have met the Negotiating Committee itself eight times, three times before the Bill was introduced and—I hope this will not be brought against me—most irregularly I met them three times whilst the Bill was before the Committee. I consider this was somewhat of a sin against constitutional practice because I do not believe a Minister ought to be running two committees at the same time, one in the House of Commons and the other outside. I did it in order to give them every opportunity of stating their case. Since the Act I have met them twice, and since August, 1945, the officials of my Department have met representatives of the Negotiating Committee 28 times. There have been continuous discussions, so miscroscopic that I am almost weary of the issues involved because they have been so much investigated. But the Negotiating Committee on its side was never in a position to negotiate. It had received from its own committees, at its own request, instructions not to negotiate. Indeed—and I would like the House to note this—when I met members of the Negotiating Committee in December of last year for a two-day discussion, I was presented with a printed circular which they had themselves caused to be printed rejecting the Act before the final negotiations had taken place. All the main features of the Act are contained in that document; not merely remuneration, not merely basic salary, not merely the appeal to the courts, but every important provision in the Act had been rejected by the Negotiating Committee before negotiations were concluded. I called the attention of the chairman of the Negotiating Committee to that fact and asked him what was the use of two days' negotiations when one side had already decided to reject the whole scheme. The answer was that they had already made up their minds."Parliament, through the National Health Service Act—'State Medical Service Act' would have been a more descriptive designation—has vested certain totalitarian powers in the Minister of Health. The Minister has not been slow in revealing these powers in his scheme of things to come. Stripped of the goodwill of his practice, subjected to 'negative' direction, denied the right of appeal to a court of law against dismissal from service and salaried from Whitehall—such is to be the lot of the physician of the Socialist future. In brigand-like fashion this would-be Feuhrer points an economic pistol at the doctor's head and blandly exclaims 'Yours is a free choice—to enter the service or not to enter it.'"
Mr. Wilson Harris (Cambridge University)
Have they rejected the whole of the hospitals section of the Act?
The hospitals section is included in the rest. This document is in the Library for hon. Members to look at—it rejects the Sections dealing with distribution, buying and selling of practices, remuneration, right of appeal to the courts, midwifery, the administrative bodies, public hospitals, hospital accommodation for private patients, facilities for diagnosis, statutory health committees, public health service, representation of the profession on the administrative bodies.We are not now dealing with a body which is seeking to bring about the modification of principles in what they consider to be the legitimate interest of the members of the medical profession. We are dealing with a body organising wholesale resistance to the implementation of an Act of Parliament. Furthermore, and I would like the House to note this, they had already rejected the Act before they knew the terms of remuneration for the general practitioner. They had not been told by me officially whether or not there would be a basic salary. They had not been told at this stage what was to be the scale of remuneration and, when they go around the country at the present time saying that one of the main causes of their decision is the basic salary, it should be remembered that they had decided to reject the Act before they knew there would be a basic salary in the remuneration. In fact the whole thing begins to look more like a squalid political conspiracy than the representations of an honoured and learned profession and, I say this deliberately, when the bulk of the doctors in the country learn the extent to which their interests have been misrepresented by some of their spokesmen, they will turn on those spokesmen. In fact, one of the weaknesses of the B.M.A.'s present position is that they have mustered their forces on the field by misrepresenting the nature of the call and when the facts are known their forces will disperse. There are four main issues on which the B.M.A. say they join issue. They say, in the first place, that they cannot accept the abolition of the sale and purchase of practices. The abolition of the sale and purchase of practices was recommended by the profession's own health commission. They voted for the abolition in their own plebiscite and all I have done, and all the Government and the House have done, is to put in the Act recommendations about this step based on the best medical information. We regard it as being inconsistent with a civilised community and with a reasonable health service for patients to be bought and sold over their heads. When I am told that all they desire is that patients should have the best medical treatment, how can that be argued when a doctor succeeds to another doctor's panel not on account of personal qualifications but on the size of his purse? How can it reasonably be argued that there is any effective free choice of doctor when the doctors negotiate the terms between themselves and the patient knows nothing at all about it? This system exists in no other country in the world. It is a blot upon our medical system. I ask the Opposition whether they accept or do not accept the abolition of the sale and purchase of practices. We should like to know. We should like the Opposition to tell us—because I think that these matters ought to be made quite clear—whether they are in favour of doctors being able to buy and sell their panels in the public service. It is very necessary that we should know. It is very necessary that we should know the body of opinion behind this practice so that we can estimate what it is worth. One of the main reasons why we are having this Debate today is not merely in order that the Government can clear up their position, but that the Opposition shall have the opportunity of making their position clear, too. After all, the second body of importance next to the Government is the Opposition, and I do not think that the nation ought to be denied the counsel of the Opposition in this matter. There cannot be, as far as we are concerned, any question at all that a Health Service which we consider to be reputable must not retain the buying and selling of private practices. The doctors have said that their second objection—indeed, many of them said that this is the one thing that is offending them—is that they will not accept a basic salary as part of their remuneration. The first time that a full-time salaried practitioner service was put before the medical profession was in 1943, in the days of the Coalition Government. It came from Mr. Ernest Brown. I hope the Opposition will note that. This principle, to which such exception is taken, which is supposed to reveal such Socialist partisanship, which is supposed to embody such regimentation, did not come from a Socialist Minister of Health but from a Government composed of Conservatives, Socialists and Liberals, and was put forward by a National Liberal. And I rejected it; I thought it contained too much of the element of regimentation. There were some hon. Members on this side of the House who expressed the view that competition for patients on panels had the effect of degrading the standards of the service, and that, consequently, it was much better to have a full-time salaried service. It was argued out on Committee stage and on the Second and Third Readings, and it was decided that that was not what we were going to do. But what I made clear during the passage of the Bill was that young doctors ought to have the opportunity of living decently whilst they were building up their practices. At the moment, the only way in which a doctor can get into general practice is either by becoming an assistant to a principal, and accepting very important limitations when he takes up his work, or by borrowing sums of money and, therefore, for the first 15 to 20 years of his professional life, loading himself with debt, so that when he is approaching his patients, he is not in the state of mind in which a doctor ought to be. We not only desire in this scheme to relieve patients of financial anxiety; we desire to relieve the doctor of financial anxiety when he approaches his patients. It is one of the most deplorable features of the existing system that young doctors, when they go into practice—and they are by no means boys, but men of 24 to 30 years of age, with young families to feed and educate and clothe and look after—just at that time when the young doctors ought to be freest of financial burdens, they have financial burdens put upon them. We consider, therefore, that a salary, only of £300—but, nevertheless, a salary of £6 a week—plus what he can get from capitation fees, would be a financial support for the young doctor whilst he is building up his practice.
Mr. Lipson (Cheltenham)
Would the right hon. Gentleman deal with the proposal that the basic salary should be optional, and paid only to those doctors who ask for it and not to those who do not want it?
It would make administrative practice extremely complicated, because we should then have to pay two capitation rates, a higher one for doctors not receiving salary and a lower one for the doctors receiving it.
I would suggest the same capitation fee, but not giving the basic salary to those who do not ask for it.
My hon. Friend is dealing with the point I was just about to meet. It is perfectly true that if a general practitioner believes that this element of basic salary is repugnant, and by its very existence makes him into a State salaried servant, he need not take it. He can give it back. The Chancellor of the Exchequer would be delighted. It will be of interest to see how many general practitioners find this so dishonourable to the traditions of the profession, so besmirched by the element of regimentation that they will hand it back as though it were poison. There is nothing at all to prevent a general practitioner from handing it back if he likes. But it would be a most complicated arrangement if we had two capitation fees running simultaneously in the Service. We can see how extremely complicated it would be if we consider what effect it would have on the national and local pool available for the payment of general practitioner's remuneration. One of the concessions made, which has not been italicised, is that for the first two years we shall pay into the pool a sum equal to 95 per cent. of the total population of the country, because the general practitioners will be assumed to be at risk for a large number of people who will not have signed their lists at all. To work that basic salary under conditions of that sort would be extremely difficult and cumbersome.Another argument we have heard advanced is that the partnership agreements will be rendered very difficult and that it is hard to see what the Act means when partnership agreements remain after the Act has come into operation. The mind of the general practitioner has been confused by the B.M.A. propaganda in this respect; but there is natural anxiety among general practitioners as to what is the effect of the Act upon partnership agreements. In order to try to clear it up I have decided, with the co-operation of the Attorney-General and the Lord Chancellor, to appoint a legal committee to inquire into it and to recommend what they consider should be done. It is a most unusual proceeding. As a general rule, when Parliament passes a Bill and it becomes law, it is left for the courts to construe it. However, if any further light can be thrown on this matter, if competent legal opinion can find any way in which those Sections of the Act can be clarified, I shall be perfectly prepared to recommend the Government to have an amending Bill for that part of the Act to make clear where the general practitioners stand. The other thing to which the B.M.A. take serious objection is what they consider to be the removal of their legal rights. Here, the representation has reached really staggering proportions. It has been said that a doctor has taken away from him his rights of appeal to the courts against unlawful dismissal. That is entirely untrue. A doctor will have exactly the same right of appeal to the courts against unlawful dismissal as any other citizen in the country. It has never been challenged during the whole of my negotiations with the representatives of the profession. They have never been able to show any part of the Act which takes away from the doctors those legal rights. But some of them want to go further than that. They want to have the right of appeal to the courts against dismissal from the service on the ground of misconduct or neglect. I want the House fully to appreciate the significance of what is being asked. It is perfectly competent to go to the courts against a Minister on the ground that he has unlawfully removed any doctor from the Service. That remains. It is an entirely different matter if they want to take the Minister—whoever he might be—to the courts on the ground that he has acted wisely or unwisely, because whether a Minister has acted wisely or unwisely is for this House to determine, not the courts. If a doctor has the right to go to the courts to ask the courts to arbitrate, not on the law, but on the merits, how can that right be denied to anybody else—to the teachers, to the railwaymen, the miners, everybody, in both public and private service? Under this reasoning, if there were this right to go to the courts of law, appealing not on the ground that the doctor has been unlawfully dismissed, but on the ground that he has been wrongfully dismissed in the terms of his contract, what would be the situation? The relationship of the judiciary to the legislature would be completely revolutionised. Day by day the courts would be arbitrating on a thousand and one matters on which they are utterly incompetent to judge. The courts are competent to judge the law and to construe the statutes; but the courts are not competent to say whether a foreman ought to get rid of a workman or a workman ought to dismiss an employer—because the converse is always the case, and under conditions of full employment it is as easy for the workman to dismiss the employer as for the employer to dismiss the workman. But if the B.M.A. had their way, if this queer constitutional doctrine were accepted, both would be tied together by an Act and with the courts. We should find ourselves in an entirely impossible situation. Therefore, we decided it was constitutionally impossible to give the doctors this concession. However, when the Act was being drawn up and the protection of the doctor being considered, I gave this point special attention. I would have the House realise that, under the existing National Health Insurance Act, protection for the doctor is merely an appeal to the Minister. It is only that. The local insurance committee reports the doctor to the Minister; the Minister makes an inquiry, and the doctor is upheld or removed. That is the existing situation. That was the situation as it was left by my predecessor. Mr. Willink, in his scheme, had left the position under the new Health Service exactly the same as it is now; but I, of my own volition, decided that that protection for the doctor was not sufficient, on the ground that the new Health Service would be universal and that removal from the Health Service of the future would carry heavier penalties than removal from the National Health Insurance Act scheme. So I decided to put a tribunal in between the local executive council and the Minister. The present position, therefore, is that, under the scheme the general practitioners are in contract with the local executive council, on which they have seven direct representatives—I emphasise, seven direct representatives—not appointed by the Minister, but elected by the doctors in the locality themselves. That is the first body to discuss the behaviour of a doctor. If, after examination, that body decide that a doctor ought to be removed, they report it to the Minister. At that stage the Minister can do nothing. All he can do is to refer it to this tribunal, the chairman of which is appointed by the Lord Chancellor, and on which there is another doctor and a layman. If that tribunal decides that the doctor should be retained, the Minister can do nothing at all about it, and the doctor is retained. The Minister is brought into the picture only where the doctor himself invokes the Minister against the decision of the tribunal. The Minister can then order another inquiry, public or private, as the doctor requires, with witnesses if need be, and with all the apparatus of full investigation; and the Minister can then decide whether or not the contention of the doctor should be upheld. There is no professional body in Great Britain or the world where more protection exists than that. The fact is, I am myself beginning to wonder whether the public is sufficiently protected under machinery of that sort. Certainly no doctor could claim that he is not adequately protected in those circumstances. Let me ask this question, which I hope the doctors will read tomorrow: what would be the consequence of the sort of protection for which their so-called spokesmen are asking? Compare it with this. Suppose that we did find it constitutionally practicable—which we do not—to give the doctor the right of appeal to the courts in these circumstances. Consider what a weapon of tyranny that would put in the hands of the Minister. Because remember, not only would the doctor have the right of appeal to the courts, but the Minister, being responsible to the House, would himself have the right of appeal to the courts for the removal of a doctor. In such circumstances any Minister would have very considerable powers of intimidation over the doctor, because he could take a doctor to the courts, force the man to undergo all the odium of publicity, to have his conduct examined, newspapers reporting it, all the circumstances of the case revealed to everybody, and his professional reputation besmirched. The fact is that, if the medical profession could be given what they are demanding, then in six months' time they would be cursing the people who asked for it. In fact, in this matter lay people like ourselves have acted with a far greater sense of responsibility in protecting the doctor than their own professional representatives. Those are the main facts on which the doctors are at present making their complaint.
Mr. Paget (Northampton)
There has been great misrepresentation on this. Is the position that a doctor can bring an action for wrongful dismissal, precisely as any other citizen can, and that everything in the Act is additional protection, enjoyed by the doctor but by nobody else?
Yes, that is absolutely correct. In fact, the doctor can go to the courts, as I understand it—my right hon. Friend the Attorney-General sits beside me, and he can correct me or otherwise if he wishes—on the ground that this tribunal or the Minister has not carried out the statute, or has prejudiced the case by the way in which it has been handled by the tribunal, or otherwise. There is adequate protection at every stage.These are the four main grounds upon which the doctors have been alleging their opposition to entrance into the service. I apologise for keeping the House so long, but this is a matter of very great importance, and I am desperately anxious to get the medical profession into the scheme, enthusiastically and harmoniously, and I deplore the atmosphere which has been created in the last six months. I would point out to the House that so anxious was I not to take part in these polemics, that I made no public speech of any sort until the meetings in January, when the B.M.A. decided to reject the Act. Although, for between six months and a year, meetings have been held all over the country and the most extravagant things have been said, I nevertheless took the view that it would be better for me to say nothing at all at that stage, or I might have added to the acrimony rather than reduced it. Therefore, I made no statements of any sort. It may be that the mis-education of the doctors is partly my responsibility, and that if I had not left their education solely to those who are supposed to speak on their behalf, they might now know a little more than they do about the Act. It may be said by the right hon. Gentleman the Member for Saffron Walden (Mr. R. A. Butler), when he replies, more in sorrow than in anger, "Well, now, cannot we get together? Is it not possible, at this late hour, for some concession to be made to assuage the high feeling and try to bring about greater harmony between the Government and the doctors?" The Opposition might want to put themselves into the position of "honest broker"—a position, historically, very difficult for them to occupy; but it might appear to them to be congenial in these circumstances to take up that position. But, that would be to assume that there have been no concessions made to the medical profession, and that we should start oft once more negotiating and making concessions. I want to point out to hon. Members in all parts of the House that these negotiations have been a long series of concessions from us, and none from the medical profession—not a single one. Indeed, one Member of the Negotiating Committee boasted that during these negotiations they had not yielded a single inch. Consider what we have done. Consider the long record of concessions we have made. First of all, in the hospital services we have accorded paid bed blocks to specialists, where they are able to charge private fees. [HON. MEMBERS: "Shame."] We have accorded, in addition to those fees for those beds which will have a ceiling, a limited number of beds in the hospitals where there is no ceiling at all. [HON. MEMBERS: "Why?"] I agree at once that these are very serious things, and that, unless properly controlled, we can have a two-tier system in which it will be thought that members of the general public will be having worse treatment than those who are able to pay. That is a very grave danger, and it is a very serious and substantial concession made to the medical profession. We have also conceded that general practitioners and specialists can have private patients. That was repugnant to many of my hon. Friends. They hated it, because they said at once that we can have, if we are not careful, a revival of the old Poor Law system, under which the man who does not pay, does not get the same treatment as the man who does. This kind of propaganda contains the possibility of developing that atmosphere. I would warn hon. Members opposite that it is not only the British working class, the lower income groups, which stands to benefit by a free health service. Consider very seriously the tradition of the professional classes. Consider that social class which is called the "middle class." Their entrance into the scheme, and their having a free doctor and a free hospital service, is emancipation for many of them. There is nothing that destroys the family budget of the professional worker more than heavy hospital bills and doctors' bills. There is no doubt about that at all, and if hon. Members do not know it, they are really living in another world. I know of middle-class families who are mortgaging their future and their children's future because of heavy surgeons' bills and doctors' bills. Therefore, it is absolutely vital, not only for the physical good health of the community, but in the interests of all social groups, that they should all be put in the system on 1st July and that there should not be some in and some out of the scheme. That is why I deplore the letter today in "The Times" from a distinguished orthopaedist, who talked about private practice as though it should be the glory of the profession. What should be the glory of the profession is that a doctor should be able to meet his patients with no financial anxiety. I now come to the Amendment on the Paper, and may I say at once that the Government are prepared to add the Amendment to this Motion? I think that the language of the Amendment reflects the political sagacity of the Opposition. They are not anxious to enter the tilting yard led by such doubtful leaders as the B.M.A. They wish to avoid the tourney, and are prepared to stand on one side and gather up whatever spoils may come to them. If hon. Members look at the Amendment, they will see that it is one to which all Members of the House can subscribe. It:
Who disagrees with that? A more innocuous collection of bromides I have never heard of or seen."declines to prejudice in any way the right of individuals in all the professions concerned to express their opinions freely, according to their traditions, and in the interest of their patients, upon the terms and conditions of service under the proposed National Health Scheme."
Sir Arthur Salter (Oxford University)
Would the right hon. Gentleman add reality to the wise decision he has just announced, by modifying the remarks he made the other day as to the absence of security in the ballot?
Why? Surely it is the accepted democratic practice that when people are asked to give votes affecting their professional future and their employment in or outside the State's service, they should do it secretly, without their names being disclosed.
Sir A. Salter
Do not the present arrangements assure secrecy as far as is compatible with notifying the authenticity of the vote? Is it not ridiculous to imply that there is intimidation of the kind to end which secrecy in the electoral ballot was introduced?
This is a complete digression from the argument I was making and to which I am anxious to return. The sting in the Amendment is, of course, that it leaves out the last part of the Motion. If Members opposite think there is anything in the Act which interferes with the freedom of choice, they should say so; we should hear it. If they think there is anything in the Act, scheme, or terms of remuneration, which prejudices the doctor-patient relationship, we should hear it. So far, we have not. We do not object, and never have objected, to the doctors expressing their opinions freely; we do not object to the B.M.A. recommending their doctors not to take service under this scheme. What we do take serious objection to is to organised sabotage of an Act of Parliament. We desire to know from the Opposition whether they support that. Do they support the B.M.A. organising resistance on 5th July, because I would warn them that the beginning of that road might look very pleasant but the end would be exceedingly unpleasant, not only for us but for Members opposite. [An HON. MEMBER: "Is that a threat?"] It must be clear to everybody that if there is one thing we must assert, it is the sovereignty of Parliament over any section of the community. We have not yet made B.M.A. House into another revising Chamber. We have never accepted the position that this House can be dictated to by any section of the community.We do concur in the right of any section of the community to try to persuade the House of Commons to change its mind. That is perfectly sound. The position we are taking up is that the B.M.A. have exceeded their just consti- tutional limitations, and that the best thing they can do now is to put on record their opinion that while they may disagree with the Act in this or that particular, or in general if they wish, nevertheless, they will loyally accept the decision of Parliament and continue to agitate for such revisions as they think proper. That is the right position for any section of the community to take up. May I say this in conclusion? I think it is a sad reflection that this great Act, to which every party has made its contribution, in which every section of the community is vitally interested, should have so stormy a birth. I should have thought, and we all hoped, that the possibilities contained in this Act would have excited the medical profession, that they would have realised that we are setting their feet on a new path entirely, that we ought to take pride in the fact that, despite our financial and economic anxieties, we are still able to do the most civilised thing in the world—put the welfare of the sick in front of every other consideration. I, therefore, deplore the fact that the best elements in the profession have been thrust on one side by the medical politicians, who are not really concerned about the welfare of the people or of their own profession, but are seeking to fish in these troubled waters. I hope the House will not hesitate to tell the British Medical Association that we look forward to this Act starting on 5th July, and that we expect the medical profession to take their proper part in it because we are satisfied that there is nothing in it that any doctor should be otherwise than proud to acknowledge.
Mr. R. A. Butler (Saffron Walden)
One never thought that the Minister of Health was possessed of a bedside manner, and on this occasion I am sure we have not been disappointed. He has certainly done nothing in his speech, so far as I can see, to make a settlement of this dispute any more likely, with the possible exception of one small concession, which he should have made long ago, on the subject of medical partnerships and the setting up of a legal committee. From my intensive study of this subject, so far as I can see, that is the only advance which the right hon. Gentleman, has made towards meeting the legitimate views of the medical profession as a whole.The right hon. Gentleman has imported into the argument such words as "squalid political conspiracy," and has done so deliberately because he knows that it is in the waters of squalid politics that he most enjoys himself. In the recent Debate on Welsh Affairs I made some remarks about the Welsh being introverted, and I am glad to see that the seeds I sowed there have come out so soon in the speech of the right hon. Gentleman. He has shown, for about the first time in his political career, that he has examined his own conscience. He has every reason to do so in view of the inept manner in which he has managed this controversy. It is not my desire to discuss on this occasion, issues which are purely political. And may I say that neither I, personally, nor my right hon. and hon. Friends are acting for any association, or any group of people, or for any interest whatsoever. I can honestly say that in my case I have had no direct connection whatever with any such interest or association. I am asked on behalf of those of us on this side of the House to express our profound convictions on certain general principles, and to discuss one general issue, which I shall name at the outset. It is this: How to reconcile the individual conscience and conviction of the doctors as to the manner in which they feel able to conduct their professional duties, with the needs of a National Health Service which, I believe, the vast majority of the doctors wish to serve. That is the general issue. It is not a case of a
words I take from "The Times" newspaper, nor is it a wrangle between the Minister and some "raucous-voiced people," to use his complimentary term applied to prominent members of the medical profession, nor is it simply a controversy between the Minister and the doctors as such. The field we are discussing today is far wider, far more extended and far more serious than one may have imagined from the Minister's speech. The dentists, for example, are far from satisfied, judging from today's newspapers, with the attitude of the Minister himself. The dentists have said in today's Press that"private wrangle between the Minister and a score of elderly doctors,"
which they later describe as a "utility service." Further than that, we have been inundated with requests, not only from dentists and doctors, but also from the optical profession, who have asked me to ask the Minister why no complete terms of service have yet been communicated to them, since their anxieties are rising. The field, therefore, is an extremely wide one."Until the Minister retracts from his inflexible and intransigent attitude, the dental profession will exercise its right to refuse to enter the service."
May I interrupt the right hon. Gentleman at once? The Spens Committee has been appointed with the approval and co-operation of the dental profession; another Spens Committee is sitting on the matter of specialists, and the reason why the dentists object is on the old ground that they want more money.
The right hon. Gentleman has said nothing about the optical profession.
The ophthalmic opticians are perfectly satisfied with the conditions of the scheme.
That is not the opinion which has been most sincerely sent to me. It is no use the right hon. Gentleman trying to ride me off on a reference to the Spens Committee about the dentists. I have quoted the last statement of the dentists today, which backs up recent statements of the dentists, that they are dissatisfied with the scheme as a whole and are not worried only about the terms of remuneration.The right hon. Gentleman, with his dialectical and debating skill which is second to none in this House, to which we are always perfectly ready to pay a tribute and to which it is a pleasure to listen, has made fun about the terms of our Amendment, but, as he rightly said, the sting of the Amendment is in the proposal to leave out part of the Motion. The point of the Amendment is, first, that this Debate shall not be used as a means of intimidating the doctors in the middle of their voting and that the doctors shall, in fact, be given an opportunity to express their views freely. That is the main object of the Amendment, and, in the second place, it is our view that the Minister's words:
are not in accord with the traditional freedom and dignity of those professions. Therefore, we have felt obliged to leave out that portion of the Minister's Motion, and to insert what we thought was a safeguard for the doctors during the period of their voting and expressing their opinions, which they are freely allowed to do under the Act. We do not quarrel with the word "generous." I want to dispose of a particular argument which is in currency in the country. I do not believe that the terms, that is the financial terms, are what is really at stake in this controversy. I do not believe that is the main issue. I am glad that the Minister did not make it the main issue either. We should certainly not wish to be less generous ourselves had we the responsibility of introducing the scheme. I speak on behalf of my right hon. and hon. Friends. I should like to make quite clear, not only to the Minister, but to other protagonists in this dispute in the country, that if the doctors come into the scheme that will not be due solely to money inducements; and if they stay out, it will be due to conscience. That is a matter upon which I wish to speak. We agree, and everyone must agree who is interested in the National Health Scheme, that the doctors are a vital element in that scheme. In fact, the Minister has said, and others have said with him, that it is impossible to see how the scheme will operate without the doctors. We accept at once what the Minister has said about the middle-class. We have worked, on our side of the House, for the introduction of the health scheme. I myself took part in the Committee which helped to draft the scheme, with the Prime Minister and others, in the time of the Coalition Government. I regard it—and I am sure my right hon. Friends and hon. Friends on this side regard it—as part of the new social mosaic which involves the educational scheme, the insurance scheme, the workmen's compensation scheme and many other features and characteristics of the new social order which we are all trying to build. We have consistently held the view that such a scheme cannot be operated without the willing co-operation of the doctors, dentists and others involved. I had the experience of bringing in a great reform in the shape of the Education Act. There, if I may say so, we approached matters in rather a different spirit from that which the Minister has adopted. We attempted by endless and patient negotiation to achieve the cooperation of those whom we described as "partners in common enterprise," so that when we came to this House we were able to present a scheme which was according to the interest and traditions of these partners, in particular the teachers, the denominations and the local authorities. I maintain that had we desired to conduct our negotiations by the method of thunder and lighting, and by the method of public controversy, there would have been no opportunity of reaching a settlement. The Minister himself is misleading the country, because we are now approaching a situation where the date for the introduction of the scheme is drawing near, and he has not yet secured the co-operation of the great medical profession and the health services. The Minister has said in the past, and in a letter of 6th January, 1947, to the three presidents of the Colleges he expressly confirmed that,"the conditions under which all the professions concerned are invited to participate,"
That is precisely what the doctors are now doing, and what we claim they must be allowed to do; and we do not think that any language used by the Minister today is appropriate in the circumstances, when not only has he said that they are free to state their opinions, but the Act lays that down. Our astonishment is that things have been allowed to drift so far. That seems to us another example of the irresponsible and incompetent administration which we associate with the present Government. We have seen them try to introduce too much altogether, without having their plans properly laid. The position now—we must frankly tell the country from this side of the House—is that the health service is in grave danger. I regard that as being essentially at the door of the Minister of Health. I sometimes read—it is not my sole diet—the "Daily Mirror." I noticed on Thursday, 5th February, a particularly well-arranged and well-ordered answer to 20 questions asked in reply to a voluminous correspondence sent to that paper from all over the country. These answers are really pathetic in their intimacy and detail, showing the nature of the service which people are expecting on 5th July, ranging from better midwifery services, free dentures, problems to do with epileptics and problems to do with those in institutions, and so forth. I have noticed in Government Bills now passing through this House—for example, the Criminal Justice Bill—provisions for the payment of expenses for mental examination or treatment by doctors under the National Health Service. I have noticed similar provisions in the National Assistance Bill. Therefore, the whole stage is ready and set for this reform, and the only person so far as I can see who is unready and unset is the Minister who is responsible."Every doctor will have to decide for himself when the proper time comes whether or not he should take part in the new service, and the profession as a whole will be free to determine their views on the service when they know what it is to be."
Mr. Kirkwood (Dumbarton Burghs)
Who is playing dirty politics now?
As I said earlier, I did not think that the situation had been improved by the Minister's speech. I want now to deal with his main point, which is that of the sovereignty of Parliament. In a speech at Pontypridd the Minister referred to the will of Parliament. He said:
Does the Minister—he is a prominent dialectician—consider that the doctors are sabotaging Parliament by expressing their opinion? Why does he say deliberately that the doctors are flouting it by their actions—[Interruption]. Perhaps the right hon. Gentleman would like to express his opinion?"Parliament has spoken; the country now awaits and expects the co-operation of the medical world."
The right hon. Gentleman is making his speech with even fewer scruples than usual. I never said that the doctors were sabotaging an Act of Parliament by expressing their opinions. I did not say "the doctors" at all. I said that the B.M.A. were sabotaging the Bill by encouraging doctors not to enter the Service. I said that they were organising collective sabotage of an Act, that they were actually organising collective abstention from participating in the Act, and that is sabotage.
I gave the right hon. Gentleman a chance to explain himself, but when he comes to the Box in answer to an opportunity to interrupt and says that it is collective sabotage of Parliament, that is a much stronger term than I used. We have from the Minister his statement that the doctors are indulging in collective sabotage of the Act. [Interruption.] That is what he said. Why then does he put specifically in his Act an opportunity to the doctors to state their opinions, because he must know that unless he obtains the cooperation of the doctors the scheme will not work? The Minister cannot escape by dialectics. My conclusion is inevitably that the only escape is by agreement.The Chancellor of the Exchequer, mobilised in support of the right hon. Gentleman—but, I rather imagine, not running the right hon. Gentleman as he runs so many other Members of the Government—has made a speech in the North of England in which he said:
What are the decisions of the nation? The decisions of the nation are that there shall be a National Health Scheme and that doctors shall be free to come in. That is specifically in the Act. Whether I take the words of the right hon. Gentleman or the words of the Chancellor of the Exchequer, I am driven to the only conclusion to which one can possibly come in this dispute—which I am as anxious as anybody else to try to solve—that doctors must agree to the terms and conditions and the Act gives them the opportunity to do so. The Chancellor of the Exchequer proceeded to say:"There are certain groups of people who seem to think that their own interests and opinions ought to overrule the decisions of the nation."
My answer to that will perhaps answer some of the growls I heard on the other side of the House when I ventured to hit the Minister in the way in which he ought to be hit. My answer is that the doctors will suffer most whatever happens in this controversy, because I do not believe— and I can only speak on the authority of what I have read in the newspapers, but I believe it to be the case—that the doctors will withhold their work or their labour. I believe they intend to go on working, and as far as I can see with the introduction of the National Health Scheme they will either have to work for nothing or accept payment which they may find it very difficult to get in view of the extra 10d. that the public will be paying on their new stamps if the scheme is brought into being in the present imbroglio. [Interruption.] I am not trying to give a lever to the doctors to make the situation worse. I am pointing out, in answer to the growls from the other side of the House, that I believe the doctors will suffer as much as the general public, if not more, if the breakdown goes on, because I do not believe any doctor of my acquaintance will withdraw the healing art however difficult his situation is politically or economically. Perhaps therefore my hon. Friends—if I may call them so—in various parts of the House will listen to various observations I want to make which may lead a way out of the impasse into which we have been so very badly and unwisely led. The Minister taunted me with trying to be an honest broker. I think he was trying to prepare the way so as to prejudice my remarks ahead, but, with my knowledge of the Minister, I do not intend to pay the slightest attention to that part of his dialectics. He said in the earlier part of his remarks that issues of principle should not be vulgarly personalised. The right hon. Gentleman has reached his present eminence by the estimable arts of vulgarising and personalising every principle with which he has dealt. I am not, therefore, to be misled by the herrings he trails across my path, and I will attempt now the odious task which he said I ought not to undertake. There are two principles upon which the doctors appear to me to rest their case. The first is that a doctor must he free to practise the art and service of medicine according to his high traditional standards, with full access to modern knowledge in all its new power with all the new drugs with which we have to deal, with due responsibility and with personal care of his patient and association with his patient, the freedom of professional judgment, speech and action, and also writing and publishing. Here I would like to refer to two answers given by the right hon. Gentleman to the hon. and gallant Member for Pudsey and Otley (Colonel Stoddart-Scott) on the subject of free publishing, to thank him for those answers, and to say that I hope those represent his final word, namely, that under the new scheme a doctor will be able to write and publish what he likes, without any inhibition whatever, in the scientific and other journals which the doctor desires. I hope that is the case. [Interruption.] The right hon. Gentleman confirms that that is the case."If some workers were to refuse to work because they did not like certain legislation that was passed, what could the doctors say in objection?"
Why should I have to confirm it? The right hon. Gentleman, first of all, cast doubt. There never was any doubt whatsoever. In fact, the right hon. Gentleman is leaving a trail of slime behind him.
My answer to that is that I particularly wish, at the request of several of my doctor friends, to obtain an assurance from the Minister and I am therefore greatly obliged to the right hon. Gentleman for dotting the "i's" and crossing the "t's" on that particular point.The second main point is that it is contrary to the interests of the community that the service of medicine should become directly or indirectly a full-time service of the State. It is under one or other of those two heads that the main points in the doctor's case fall. The first point, which was referred to by the right hon. Gentleman, is that of the basic salary. The Minister said that there was a case for basic salaries for young doctors. Then he went on to say that people who did not need the basic salary could give it back to the Chancellor of the Exchequer, who would be glad to have it. As I see the position of the doctors, their real anxiety is that the Minister has power, under regulations, to extend this basic salary and to make it eventually the main feature of the service. That is the real fear of the doctors—perhaps we shall have a rather better interruption from the Minister.
That is a power which has existed since 1911. It exists under the new Act no more than under the old Act.
I am trying at this stage—[Laughter.] The right hon. Gentleman need not laugh. I hope we can remove the anxiety of the doctors. That is the object of this portion of my remarks, and those remarks are judiciously interlarded with questions to the right hon. Gentleman in the hope of making some progress in this controversy. If that which the right hon. Gentleman has stated is the case, can he, by following up this intervention in the course of my remarks, make it perfectly clear to the medical profession that it is not the intention of the Government to extend this basic salary so that the members of the profession become, in fact, civil servants? What they are alarmed about is a little remark of the Minister's made on 2nd May, 1946, on the subject of the basic salary:
That remark, read with the Labour Party resolution passed at their conference in 1943, that the Labour Party believe in a full-time State salaried service for medicine, has created among the doctors a considerable amount of despondency and alarm. My own view is that if that threat were removed, the doctors might view this matter with less passion. The Minister said during the Committee stage that he desired an element of basic salary. Can he follow up the intervention which occurred in the course of his own speech this afternoon and introduce such an element which is not susceptible of indefinite expansion, thus making the service into a salaried State service? Can he use the basic salary for assistance in cases where it is necessary and not use it in such a way that it will become a uniform basic State salary? If the Minister cannot do that, I have done my best—
"There is all the difference in the world between plucking fruit when it is ripe and plucking it when it is green."—[OFFTCIAL REPORT, 2nd May, 1946; Vol. 442, C. 392.]
Is the right hon. Gentleman asking that question as a rhetorical one or a real one?
Does the right hon. Gentleman, if I may take up his own language, wish to insult me? It was a perfectly genuine question.
The epithet or description "rhetorical" is not offensive. It was merely meant to discover whether the right hon. Gentleman was asking the question for the purpose of continuing his speech or for the purpose of obtaining a reply. If he wishes to have a reply, I am ready to give it. I said upon the Second Reading that it was the intention of the Government to pay the general practitioner mainly by way of capitation and the rest by a small element of basic salary. I repeated that on the Committee stage and I repeat it now. In the course of my speech I specifically made reference to the fact that I rejected the proposal of the right hon. Gentleman's own Minister for a full-time salaried service. There is no intention of extending it to make it a full-time salary.
That is so far so good. I maintain that the Minister will have to go further still if he is to allay the apprehension of the medical profession. He will have to remove the general basic element in all salaries if he is to overcome the general anxiety among doctors. [HON. MEMBERS: "Why?"] It is legitimate to mention that the anxiety that there shall not be a State salaried service is at the basis of the doctors' fears. The doctor fears that if his status is changed from that of a personality dealing with another human personality as his patient, into that of a civil servant, who in the words of Doctor F. M. Walshe,
then his whole position in practising the art of medicine will have been undermined."stands in a fugitive and impersonal relationship to individuals,"
Mrs. Leah Manning (Epping)
How does the right hon. Gentleman tie up that part of his argument with his general views about teachers? Are teachers not personalities dealing with personalities?
That gives me an opportunity of dealing with a matter with which I did not wish to trouble the House. When I was dealing with the Education Act it came to my notice that in the autobiography of Mr. H. A. L. Fisher he said he had considered whether to make the teachers civil servants or not and that he had definitely decided against it. I reviewed the position when I was Minister, and I came to the firm and definite conviction—and I think this is why I achieved the support of all the teachers in the country—that they should not be civil servants and that they should be free of the Civil Service, and free to occupy their position.The Minister is trying to catch me upon a dialectical point. I will answer him, since I have also done some debating before. It is not the basic salary which, I believe, is causing alarm to the medical profession, but the fact that it may be extended and that members of the medical profession may thus, by that door, be brought into the position of being members of a State service. That is the whole point. If the Minister can allay that apprehension he will have gone one stage further. The main fear of "interference" covers the other three points with which I wish to deal. The question of interference with clinical liberty is one to which the dentists attach particular importance. I have not had an opportunity of seeing the regulations affecting the dentists, but I hope that the Minister, when those regulations are publishable or published, will see that there is no interference with the clinical liberty of the dentists. Secondly, the Minister did not refer to the power of negative direction. That is a point upon which the profession feels deeply. Steps ought to be taken to do away with direction. In the modern State service doctors will not, I believe, congregate in places like Bournemouth, but will tend to go to the more populous places where their capitation rates are greater and they will be able to get a better opportunity for practice. I, therefore, believe that direction will be unnecessary. The final question is that of appeal. I urge the Minister to think again about this matter of appeal, in which connection I think the Minister has a stronger case than in any other. There are improvements here upon the old National Health plan and I think that the profession as a whole realises that. I agree with the Minister that it would be very difficult to make a court of law decide upon matters which are, wisely or unwisely, done by a Minister. I also agree it would be very difficult for a court of law to decide upon the actual conditions within the service, because the court of law does not exist for that purpose. The Minister has set up this tribunal, and I believe that the fear of the doctors is that there is an ultimate political chief at the top. That may seem unreasonable to the Minister, but I want to ask him whether he could not leave his elaborate system of the tribunal there to decide these matters, and simply allow an appeal on fact to the courts from the tribunal and omit the Minister as the final authority; that is to say, on fact whether the different operations have been carried out in a fair way according to all the regulations laid down.
That would mean that the Minister would not actually come in as the final appeal. If the Minister would follow that line of thought, it would keep the Minister out of the picture; it would retain the tribunal as the ultimate authority and not the Minister himself. I am merely putting that forward because it would lead to a possible method of getting the two sides together.Those are the various points to which the profession attach importance, and I shall not press others, such as the sale of practices, which I regard as having been settled upstairs in the course of the previous discussions. I have simply mentioned the points I have indicated because in doing so one sees that there is very little that cannot be settled by good will, toleration and common sense. We want an approach rather broader than the party approach. You cannot nationalise conscience; it is no good trying to do so, and it is no good the Minister thinking that he can get agreement unless he can get the confidence of the profession. The burden of my remarks this afternoon has been that it is intensely important that the Health Scheme should work by agreement and not by coercion. It is my view that the doctors can be gained, and I think that an extra effort should be made to meet their basic anxieties. Health is not a matter for triumph on one side or the other, either personal or party. What is wanted, in the words of another place, is a victory of common sense. We hope and pray that the spirit of the Act may be carried out. I have indicated, I hope fairly, that I do not think it will be the public who will suffer as much as the doctors if this impasse continues. I trust that after this controversy is over, if the Government bring to it a little more toleration, a little more patience and a little more common sense, that the doctors will be able still to take their traditional oath, they will be able to say, "I will follow that system or regime which, according to my ability and judgment, I consider for the benefit of my patients," that the traditions of 2,000 years will be able to go on, and that the art and practice of healing may be practised not by helots of the State, but by free men serving the interests of the State.
Dr. Santo Jeger (St. Pancras, South-East)
I want to address this House as one who has been a general practitioner for 23 years previous to becoming a Member of this august assembly, and I want to start by saying a few words on the buying and selling of practices, despite the fact that the right hon. Gentleman announced that he did not intend to discuss the question. Somewhere about 1943 or 1944 the B.M.A. itself set up what it called a Medical Planning Commission composed not only of members of the British Medical Association but of members of the medical profession outside. This Medical Planning Commission reported against the purchase and sale of practices, and the B.M.A. subsequently set up their own committee to discuss this question. They knew, of course, that the custom was at least open to criticism, but were not prepared to come to a definite decision. There was on this committee a gentleman of the name of Dr. Wand. He was appropriately named because he proposed to carry out a miracle. He suggested that there should be for doctors a kind of perpetual mortgage of their practices, a sort of Marshall Plan in embryo. Doctors were to receive, when they wished to purchase practices, a perpetual loan; they were not to repay the loan but only the interest. The B.M.A., for some reason best known to themselves, turned down this plan, and so we still had the position that the British Medical Association were determined to go on supporting the purchase and sale of practices.When a young doctor wants to acquire a practice, he has to raise the purchase money for it, and in order to get his loan, which he may get from a bank, from a moneylender or from an insurance company, he has to insure his life, and to enter into certain undertakings, which may go on for a very long period, for repayment of principal and interest. In the present circumstances of the high cost of living and high taxation level, a doctor who undertook these serious obligations, a young man entering upon his life career, would find that he had no margin to spare. Therefore, it is becoming increasingly difficult for doctors to buy practices when they have no means of their own. Further, there are quite a lot of uninsurable doctors. I am acquainted with one who has a tuberculosis joint. His tuberculosis is pretty well healed up, the joint is no longer actively diseased, but this man is condemned to locums and assistantships all his life because no insurance company will accept him as an insurable life. He is only one of a large number. Let me say a few words about direction. Doctors complain of negative direction to which they would be subject under this Act, but the right hon. Member for Saffron Walden (Mr. R. A. Butler) said he was quite certain that doctors would not congregate in areas like Bournemouth but in more closely packed areas of population where the capitation fee would be somewhat higher. If that be the case, then why all the fuss about direction? In those circumstances there would be no direction, but is there no direction of the doctor searching for a living under present conditions? Today he applies for a job, for an assistantship or a locum where these jobs are available. He reads the advertisements in the columns of the "British Medical Journal" or the "Lancet," he goes on a tramp through London to the various agencies—I know he does these things because I did them myself—and he goes where there is a vacancy. When, having acquired some experience and perhaps having also the possibility of obtaining some money, he wants to buy a practice, he again goes to the agencies, studies the columns of the medical journals, and again goes where there is a vacancy. That is all this Act is doing in the way of direction—it is sending a doctor to the place where there is a vacancy. It is a pure accident where a casual vacancy will take place under the Measure, just as it is a pure accident where a casual vacancy will take place today A great deal has been made of the doctor-patient relationship. I have studied this question as closely as I can, but for the life of me I have never been able to see how this Measure will interfere in any way with the relationship between a doctor and his patient. Indeed, if there were any interference, I would be the very first to object. The doctor's responsibility for his patients and to his patients will be no less under this Measure than in the years preceding the passing of the Act. The Minister is not interfering one scrap in this matter. He is not sending a snooper into every consulting room in the country to see whether the doctor is subordinating the interests of the State to those of his patient. That is not the purpose of the Measure at all. There is no interference whatever between a doctor's responsibility for his patient and his responsibility to his conscience and to the ethics of his own profession. The circumstances of medical practice are likely to improve steadily in the future, both for the doctor and for the patient. In the new service the doctor will get much greater representation on his own local executive committees than he has ever had previously in the administration of medical work. We have heard a great deal on the subject of basic salaries. How true is it that fixed salaries, or fixed wages, lead to neglect or careless or inefficient work? There have been a very large number of doctors working in many branches of the public service for fixed salaries and no one has dared to say that they worked any worse on that account. It may be true of some people, not only in the medical profession, but in all walks of life, to say that they dislike their work and live only to draw their pay; but most men work better if they are free from financial worry and in so far as this Measure frees the doctor from financial worry, I support it wholeheartedly. I have a much higher opinion of my own profession than to think that the principles it puts forward to the Minister or in its propaganda are based on the freedom to mulct a sick man who is already embarrassed by illness. I wish to add my support to any kind of plan which will save the doctor and the patient from that kind of situation. I confess that I would have liked a full-time salaried service, but, as we cannot have that, I am prepared to take the next best thing, which is a basic salary. I think the case can be made out for a basic salary by pointing out how it can be supplemented by special experience, or work in distasteful conditions and unpleasant areas. The Minister has pointed out that the service is flexible. It must be flexible; it must provide for a periodic revision, to fit the ever-changing environment; it must allow of immediate modification when necessary. Never before has such full consultation been carried out with those affected as there has been with the medical profession today with so wide an exploration of alternatives. I do not see what the medical profession have to grumble about. Reference has been made to the courts, and the British Medical Association have made a great deal of play with this point about courts. I was glad to hear the right hon. Member for Saffron Walden, who spoke for the Opposition, say that he thought in this case the Minister was right. Now I can much better understand the B.M.A.'s love for asserting its right to engage in litigation in the courts, because I have recently received a threat of legal action in the courts for being one of those who wrote a letter to the Press concerning this controversy, People who appeal to the courts too often, and people who threaten to appeal to the courts too frequently, do not always get the sort of result that they expect, and the Minister has pointed out, very rightly, to what danger the doctor exposes himself when he demands this right of appeal to the courts, which he says the Minister has refused him. I listened with great care to the speech made by the right hon. Member for Saffron Walden and, except for the last 10 minutes, it appeared to me to contain no argument whatever, but to be a mere tirade of abuse. That is not the sort of way in which an important question like this should be considered in this House. I felt that the Minister made out a case which is unanswerable, and that the right hon. Gentleman who spoke for the Opposition took the line, "I have no case, I will therefore abuse plaintiff's attorney." I hope that reason will now prevail in this question, that we shall have the word of Parliament accepted by the constituent bodies in the community, and that the doctors will decide that they will help to build what we all want—the best possible National Health Service we can construct.
Mr. Frank Byers (Dorset, Northern)
I would like to begin by agreeing with the hon. Member for South-East St. Pancras (Dr. Jeger) that I hope reason and good will will now prevail, because, from my point of view, I feel it is not so much the details of this dispute that matter, as the fact that the presence of the dispute itself might jeopardise the efficient working of a National Health Service, to which many millions of us have been looking forward for so many years.The question has been raised whether this Debate should have taken place while the plebiscite was being held. My view is that this Debate should have taken place two or three weeks ago. I have never seen a situation in which so much obscurity required clarifying. I do not believe the average doctor understands the situation yet. I do not think the speech of the right hon. Member for Saffron Walden (Mr. R. A. Butler) is going to help it much. The fact is that the doctors are voting blindly, and they have been grossly misled, and badly led, by that small clique in the B.M.A. I do not expect to get the doctors' votes by making a remark like that, but I will tell the House why I think it is true. A fortnight ago I was very nearly taken in by the doctors' case. I began to believe that it was really a substantial case. I went into it with great care, and I propose to tell the House the conclusions to which I came bringing, I hope, an impartial mind to bear on the matter. The Amendment which is down on the Order Paper in the name of the Conservative Party, strikes me as being utterly puerile. It is about time the Conservative Party made up their minds where they stood in this matter, or in any other matter. They cannot remain suspended between the Dark Ages and the "Industrial Charter." We want to know exactly where they do stand. Do they look at these things impartially? I will try to do so. Having looked at it impartially, I cannot absolve the Minister completely from blame. I think he might have been a little more tactful. But, when I heard that he consulted with the Negotiating Committee on eight different occasions, and that 28 times his officials met the B.M.A., I thought we must appreciate the exasperation which the frustration of meeting the B.M.A. must lead to. The Minister would have been well advised to make more public utterances in order to show to the average doctors exactly what the truth was in order to counter the misrepresentations which have been made by the, leaders of the B.M.A. They say that it is a matter of freedom. If it were, we should be the first people to be challenging the Government upon it. I do not believe it is a matter of freedom at all. When we are talking about freedom let us think about the freedom of the poor people who have been denied proper medical attention for years. Freedom can often be one-sided. Having looked at some of the propaganda put out by the B.M.A., I consider that there is no question that much of it is a direct challenge to the Act itself, and Members of Parliament in all parties must resist that. The time to challenge legislation is when it is going through the House of Commons and the House of Lords, but once a Measure has been passed it is the duty of every democrat to accept it. Work to bring influence to bear to change it, certainly; change the Government, if necessary. But the suggestion that there will be a sort of resistance movement to prevent the Act working at all, seems to me to be a totally undemocratic argument which cannot be sustained. I have disagreed with many Bills which have been introduced in this House, I disagree with certain features of the National Health Service Act, but it is our duty to make them work, and if necessary to change the Government so that we can introduce other Measures. Let us consider for a moment, as other speakers have done, the main arguments in this Debate. The sale and purchase of practices is and must be regarded as a complete anachronism. I cannot believe that any progressive person can really believe in the continuation of the purchase and sale of practices. And what about the young doctor? Who really wants to retain the sale and purchase of practices? I cannot believe it is the young doctor who will be faced with a burden of borrowing money or of not getting the practice he wants. It is also impossible, in a National Health Service, to admit the principle that practices built up out of public money can be sold. I cannot see how anyone can argue on those lines. It seems to me to be totally impractical to hold that view.
Mr. David Renton (Huntingdon)
Would not the hon. Member agree that under National Health Insurance no fewer than 20 million patients are paying capitation fees and are allowed by the State to be attended by doctors whose practices are bought anti sold, even when it includes these patients?
That is correct, that is what is happening, but it is no argument for continuing it. We are to have a comprehensive national service with presumably about 95 per cent, of the people in the scheme. The fact that the sale and purchase of practices is happening now is no argument for preserving it, except to people of conservative tendencies.Let us turn to compensation. The doctors have already been assured that they will each get a share of the £66 million which has been agreed upon with medical representatives as a global sum to be payable on death or retirement, with interest in the meantime, and with provision that in cases of hardship, or, if the doctor wants to get out of the service, it can be paid immediately. Are these facts known to doctors in the country? They were not known by doctors to whom I have spoken. When I told them they said, "I do not believe it," yet it is there in writing. The matter has been totally misrepresented by the leaders of the B.M.A. We now get the suggestion that doctors should be compensated if they come into the scheme after the vesting date. How can that work? I cannot envisage the administration that would be involved, because if it were done, it would not be known how the sum was to be divided between the doctors. There has to be worked out first of all how many doctors are coming into the scheme, and there must be a date—it may be 5th July or next year—a point from which to calculate the number of doctors who will be entitled to share in the £66 million. If it is said that doctors can come in later, very well, but it will not be possible to pay out compensation to hardship cases until the date is settled. I do not think there is any substance in that argument which is put forward by the B.M.A. I am glad that the Minister has set in motion machinery to clear up the obscurity over partnership agreements. Doctors who had not seen the report of a case in the "Manchester Guardian" did not know the position six or seven days later. They are still writing to me. I got a letter this morning saying:
There was a statement about 10 days ago. Then there is the issue which has been raised of the direction of doctors. There is no positive direction in the Act. It merely preserves the right to prevent doctors from going to over-doctored areas, and the decision is not made by the Minister but by the Medical Practices Committee. That principle was put into the Liberal Party's "Health for the People" Report which was produced in 1942. The people who drew up that report were by no means Left-Wing Socialists. They included Sir John Stewart-Wallace and Lady Rhys Williams. They came to the conclusion that that was the best way of doing the thing. They stated:"Please raise the question of partnership obscurity."
They also pointed out that doctors wishing to change from one practice to another would be able to do so by applying for a vacancy, and that"Difficulties of allocation would be solved most easily by the ordinary system of advertising such as is normally used for appointments to hospital staffs or public organisations. The local authority computes the number of medical practitioners who will be required in the area, and then advertises in the usual manner."
That should be remembered. It is an important point against direction. I suggest that the claim made by the B.M.A. that a doctor should be allowed to practise anywhere he likes undermines one of the fundamental aims of the whole of the National Health Service. One of the reasons why we as Liberals have been pressing for a comprehensive National Health Service was because of the appalling conditions in the under-doctored areas. I would certainly not give in on that point. I want areas to be known which are under-doctored, and doctors should be attracted to them so that people there can get proper medical attention. So far as basic salary is concerned, no Liberal wants to see a State salaried medical service. If a doctor is to preserve his freedom, obviously the overwhelming proportion of his income must come from the capitation fee. Again, that was stated in this report produced in 1942 by an independent committee. We have shad a guarantee from the Minister that this will be so. A basic salary is really required for the young doctor starting his career and as a means of inducing other doctors to go into under-doctored areas. I am glad we have had this suggestion from the Minister that a doctor need not accept the salary. I have often thought that that might be the solution. It seems to me that it will be impossible to say that a salary can be allowed to the young doctor and as an inducement to other doctors, while at the same time provision is made for no basic salary for the others, because in that case there would have to be a higher capitation fee for them. I would ask hon. Members who are likely to talk glibly about this idea of the basic salary to remember, in the light of the assurance that has been given, that it will not be used as the main source of income, that the administration of a scheme which provided for a small basic salary for an undefined number of people, with varying capitation fees for the rest, would be totally unworkable, and the matter would have to come back to the House. So far as appeal to the courts is concerned, we, as Liberals, fought and lost that battle, and we accept that decision. I have gone into these things as carefully as I can, and I am not saying that people, even in my own party, will agree with me, but I have come to the conclusion that the doctors' right of appeal to the courts on points of law is fully safeguarded, the same as that of anybody else in this country. It is on questions of fact that the real issue should be challenged. I think the right hon. Member for Saffron Walden did not really know the difference between law and fact when he was making his speech. I suggest that the right of the doctor on a question of fact is fully safeguarded under the Act. He has a better protection, in my opinion, than any other profession, or any other type of worker in the country. So long as he can go to the courts over the questions of wrongful dismissal and unlawful termination of contract—which he can—I should have thought that, in the circumstances, the doctors would be well advised to accept the situation as it is. I have referred to good will. We have got to get this dispute settled. The Minister, I hope, will be prepared on his side to give and take. The B.M.A. have got to do the same. If one looks into this in an independent and impartial way, it appears that the initiative should be taken by the B.M.A. If it is not, then the doctors should get rid of the people in the B.M.A. and appoint a new committee to negotiate with the Minister. That is not a matter of party politics. I am no Socialist. I disagree with a great deal that the Government has done and intend to do; but in matters of social reform and health services I am with them the whole of the time. The problem in this Debate and this plebiscite is that people do not understand the issues involved. I suggest that the duty of the doctor now is to look at this thing from both sides and if he is not satisfied with his representatives, to get rid of them and appoint somebody who is prepared to negotiate and establish this service. I am convinced that there is very little substance in the case put by the B.M.A. The main thing is to get this service working in a spirit of good will, which means give and take on both sides. We have the time to do it and I am certain that we can and will do it."a National Health Service would remove the need to purchase a practice and to stay long enough in it to repay the money borrowed."
Dr. Stephen Taylor (Barnet)
The British Medical Association must indeed have been disappointed in the stand which the right hon. Member for Saffron Walden (Mr. R. A. Butler) made on their behalf. He advised them to drop their opposition to the sale and purchase of medical practices; he advised them to drop their demand for appeal to the courts; he advised them to accept the basic salary, at any rate in some cases, and even when it came to negative direction he did not seem to urge the case against negative direction with any real vigour.If ever there was a bewildered profession, it is our unfortunate medical profession. The British Medical Association spokesmen have spoken in passionate terms, but the burden of their message ranges from emotional condemnation of the whole Act to admissions that much of the Act is good, except for four or five essential details. Lord Horder tells us that the choice is between collectivism and individualism. At the same time, he accepts the principle of National Health Service. How he imagines one can have a National Health Service without some measure of collectivism is impossible to see. The "Lancet," which approximates to "The Times" or "Manchester Guardian," advised the doctors to acquiesce in the plebiscite. The "British Medical Journal" which is more in the nature of the "Daily Express" or "Daily Telegraph," urges them to vote "No, a thousand times no." If the average doctor has time to read either or both of those publications he would be in a much better position to make up his mind than he is. If one goes into a doctor's surgery one sees a pile or pyramid of unopened copies of the British Medical Journal which he has not had time to look at. When doctors speak about becoming civil servants they speak in all sincerity, but in complete ignorance that the Act specifically provides that this will not be so. It is interesting that the right hon. Member for Saffron Walden should be asking my right hon. Friend for an assurance in the matter of the right to publish when this assurance was given in the Committee stage, and should have been well known to every member of the medical profession. On the question of appeal to the High Court there is a basis of reason—even if it is distorted reason—behind the medical attitude. Doctors really are only familiar with one statutory tribunal and that is the General Medical Council. On the whole, the General Medical Council does its work admirably, but when things do go wrong—
Dr. Morgan (Rochdale)
The hon. Gentleman cannot have had much experience of the General Medical Council. I do not know whether he has ever attended a trial, but if not I advise him to do so. Although they have improved a great deal in the last six months, previously they were hopeless. I have actually seen them asleep and snoring during the trial of a case.
On the whole, the profession is not dissatisfied with the work of the General Medical Council, except on rare occasions, and those are the occasions which get publicity. It is on those rare occasions that every libertarian doctor's hair bristles—as does that of the hon. Member for Rochdale now. I think those occasions are distorted by practitioners. If they have experience of Ministry of Pensions tribunals they would be a little different in their attitude. They appear to be completely unaware that for 36 years they have conducted their panel services with far fewer safeguards in respect of dismissal than they have under the new Act. Indeed, under the panel service there has not been, so far as I know, a single demand for appeal to the High Court as an additional safeguard.On the subject of negative direction, again there is immense misunderstanding. I had a letter from a doctor a few days ago in which he said:
He goes on:"What do you propose under this new scheme? Take an area where there are 4,000 more patients than the doctors there can cope with. You direct another doctor in the public interest into that area."
Under the Act the Minister has neither of these powers, and yet it is the doctors who believe this who are now voting in the plebiscite. The power vested in the Medical Practices Committee is simply the power to prevent the establishment of new public practices in over-doctored areas. The Minister has assured us that the number of over-doctored areas is likely to be few. As long as under-doctored areas persist it will be necessary, in the public interest, to say that no more doctors should go to an over-doctored area. Once the under-doctored areas are fully served and properly covered the need for negative direction will disappear, because good distribution will have been achieved. If we succeed, as we believe we shall under this Act, in getting a better distribution of doctors, then even negative direction should fall into innocuous desuetude, and we can look forward to a time when it certainly will not be necessary. The new system will give the doctor much greater freedom of movement than he has had in the past, without having to buy a practice, to sell it when he wants to go somewhere else, and then to buy another in the place to which he wants to go. There are two safeguards which the British Medical Association might well have thought to be important considerations. I hope that my right hon. Friend will consider them in making regulations. The first is the compulsory public advertisement of all vacancies in medical practice. In the past there has been a tendency for practices to be filled in a kind of hole-and-corner way without public advertisement. We want doctors to have the maximum degree of freedom of movement, and I hope that it will be possible to arrange for the public advertisement of all vacancies. The second safeguard is the regular publication, say quarterly, of the actual extent of the over-doctored areas. There is, as far as I can see, no objection to the basic salary as such. The objection is because of fear of what it may rbecome—fear, as has been said over and over again, of a whole-time salaried service. It is important to realise the reasons behind this fear. Doctors have tended—usually wrongly but occasionally rightly—to look down on those members of their profession who work for salaries. Generally speaking, the salaried doctor in the public health service has earned salaries lower than the receipts of doctors in private practice. There has grown up the traditional idea that doctors who work for salaries are less good and do less good work than those who work for private fees. There is no truth in that, but it seems that in the minds of doctors this association between salaries and less good work has grown up without any justification. Secondly, there is a firm belief on the part of doctors that the Labour Party intends to introduce a whole-time salaried service at the earliest possible moment. The Government and the Minister have denied this frequently. The Minister denied it today, and I hope that doctors will be convinced. Doctors ought to realise that the National Health Service departs in a wholesale manner from preconceived Labour Party policy. The Minister has made concessions in connection with private beds and private practice. He has made great changes in the structure of the hospitals, and granted concessions in respect of whole-time salaries. Why doctors should accept the first three concessions and doubt the fourth, is something which one cannot fully understand. There is nothing inherently Socialist in payment by salary. There is nothing inherently un-Socialist in payment by capitation fees. It is a question of what is the most efficient way of working the organisation. The case for paying a basic salary in the under-doctored areas has been fully argued, as has been the case for paying a basic salary to the young doctor coming into practice. There is a strong case, also, for the older doctor who is cutting down his work, for the man who finds his work too heavy and wants to reduce it. If he were paid by salary alone, it would be very difficult to reduce it, but if he were paid by capitation fee plus basic salary, then he could cut down if he wished. Then there is the question of extra salary in the case of doctors who take special qualifications or refresher courses. There is a strong case for paying them a little extra. Finally, there is a case for anybody who wants it to have a basic salary. After all, the majority of the members of the medical profession voted for it on their original plebiscite. If some doctors are to have a basic salary and others not, there will be great complications, which, administratively, will be out of the question. The alternative is to say that those doctors who do not want the basic salary should have it paid into their superannuation fund. That might well provide consolation for them. It would be interesting to see how many decided that they wanted the money paid into their superannuation fund and how many wanted to take the money. There is only one possible reason for contemplating a change to a salary system and that is if the service fails. If the proposed machinery fails, then there would need to be a change. It is up to doctors to make a success of it. If they do, I think that they will have the full backing of hon. (Members on this side of the House. On the question of the whole-time aspect, it is our ambition that it shall be a whole-time service both for the doctors and the public, but the Act has made provision for it to be voluntary on both sides. It has done that because we hope that the doctors will choose this deliberately, because they will find that the whole-time practice in the National Health Service is better than practice with private patients. We hope that the patients will choose it because they find that they get just as good a service inside the provisions of the Act as out- side. We trust the doctors not to run two standards of service. It is up to the doctors to trust us. There is one person who has rather been left out—I refer to the patient. Doctors talk glibly of not withholding their services but of charging fees. I would like to commend to them a letter which I received a few days ago. It says:"Take your seaside residential area with its population of 6,000 people, say, at present served by four doctors. There will be at least two redundant doctors in that area. How do you decide which two are redundant? You make a harsh and arbitrary decision and direct the two you choose away to somewhere else."
It was, incidentally, a hospital with limited specialist services."I am writing about my younger son, aged 20. Two years ago he started getting headaches, increasing more frequent and severe. He was admitted to hospital. They could find nothing wrong …"
He asks whether I can arrange for the payment of his postwar credits to be speeded up. That is the price which this poor individual has had to pay for health services. He has had to pay £350 which he could ill afford. That has been the price of health in the past; it is the price of health now. It is because we are determined that it shall not be the price of health in the future, that this Act must come into operation on 5th July."… so I took him a specialist, Dr. X, in Devonshire Place. He arranged for him to be admitted to a private ward at a cost of 53 guineas a week. Eventually the cause of the trouble was located and an operation performed. The total cost to me was close on £300, which was rather a lot for a man in my position. I should like you to know I am a postman and this expense hit me very hard. I am pleased to say my son has made very rapid progress and is now on the way to recovery, but since his operation he has had double vision and has been attending an eye hospital for further treatment. It has been decided by the specialist that to have them put right, an operation has to be performed. I have made arrangements for my son to occupy a private room during the coming week at the hospital and it is expected that he will be there about a fortnight. The cost of the room will be from eight to twelve guineas a week and the surgeon's fees 30 guineas. I am not quibbling about the cost, as my son has suffered more than enough already and I want him to have the very best possible chance of recovery, so that he can have his chance of resuming normal life again."
Mr. Linstead (Putney)
I would like, in following the hon. Member for Barnet (Dr. Taylor), to make it clear, as I am sure he will be the first to agree, that there is no one on either side of the House who would not at once sympathise with the type of case he put forward. I would say also to the hon. Member for Northern Dorset (Mr. Byers), that in claiming that his party supports the general principle of a comprehensive and universal health service, he was only outlining something which everyone in this House supports. In the manner of its development this may have become a party matter, but in its inception and in the desire of all of us to see something of this kind brought about, the party element disappears.I have listened to the Minister and to the other speeches which have been made from the other side of the House, and it still seems to me that even the Minister has not understood the root cause of the objections which the medical profession have been taking to this Measure. I believe that the best service which this House can do this afternoon is to examine the situation as objectively as it can in the hope that such an examination might suggest new avenues to be followed by those responsible. Before making such an examination very briefly, I would ask the House to look at the actual terms of the Motion which the Minister has asked the House to approve. We are being asked to say that we are satisfied that the conditions under which all the professions concerned are invited to participate are generous. There are four professions concerned—the doctors, the dentists, the pharmacists and the opticians. As regards two of them, the dentists and the pharmacists, the conditions under which they are invited to participate have not been made known. The committee is still sitting to decide what the dentists are to do, and, so far as the pharmacists are concerned, negotiations have only just begun—and I have been in close touch with what has been going on—and no terms are known at the present time. The Minister, in asking the House to agree to this Motion, is asking us to vote upon two matters at least on which no one in this House has any final information whatever. I think that point should be borne in mind by hon. Members opposite when, as they doubtless will, they go into the Lobby to vote in respect of two matters on which they have no knowledge at all. This controversy between the Minister and the medical profession seems to have assumed the aspect of a gladiatorial contest, which is a great pity, because the people really concerned are the 45 million potential beneficiaries under this Bill, With all respect to both, it is neither the reputation of the Minister. nor the standing of the British Medical Association which is the real question at issue here. The matter which concerns me is that I do not believe the Minister understands the background of the doctors' objections to what he is doing. Partly, I agree, the background is one of the future of the medical profession, but, partly, too, it is a very real belief that something not so good is going to be available, not for all, but for a very large number of their patients. I believe that the Minister thinks that what happened in 1911 is going to happen again, and that, when he goes over the heads of the Negotiating Committee direct to each practitioner, he will find that sufficient will come in to enable him to operate the service. If he believes that, it is my feeling that he has missed the essential point. As several speakers have made clear already, we cannot look at this controversy otherwise than against the social and political background of the country as it is today. In 1911, nobody thought about direction of labour, and nobody thought about the possibility of the medical profession becoming a full-time, salaried, State service, but both these things are very much in the minds, not only of the doctors, but of the public as a whole at the present time. I believe that the temper of the medical profession today is very different from the temper of the medical profession in 1911.
Mr. Mitchison (Kettering)
Is it better or worse?
I do not know whether one would call it better or worse but I do know that it is different. I do not think that the Minister can rely on the collapse of opposition as his predecessor was able to do 20 or 30 years ago. The problem at issue is this: What is to be, in future, the relations between the great liberal professions of this country and the State?
Mr. Leslie Hale (Oldham)
Will the hon. Gentleman allow me? As representing one of the great liberal professions, may I tell him that we have regarded as most welcome the decision of the present Government to introduce reforms which provide for the cheapest possible service that has ever been provided in the history of the country?
I am not quarrelling with that. I am only pointing out that more and more members of various professions are becoming, either directly or at one remove, State employees, and that is a completely fresh state of affairs, introducing a whole series of new problems, which cannot be worked out in haste, but which should be worked out in the British fashion by trial and error. Doubts about this new relationship lie at the root of the differences between the Minister and the doctors. Hitherto, the professions have been free to lay down by their own disciplinary machinery, their own general professional standards, and the doctors fear that that tradition is going by the board. Hitherto, each individual professional man has been free to do his own professional work according to his own conscience and his own standard of professional skill. Rightly or wrongly, the doctors fear that that tradition is going by the board.
Mr. Ungoed-Thomas (Llandaff and Barry)
Will the hon. Gentleman say whether there is any need for that fear?
I do not think it matters whether they can find a statutory basis upon which that fear can be founded or not. What is, in fact the case—and it is one of the things with which the Minister has to contend—is that it is there in the minds of 40,000 or 50,000 medical practitioners.The third point, which has always been traditional in the liberal professions of the country, is the right to practise their profession wherever they desire, and, again, rightly or wrongly, the medical profession fear that that tradition is going by the board. Until the Minister, either by personal assurance or in the Statute, can make the doctors believe that these old traditions of their profession are going to be respected and that the new details are going to be worked out, not by dictatorship, but by argument and by trial and error, so long—
Mr. John Paton (Norwich)
I am anxious to understand the point which the hon. Member is making. Do I understand that he thinks it is quite right that the doctors in future, as in the past, should go to the areas in which they have the greatest prospect of financial gain?
That is not part of my argument at all. I was not dealing with that particular point. What I am trying to make the hon. Gentleman understand is that the fears are in the minds of the medical profession, and that until they are removed, the Minister will not get the co-operation that he wants.
Mr. Sydney Silverman (Nelson and Colne)
Will the hon. Gentleman allow me? I understood him to say that he was in favour of a State medical service of some kind. If we are to have a State medical service of some kind, how in the world can we have special remuneration for doctors without having the right to send the doctors where there is most need for them?
That is an important dialectical argument, but it entirely ignores the realities of the situation. Ever since 1911, the State has provided a service for something like 20 million people under the Insurance Act, without the necessity for powers of negative or positive direction, and it is idle for the hon. Member for Nelson and Colne (Mr. S. Silverman) to say that direction is an essential feature, or that a salary is an essential part, of the State service.Very briefly, I will deal with the three specific points at issue between the Minister and the medical profession. On the first point, that of negative direction, it is very significant that the Minister did not say a word on that subject this afternoon. The reason why he did not was because he knew he would be batting on a bad wicket. I do not believe that the powers of negative direction are likely to be used to any substantial degree in the operation of this scheme. Therefore, that is one of the points on which, if he wishes to reassure the medical profession, the Minister could give way without in any way weakening the effect of his scheme.
Mr. Deputy-Speaker (Sir Robert Young)
There have been many interruptions. There is a very long list of hon. Members who wish to speak in this Debate, and every interruption precludes, to some extent, the opportunity of certain hon. Members doing so.
I will be as brief as I can, and I shall not be able to give way any more. The next point at issue between the Minister and the doctors is the question of the appeal to the High Court. Here, again, that right of appeal to the High Court is going to be of no substantial value to the doctors, nor do I believe that if it were conceded it would in any way weaken the authority of the Minister. But it is one of those things which the doctors take as an outward and visible sign of whether or not the Minister is going to be their master and whether or not they are going to be the independent servants of their patients. Because there is no practical issue in the appeal to the High Court, it is another thing upon which the Minister could give way, without losing anything from his scheme, if he really wants to carry the medical profession with him.Similarly, with regard to the basic salaries, if we accept the assurance which the Minister has given today that neither he nor the Government have any intention of turning the medical profession into salaried servants—although the doctors believe that the element of basic salaries means just that—why cannot he carry on with the capitation fee which has worked for many years under the National Health Insurance Act, and thereby remove the fear felt by the medical profession at the present time? The last point I wish to make is this. Perhaps the Minister believes that he may be able to break the resistance of the doctors. He has the power of the majority in this House, and he has the power of the purse. He has already offered something like £60 million in various ways as an encouragement to medical practitioners to come into the service. If he does that, I would say that it would be a dearly bought victory in which neither the Minister nor the doctors would be the victors, and only the public who would be the victims, because, with controversy between the Minister and the doctors, no national health service scheme will work. I believe that the Minister is likely to find his greatest ally, in an attempt to build up a really first-class service, in an independent medical profession. If the Government are going to subjugate the profession to the State, there will be a pitched battle. It is surely still possible, by some act of statesmanship, to enable the medical profession to be brought into this scheme on a basis which will reassure them that their old traditions are being respected. If that is done, we shall have a good and workable scheme; if it is not, we shall have chaos on 5th July, and a second or third-rate scheme afterwards.
Mr. Leslie Hale (Oldham)
The hon. Member for Putney (Mr. Linstead) has just made what is, perhaps, the most amazing speech to which this House has listened to for some time.—[HON. MEMBERS: "Hear, hear."]—I am glad to hear the applause from hon. Gentlemen opposite. He said that the choice is between democracy or dictatorship, and that it is a question of whether we are going to have a dictatorship. That is a direct attack upon the Crown and upon the hereditary Second Chamber of which, we understood, hon. Members opposite were rather fond, because we are discussing whether a Measure should come into force which has passed through this House in all its stages, has had the complete approval of the hereditary Second Chamber and the gracious Assent of the Crown.The Conservative Party have now come to the stage when, in support of a retrograde minority movement, they talk in terms of dictatorship about the administration of the law of the country. I listened with pleasure to the hon. Member for North Dorset (Mr. Byers); I thought we were hearing the authentic note of the Liberal Party. That party has a very good record in this connection, and had some experience of this same type of splinter union agitation in 1911. It was suggested by the hon. Member for Putney—who may be too young to remember it; I hope he is—that the behaviour of the doctors in those days was most friendly and co-operative. At that time, the noble Lord the Member for Horsham (Earl Winterton) was putting down Questions asking what would happen when there was not a doctor in a particular county who accepted the scheme, and others were saying, "We will not lick Lloyd George's stamps," and a year or two later they were the very people who were licking his boots. I think it would be the wish of the whole House to congratulate the right hon. Member for Saffron Walden (Mr. R. A. Butler) on achieving, what I thought would be a quite impossible feat. He achieved a new low record for Opposition Front Bench oratory. His speech was full of vituperation without arguments, full of declamation without reason, supporting a personal attack upon the Minister, and without one single constructive contribution to this extremely difficult, extremely delicate, and very important situation.
I do not agree with that.
If the hon. Gentleman will read the opening sentences of the right hon. Gentleman's speech and the personal sneers he made at the Minister, he will find that I am right. I am going to bring before the House the real position in this connection. I have very many great personal friends in the medical profession and owe them many great debts, but I say that the B.M.A. do not represent, and have never represented, the medical profession in this matter. My right hon. Friend the Minister of Health is a very experienced Parliamentarian and one who has the overwhelming respect of this side of the House, and, I believe, of a very great deal on the other side. He conducted this Bill through Committee with great tact and conciliation, had conversations with the medical profession, and made many concessions, without a single one being made in return. Yet the chairman of the Negotiating Committee, in the columns of "The Times," made one of the greatest personal attacks upon him to which any Minister has ever been subjected. In a letter to "The Times," he said:
"He treated the representatives of a not unworthy profession with that contemptuous derision of which he is a master."
Mr. Quintin Hogg (Oxford)
Every time I hear the derisory laughter of the hon. Member for Oxford (Mr. Hogg) I feel fortified in the accuracy of my views. The letter went on:
The argument there is that when the Government make a concession, they are adopting diversionary tactics, and that when they refuse to make concessions, they are being contemptuous and derisory, and it is impossible to negotiate. It is right that the House should ask itself, and should know, just what the attitude of my right hon. Friend has been in this connection. The proposals of my right hon. Friend and his attitude in the matter were circulated to every medical practitioner. The circular stated:"True, on the next day, when discussion moved on to the subject of consultant services, we saw a new Mr. Bevan—smiling and urbane, and clearly anxious to divide the consultants from their general practitioner colleagues."
Could that be more generous? Could there be a more sincere offer? Could any profession be offered a fairer Measure? There has been no controversy about the terms of this offer, but it is right that we should see just what this offer substantially is. It means this: the average general medical practitioner who now has a panel and who has on that panel anywhere near the normal maximum allowed, which is about 2,500 plus certain increases for juveniles, if one assumes that he gets the normal signatures of the rest of the family, will automatically be entitled to the following. He will have compensation for the value of his practice of a substantial figure; a basic salary of £300 a year; fees amounting to not less than £3,000 a year, on that basis—a total of £3,300 of income from his State patients. He will have 7 guineas for every maternity case which he undertakes, if he possesses the necessary qualifications. He will have a superannuation scheme with an 8 per cent. contribution. There will be a pension for his widow at the end of it, and complete security for the rest of his life against losing his post. That is the offer. Beyond that, he can take any appointment outside; there are certain limitations, but under the National Health Act he can accept appointments. He can accept any amount of private practice without any interference, and he can write freely in the medical papers and so on. He is subject to no direction in the maintenance of his professional practice. That is an offer such as has never been made before in the history of this country. It might be said to be over-generous, although it would certainly be the wish of this House that the medical profession of all professions, should have the most generous terms, should have the maximum co-operation and should be permitted to carry on their beneficent and healing work without let, hindrance or interference and with security and good will. The attitude of the Conservative Party in this matter has not been so satisfactory as has been the attitude of hon. Members on this side. When my right hon. Friend introduced this Bill, from every Conservative platform in the country there went up the howl, "The blighters have pinched our Bill." They claimed for months that they had invented it. The right hon. and learned Gentleman, now the Steward of the Manor of Northstead, who has sought to become endeared to the populace under the title of "Happy Harry," was looking miserably and dismally around and saying, "I have been robbed of my copyright; I am losing my place in history. The Minister of Health is having the credit for this masterly document." A few hours before the Second Reading the party line came down on a silver salver from Hatfield, and they found that they did not approve of the Bill. They tabled an Amendment and criticised nearly every feature of the Bill. The extraordinary part of the Amendment is that the features which they criticised are the features which everybody has accepted. They did not raise the points now raised by the B.M.A. The right hon. Member for South Kensington (Mr. Law), who has a certain hereditary interest in these discussions, moved an Amendment upstairs in which he asked for a basic salary in what, if I may abbreviate his Amendment, I imagine he referred to as special areas. It has come out in the course of these discussions rather surprisingly and amazingly that in certain areas of the country the basic salary has existed for years. In those vast and beautiful areas to the north of the Caledonian Canal, where the war with Japan is still being waged with relentless vigour, there are scores of medical men rendering devoted service to the community on the basis either of full salary or a basic salary and capitation, and not one of their patients has yet recognised that they are State hirelings. No one knew it for 30 years. On this question of the right of appeal, for 30 years the doctors have been in a worse position than they are now, and as a result of this agitation the figures have been perused. There were not the same rights of appeal as are given under this scheme, yet no one complained. Indeed, what was the point in complaining when from 1921 to 1947, only 46 cases had been the subject of the procedure at all? Of those, in 16 cases the doctor's appeal was allowed. In 12 cases he was allowed voluntarily to resign; in 18 cases disciplinary action was taken, and in nearly every one of those 18 cases he was allowed to be restored to his practice after a short interval of repentance and reflection. How can it be said that, in those circumstances, the rules are a threat to the liberty and the individuality of the doctor? I think we ought to refer to the conditions and terms of this plebiscite. It is quite right that the doctors, if they like, through the British Medical Association or any other representative association should be able to express their opinions on any of the terms of this scheme. It is right that they should have free expression. We have preserved their right to say that they do not care to enter the scheme by reason of age, infirmity or lack of interest or for any other reason. It is also right that the House should have the actual terms of the plebiscite, and the questions which the doctors are asked to answer. The answer which the doctors are asked to give under their own names is:"The Minister knows, without need of reassurance, that the medical profession—like the other great professions in the health sphere—is actuated in the ultimate resort solely by its professional concern in the welfare of the men, women and children whose care it undertakes and who are wholly dependent on that care. As the responsible Minister of the Crown in that sphere, he has precisely the same object at heart. Differences of opinion as to means and methods are important, but never insurmountable—and cannot conceivably be allowed to override the main objective. A sincere cooperation between the profession and the Minister can ensure the greatest health service this or any other country has yet known; a failure to co-operate can redound only to the detriment of the people whom both wish to serve. Acts of Parliament are never infallible; legislation is a constantly renewing and reshaping process. There will be amending Acts, without any doubt, and the scheme will be so bettered and remoulded as experience is gained."
or:"I approve of the National Health Service Act, 1946, in its present form,"
One might as well ask whether I eat food to find out if I approve of oysters. Here is an Act with 153 Sections, and according to whether a doctor agrees with the dental part, or the ophthalmic part, or the private practice part, or any other part, he has to say whether he agrees with all its terms. However, I appreciate the difficulty of obtaining a fair view. The next answer is:"I disapprove of it."
or:"I am in favour of accepting service under the Act in its present form,"
I have no objection to that, but the third answer is this, and it raises a constitutional issue:"I am not in favour."
The doctor is asked to give that answer over his own signature, knowing that all sorts of things can be done to him in his practice. The hon. Member for Cheltenham (Mr. Lipson) shakes his head. He is one of the Members of this House for whom I have a great respect and, therefore, I begin to wonder whether I have said anything extravagant. However, I think if he reads the report of the Coventry case and the court proceedings he will agree that there is substance in what I have said."I agree to abide by the decision of the majority and undertake not to enter the service if the answers to Part B reveal a majority against undertaking service as defined in paragraph 4 of the preamble and if so advised by the British Medical Association."
Will not the hon. Member agree that, as I understand it, the voting paper is not in fact itself going into the hands of the B.M.A. at all?
Let us assume that the hon. Member is right. I do not know whether he is right or wrong. The other side may very well be doing some window dressing in it, but the question is that a man is being asked not merely, "Do you wish to come in?" but "Are you prepared to put yourselves in our hands in trying to break this scheme and defy the will of Parliament?" Let the hon. Member read the "British Medical Journal" on this matter where they are advising members on what action to take when they are out—disaffecting the population, the type of thing to say about the 10d. a week and so on.
Sir Hugh Lucas-Tooth (Hendon, South)
Will not the hon. Member agree that in the Minister's statement he said that every doctor will have to decide for himself when the proper time comes whether he should take part in this scheme and that the profession as a whole will be free to determine their views on the matter? What does "the profession as a whole" mean? Does it mean they can organise their views or not?
Is the hon. Gentleman seriously stating that he feels the words have the meaning which has been put upon them? It is unlike the hon. Member to raise purely debating points.I want to make a point on the question of compensation in respect of the sale of practices which has not been made up to now and is specially important. If the Government permit, under this new scheme, the sale of practices it is permitting the old system whereby a doctor had to enter into a long-term contract to pay the purchase price by instalments and, in effect, it permits the elderly doctor wishing to retire to put in a locum to run his practice and to pay off the purchase price by instalments. It permits him to farm out his practice and to make a continued profit out of it. I say that should not be permitted and the Minister is justified in every action he has taken on this. I want the House to consider for a moment the position of two people who are important: the first is the medical practitioner and the second is the patient. The Conservative Party opposed the National Insurance Act when it was first passed and, because of artificially stimulated agitation, a great many doctors did so at the time. The picture Bernard Shaw drew of Dr. Blenkinsop was a true picture and "The Doctor's Dilemma" was written in 1906—the doctor who did consultations at 6d. a time, the doctor who was behind with his surgery rent, the doctor who had to borrow some brown paper to pad his chest because he could not afford an overcoat, the doctor whose ambition after three years of practice was to buy a bicycle and save himself walking round the large district to see his patients. What was the position immediately before the Act was passed? I find in the Borough of Oldham, which one would expect to be as progressive as any in the country, they had a medical officer of health at £500 a year, a fully qualified assistant medical officer of health at £200 a year, a chief Inspector of Nuisances at £3 a week, a factory inspector at £2 a week and one nurse—just one nurse—for this borough of 150,000 people at 24s. a week. The total employees in the inspection of nuisances, smoke, factories, medical and health—about 15 of them—together got less than one average general practitioner will get under the new scheme under the terms offered.
Sir A. Salter
The hon. Member will realise that although there was a great deal of discussion there was nothing like a doctor's strike and the number of absentees was negligible because they were convinced that the powers under the new Bill would not in fact be used; there was no danger that they would be used to make a wholetime medical service.
What the right hon. Gentleman says reveals that it is political agitation and has nothing to do with the merits of the case. The only reason the B.M.A. will not accept this Act is because a Labour Government is in power. That is a challenge to the whole fundamentals of our democracy and one which we ought to take up. I want to finish on the higher note on which we could have kept this Debate if it had not been for the speech of the right hon. Gentleman the Member for Saffron Walden (Mr. R. A. Butler). Members of the medical profession have brought to nearly all of us here comradeship and care in our time of distress, solace in our hours of suffering and comfort in times of parting. We have a right to be infinitely grateful to them and to wish to co-operate with them—as indeed we do—and to seek their support in carrying on the great work started by the late right hon. Member for Caernarvon Boroughs, whose daughter I see here with pleasure today.We have a right to ask for their co-operation. The life of the average doctor, even after the National Health benefit, has not been an easy one. It has never been an easy one. All too often the first cry of the new-born child is heard in the back to back houses which still survive or the last gasp of the dying patient takes place in some cellar which we are now abolishing. All too often one sees the case, amply reported in the medical reports, of the child suffering with rheumatoid arthritis on a mildewed bed, with its only hope the occasional visit of the panel practitioner. It is our desire and our wish that they should have the best of everything. The right hon. Gentleman the Member for Woodford (Mr. Churchill) said rather winsomely a few weeks ago that the years between the war were years of unparalleled expansion of prosperity. Those were years of which the doctors could speak as effectively as anyone—when they were treating, in this great Metropolis, patients, working men, of whom one in every 12 was unemployed, where 79,000 children were verminous and five out of every six children were under-nourished and 5·7 per cent. were suffering acutely from malnutrition, in which 50 per cent. of children under five years of age had decayed teeth and 22,000 children were suffering from chronic diseases; in this great Metropolis in which, of every three men who died, one died in the workhouse. These are the conditions we on our side are seeking to destroy and no man has done more in the past few years than the right hon. Gentleman in charge of this Bill. We ask the doctors to disregard this political propaganda and not to let themselves be used for political purposes, but to march with the right hon. Gentleman himself in comradeship along this great road to the reconstruction of our national health and the restoration of this country to full health, prosperity, leisure and enjoyment.
Sir Ernest Graham-Little (London University)
I do not propose to discuss the personality of the Minister, and the arguments which have been made about that issue, because it is an entirely irrelevant one. What matters is what is in the Act. It is that and not what the Minister says of which we must take notice. What is in the Act, is what matters. My great urge at present—and the reason why I have come here to speak tonight—is to point out that we are faced with nothing short of a disaster, a disaster that seems to me assured in five months' time.In the Government's Motion before the House there are three statements, which I propose to take in turn. I think it will be possible to show that all those statements, are, in fact, untrue. The House is asked to note, first, that the appointed day for the National Health Service has been fixed for 5th July. That, however, does not mean that it would come into operation on that date. That is a very different thing. I want to show that for the effective fulfilment of the promises of the Act it would not be dis- puted that a very much larger provision must be made than now exists for both staffing and for buildings. I propose to demonstrate that neither the staff nor the buildings can be provided by the appointed day or, for that matter, in any near foreseeable future. I think the whole of our attention should be directed to that practical consideration, and not so much to points of view about the buying and selling of practices, to which I personally attach little importance. Neither the Government's Motion nor the Act will furnish either the buildings or the staff which are absolutely necessary if all the services treated of in the Act are to be available. The services to be provided are to be provided for the whole community without any limitation as to financial needs or means, or sex, employment, vocation, or even insurance qualifications. The services to be provided fall into two principal categories, the hospital services and the general practitioner services. Under the National Health Insurance Act only the latter category are provided for, and only for persons whose incomes are below £420 per annum. Estimates have been made that the staff required to meet the new services must be from two to three times as large as the staffs under existing arrangements. The Health Services are to be provided free of cost to patients. If this promise which is held out is to be fulfilled, it is obvious that there will have to be a much larger staff than is required at present. The fiction that the services are to be free—it is only a fiction—will undoubtedly augment the demand upon those services and increase the calls made upon the medical staff.
Mr. S. Silverman
I understand that the hon. Gentleman is explaining that under this scheme there will be need for more doctors than we have. Would he then explain how the position would be affected if young professional men followed the advice which the hon. Gentleman gave on 12th October last:
"If I were a young professional man with good health and training I would most certainly leave this country whilst the going is good."
Sir E. Graham-Little
I am glad to say that very many young doctors are emigrating from the country and they are very wise in doing so.
Mrs. Florence Paton (Rushcliffe)
Why are they wise in emigrating?
Sir E. Graham-Little
What assurance can the Minister give the House that by the appointed day the medical staff will be in any way adequate to implement the Act? I want to show that it will not be possible. The medical staff which will operate the Act is divided into two sections, the consultant and specialist section and the general practitioners' section. There is no evidence that the specialists will enter the service. At a meeting of 250 specialists in the London area on 31st December a vote was taken in which 248 members voted against and only two for acceptance of service under the Act. On 27th January at a much larger meeting of specialists, not only from the London area but from outside, 766 voted against and only 11 for acceptance of service under the Act. I submit that that is a very important indication of the feeling of the specialist section of the profession.The consultant and specialist section is not as important as the section of the general practitioners. The general practitioners number at least three times as many as the specialists. The general practitioner section is represented most authoritatively by membership of the B.M.A. The position of that Association is widely misinterpreted, as has been evident throughout the Debate today and, perhaps, most notably by the Minister himself. He has railed against the officers of the Association, and every time he speaks of the B.M.A. he criticises them. Let us see exactly what the Association is and does. The Council is only an executive body acting as an executive to carry out resolutions of the representative body. The Council is elected by the members of the Association. The representative body is elected by members who are grouped into divisions all over the country. Each division with over 50 members sends one delegate to that body. Here is a point I want the House to observe very carefully. By Article 39 of the constitution of the Association, the Council is obliged to adopt as its official policy resolutions passed at a properly constituted meeting of the representative body, with not less than a two-thirds majority. A meeting of that representa- tive body was held on 8th January. It was attended by 370 delegates constituting full membership of the representative body. Through their representatives 54,000 members of the Association unanimously rejected the Act unless amended. It is entirely wrong and very stupid to say the Council is a caucus acting on its own as though it were not representative of the whole body of the members of the Association. In fact, the members of the Council are the elected executive of the members of the Association. The Council would be entirely within their right to announce that they adopt the resolution of 8th January and so finish the matter; but—I think wisely—they have decided to approach a larger audience, comprised not only of its members, but of every general practitioner. I want the House to understand that it is the membership of the Association, not the Council, which is pushing this opposition to the Act. It is highly important to remember that. When reference is made to "a handful of people" one is talking of 54,000 registered medical practitioners. Apparently, the medical profession is reproached for entertaining the dislike it undoubtedly has for salaried medical services. We cannot quarrel with that for it is the decision of the profession itself. The first note of alarm in the medical profession was sounded by the Beveridge Report, published in 1942, and accentuated by the Labour Party pronouncement in 1943 that a State salaried medical service was the objective of the Labour Party. From 1943 to the present time meeting after meeting of the representative body has recorded practically unanimous opposition to a full-time salaried service. The membership of the B.M.A. jumped from 40,000 in 1940–42 to 54,000 this year. That enormous increase was due to the resolve of the rank and file of the profession to resist a salaried service. It is rather instructive to note that the Medical Practitioners' Union—a body which supports a State medical service, and which is indeed, the only medical organisation recognised as a trade union and affiliated to the Trades Union Council—dropped in membership from 7,000 to 4,000 in the same period. Surely, that must convince even unwilling hon. Members of the real feeling in the medical profession. I turn to the provision of buildings, which is equally remote. The whole structure of the new Health Service, and especially the general practitioners' section, was based on the provision of health centres, designed to make available to the whole community a general medical service, dental service, pharmaceutical service, specialist service, out-patients' service, and hospitals. Those of us who attended the various stages of the Act during its passage will remember the praise which was given to that departure. It was said that it would no longer be necessary for the State doctor to provide his own surgery, or to live near his prospective patients; that he would be relieved of the initial outlay involved in finding for himself his professional equipment, which was to be found by the local authorities. On 14th January, 1948, three weeks ago, the Minister announced in a circular that, while he regarded the establishment of health centres as a key feature in the general reconstruction of the country's health services, their provision must be postponed indefinitely on account of the building stringency. One can appreciate at once the enormous hole that pronouncement makes in the Health Service scheme, especially as it affects general practitioners. The promise of greatly augmented institutional treatment calls for a vast new building programme. As a member of the Court and Senate of London University, I know that the great hospitals of London, which are all schools of the university, have been terribly devastated by enemy action. Some of our largest hospitals have been almost entirely destroyed. Hon. Members have only to look across the river to see the damage done to St. Thomas's Hospital. It is well known that the demands for admission to our hospitals before their destruction greatly exceeded their capacity, resulting in long waiting lists, with corresponding injury to patients deprived of immediate admission. It is clear—as indeed, the Minister has admitted—that the provision of new hospital accommodation is even more remote, although perhaps even more urgent than the provision of health centres. The buildings imperatively required to meet the new needs will not be forthcoming by the appointed day, nor for very long after it. The provision of a full dental service is also promised, but the shortage of dentists is even more serious than the shortage of doctors.
Mr. Baird (Wolverhampton, East)
Does not the hon. Member know that the British Dental Association says that there is no shortage of dentists?
Sir E. Graham-Little
I think my information is superior to that. On 8th October, 1946, Lord Teviot—who was chairman of the Inter-Departmental Committee on Dentistry which, for two and a half years, inquired into the provision of dental services—in a speech in another place said that the intake of dentists would have to be at least three times as great as it is now to offer any prospect of an adequate dental service being provided. The reaction of the dentists has been made known in the House, and is even more uncompromising than that of the doctors. It is to be noted that the "criminal" B.M.A. cannot be held responsible for the dentists, for the B.M.A. admits to its membership only registered medical practitioners.The new Act is also said to
I submit that statement will not bear examination. The Beveridge Report—which is recognised to have been the blueprint for succeeding health schemes—admitted that the existing health services were as good as, or better than, those to be found in any other country. In Volume I, page 293, of the Beveridge Report it was stated:"lay, for the first time a sound foundation for the health of the people."
A report quoted on the same page by the International Labour Office expressly declares that the British system excels all others in four important particulars: unemployment insurance, distributive pensions, unemployment and old age assistance, and continuity of medical benefits granted from the first day of insurance during employment, for sickness, unemployment, disablement and old age. It is common form with supporters of the new Act to make false statements for the purpose of creating prejudice against existing services. In a broadcast on 12th January a speaker appointed by the B.B.C. declared that, in present circumstances only the rich have access to the greatest specialists, and the Government are resolved to furnish this help to the poor. No mention was made throughout that broadcast of the provision afforded by the great hospitals throughout the country, under which services by leading specialists are made available to the poorest members of the community. Lord Moynihan, one of the greatest surgeons of our day, and for many years on the honorary staff of the Leeds Royal Infirmary, made and published an analysis of his working professional day. This demonstrated that 80 per cent. of it was devoted to the hospital services. It would be true to say that the very rich and the very poor see exactly the same doctors. The best index to the efficiency of any medical service is its performance in medical research. It would not be contested that the achievements of medical research, chiefly carried out in our voluntary hospitals, placed English medicine in the very vanguard of medical advance throughout the war. One need quote only two examples, firstly, the discovery of penicillin, made at my own hospital, which completely revolutionised the treatment of wounds, and, secondly, the invention at another London hospital of a method of preparing dried blood plasma, which made blood transfusions more accessible and saved countless lives. It is to be noted, with some misgiving, that the Act devotes exactly six lines to the subject of medical research, which is to be "conducted" by the Minister: The last part of the Motion asks the House to declare its view that"The total range of social and health services in Great Britain is greater than that of nearly all other countries."
The medical profession is a very old and proud profession. Its roots are in a code of ethics laid down more than 2,000 years ago by the ancient Greeks, who were the pioneers of so many things. I submit that this profession is a better judge of what constitutes their traditional freedom and dignity than any vote recorded in the House of Commons. I propose to demonstrate how completely the traditional feeling is destroyed by this Act."conditions under which all the professions concerned are invited to participate are generous and fully in accord with their traditional freedom and dignity."
Do I understand that the hon. Member is opposed to the whole Act?
Sir E. Graham-Little
No, Sir. I am concerned to stress the traditions of the medical profession. That is what I am speaking about. The position is extremely critical, and I do not think the House has realised it. In five months' time, we are faced with the coming into operation of this scheme. The whole medical profession is extremely suspicious of the Government and the measures they are proposing. The profession is very reluctant to forgo its principles, and I hope that the proceedings today will not diminish their authority.
Mr. Baird (Wolverhampton, East)
I have been puzzled by the mass hysteria engendered in the medical profession during the last six months over what the Minister has rightly described as this "compromise" Bill. It is quite obvious why the Secretary of the B.M.A. and some of his colleagues have taken up this attitude. It is purely a political attitude, which we can fully understand. As far as the rank and file are concerned, there is, however, a certain amount of genuine worry about the objects of this Act. The conclusion I have come to is that many of the medical men are taking up this opposition because of ignorance of what the Act really stands for. That is not to be wondered at because, as many of us who are in the profession know, the profession is in many ways politically immature, due to the fact that doctors are working long hours and have not the time to think about politics.We can understand a certain amount of their opposition, when we consider the constant stream of propaganda which has been poured into them for the last six months. That propaganda has come not only from their leaders, but from the national Press. Many respectable journals have sunk to great depths in trying to misrepresent this Act. I will quote one small paragraph from my own local paper in the Midlands, which is a paper I respect very highly. This paper, in referring to the regulations about midwifery, said:
The report is unsigned, but I presume that it received editorial sanction. It is typical of the propaganda during the last six months which has helped to mislead not only the general practitioner, but the public as well. I believe that what is worrying the doctors is not the sale or purchase of practices, or the basic salary, because in my opinion both these issues were determined in 1944, when the questionnaire was sent out to the doctors, and over 50 per cent. agreed that the sale and purchase of practices should be abolished, and that some element of basic salary would be welcomed, but that they are going to be subjected to an unnecessary bureaucracy. That feeling which is genuinely worrying the rank and file of medical and dental practitioners has come about as a result of this propaganda. The Minister has been pictured as a kind of octopus controlling the whole scheme from Whitehall, whereas there is nothing further from the truth. The profession to which I belong, which I respect very much, has even gone further in lowering itself by publishing a pamphlet this week entitled "Fight On." This comes from a branch of the profession which cannot claim to act in a dignified way. The pamphlet states:"It is also pointed out that to make it obligatory for a woman to carry out the instructions of a medical practitioner may involve the woman in something which is contrary to her religious beliefs. It is pointed out, for example, that if a woman were medically advised for health reasons not to have children, and then found herself pregnant, she might be disqualified from receiving maternity benefit on the grounds that she had not followed her doctor's advice."
"Your governing body has made its decision.
You must now make your decision.
You must fight for the freedom of your profession.
Fight for principles—pence will follow.
If you fail to fight now—
You will have lost your last battle for a free profession.
You will have sold your patients' permanent panel dentistry.
You will have bowed the knee to bureaucracy.
That is rubbish, but it is the type of thing which is coming out at the present time. The position is entirely different. I do not believe that there are any professions in the country, or the world, which are as much safeguarded as the medical and dental professions are under this Act. There are the local medical and dental committee, the local executive committee, the regional hospital board, and the Central Health Services Council. Throughout the whole system the medical profession has a say, even a majority say, in the conduct of its own affairs. It is completely wrong for the leaders of the profession to try to mislead the rank and file. If this Debate convinces medical and dental men that they have been misled about so-called bureaucracy, and that they have control over their own destiny and future, it will have been well worth while. The dentists have an even greater guarantee. Their most respected and beloved former leader, the ex-Secretary of the British Dental Association, who is the counterpart of the Secretary of the B.M.A., has just resigned his post to take a position as senior dental officer to the Ministry of Health. That is a further guarantee that the regulations for dentists will be administered in a sympathetic way. I hope the House will bear with me it I speak from the dental aspect of this matter, and will not be bored because of its technicalities. The hon. Member for Putney (Mr. Linstead) criticised the Minister and those of us on this side for asking for a Debate now. He said that the dentists' regulations had not been published. The dentists themselves, however, have come into the open in a public statement 10 days ago criticising the Minister. I want to point out that the British Dental Association does not represent the dental profession. There are three dental organisations in existence today, the largest is certainly the British Dental Association, but it by no means represents the views of the rank and file. Indeed, I doubt very much whether the Association can rely on the support of its own members. When, 18 months ago, they tried to lead the profession into a strike against National Health Insurance dentistry, within 12 months the great majority of its members had crawled back, and were working the scheme against the advice of their own leaders. It cannot be accepted that the British Dental Association is speaking for the profession as a whole. Yesterday "The Observer" published a B.D.A. statement accusing my right hon. Friend in these words:You will have accepted a standardised wage."
That is a complete misstatement, and if it were not un-Parliamentary to do so I would use much stronger language about it. It is completely untrue to suggest that we shall continue with the old National Health Insurance dentistry as we knew it in years past. National Health Insurance dentistry started 18 years ago. Then, and even today, the dental benefit for the general public was, and is, dependent entirely on the surplus funds of approved societies. The fees paid to dentists for that work are entirely inadequate. They are forced to make prior estimations for all their work. The British Dental Association tells us that these conditions have existed for 18 years. If that is so, why has the Association done nothing about it during that time? Is it because we had a Tory Government in power then? The circular which the Minister sent to the profession recently makes it clear that the fees paid to dentists under the new Act will be determined by a committee—the Spens Committee—on which dental representatives will sit. There will be no waiting for approval to carry out minor extractions, fillings and other works of restoration, no prior estimation. If I have a word of criticism to offer to the Minister it is this: I hoped that he would have included inlays and crowns in the work to be carried out without prior estimation. It is a small point, but it would meet the dentists to a certain extent. There is therefore the removal of the main criticism of the old National Insurance dentistry. Why is it that after submitting placidly and patiently to this iniquitous system for 18 years the Association suddenly says: "It is wrong, and we shall go on strike"? Is it because we have a Labour Government; or that the objection is political? The British Dental Association is now asking for complete clinical freedom, which means that practitioners want to be able to perform minor extractions, fillings, crowns, bridges, and restoration work without first consulting the Minister. They want to go further, and have the right to carry out multiple extractions and fit appliances and dentures without previous consulta- tion with the Minister. In every profession there are some black sheep. The public must be protected against them."The dental profession has had 25 years' bitter experience of trying loyally, but under protest, to give an adequate standard of treatment under the present National Health Insurance conditions of service. All the undesirable features of this panel dentistry are to be perpetuated in Mr. Bevan's scheme which will affect every patient in the country. It is nothing but an extension of the present panel dentistry, which must bring to every person in the country a lower standard of dentistry than the profession is able or willing to give."
Will the hon. Gentleman explain how the Ministry of Health can say whether or not a patient should be provided with dentures?
A Dental Estimates Board has been set up—to which I shall refer later—on the setting up of which there will be direct consultation with the dentists. The officers who are appointed in consultation with the profession will adjudicate between the Minister and the profession.
Sir Henry Morris-Jones (Denbigh)
Is the hon. Member, who is, I believe, a professional dental surgeon, asking us to believe that interference by the State between dentists and patients is likely to be a good thing for the patients?
Yes, and I will prove it if I am given the time. The British Dental Association itself has pointed out the need for some protection of the patient, and of public funds. In 1946, the Association, before it was controlled as a political association, published a pamphlet entitled, "Proposals for a National Health Service for the Nation, June, 1946." In that pamphlet it states:
with the exception of crowns, they will have that under the new Act—"The Practitioner should be entitled to proceed with all the necessary conservative treatment as may be provided by means of scaling, crowns, inlays and fillings"—
They have that. It goes on:"and shall also be entitled to make any radiographic examination which he considers necessary."
That was the policy of the British Dental Association in 1946.They changed it within 12 months. I still say that the public must be safeguarded. Responsible members of the profession have always agreed that they should be safeguarded. With regard to National Health Insurance dentistry, as I said earlier, the dentist will no longer, so far as payment is concerned, be at the mercy of the approved societies. May I give this word of advice to the Minister? He is setting up a Dental Estimates Board which will determine these questions where there is any difference, and he will have under that Board regional dental officers. It is essential that the Board and the officers should have an entirely different outlook from that of the old regional dental officers and the old Dental Benefit Council, because then the patient's good was secondary to the finance available from the approved societies. We must see that there is a complete break, and that under the new National Health scheme the patient's good comes first and financial consideration second. I am confident the Minister will do that. The other point at issue between the dentists and the Government is the method of remuneration. The dentist asked for what is called a grant-in-aid. May I explain that in the past there have been two standards of dentistry, speaking generally, in this country? One standard was for the rich and middle classes—a standard of conservative dentistry by preserving the natural teeth—and the other standard for the workers was that of multiple extractions and the fitting of dentures, or what we call "blood and vulcanite." I want to qualify that, because one of the reasons was lack of education among the working-class, but, on the whole, in the years between the two wars, the working-class could not afford to pay for conservative dentistry. Now the dentists say that they want a grant-in-aid. By that they mean that they should be allowed to charge, where they think fit, a fee aver and above that which the State pays for the treatment carried out. "The Observer" yesterday stated that:"He shall not carry out extractions, other than for the relief of pain, if such extractions necessitate the provision of appliances without the prior knowledge and consent of the competent authority."
The dentists today are asking for a perpetuation of that two-standard system of treatment. In their statement "The Observer" argued that there was no shortage of dentists. I agree that there is no shortage of dentists, because there is a financial enforced priority for dental treatment, and the workers still cannot afford good dental treatment. Therefore, there is a service available of competent dentists to treat patients who can afford to pay for their services. If we give the dentists the grant-in-aid system, they will continue the system whereby they will provide treatment for those patients who can pay over and above the State fee, and the devil take the rest of us. I believe that the British Dental Association want to perpetuate that class distinction which has existed for so long, but the statement of members of the British Dental Association does not represent the dental profession in this matter. Last June, the three dental organisations met on a representative basis and discussed grant-in-aid, and, speaking generally, the decision was 50 per cent. in favour and 50 per cent. against. I think that it was actually 52 per cent. to 48 per cent. Therefore, the dental profession is not nearly completely in favour of this system of payment. One cannot possibly judge the standards of a dentist's work by the fees he charges. If we allow dentists to charge extra for the same type of work that is giving wealthy men and women the opportunity of buying priority service to the detriment of the poorer people. It may be that dentists are worried, so far as this matter of payment is concerned, about what their remuneration is to be, and they want some extra payment. The Spens Committee at present sitting is inquiring into dental remuneration, and it is in a difficult position. Its Report has not yet been published, but I have been informed from a reliable source that the Committee asked the dental profession to make returns of its income, and, when those returns came in, they were surprised to find that they were very low indeed. If the returns of income sent in bore any relation to the facts, and if the Spens Committee makes a report and suggests that the income for dentists should be in some relation to medical income, there will be a substantial increase in dental salaries under the National Health Service Act. But if, as may be possible, the returns sent in were returns for Income Tax purposes only and bore no relation to the true facts of their income, one cannot trust the dental profession either with a system of grant-in-aid or of clinical freedom. They can have it one way or the other, but they cannot have it both ways. I have every confidence that, so far as the National Health Service Act is concerned, the solution to this question of remuneration and freedom is to see that the State pays the dentists adequately for a high standard of work. We must get away from the utility idea, and pay a decent remuneration for the job. The little men at present representing the dental profession are not worthy of the rank and file. Eighteen months after the older leaders of the profession, who had led them ably, were overthrown, the new leaders led the rank and file in a strike against National Health Insurance dentistry. Within a month or two of that strike, the rank and file were crawling back, accepting the scheme.' This Act is much better. The remuneration is much better. How can they hope or expect to hold the membership together when better terms are offered? This is a lesson to doctors and dentists. If they stay out of this scheme, it means that the rank and file of the profession will eventually crawl back one by one. I believe that will do great damage, and be a great danger to the profession to which I belong, and to the medical profession. I think that it is essential that within the National Health Service Act we should have doctors and dentists and other professional workers strongly represented and organised. It would be quite wrong if the Minister of Health had it all his own way. If the medical and dental organisations stay out of the scheme, that is what will happen, and the rank and file members of the profession will suffer accordingly. During the last few years, the dental profession has greatly progressed under the Act. Dental education, both research and post-graduate has developed tremendously. The status of the dental surgeon in relation to the doctor has also been improved under the National Health Service Act. School dentistry has developed for the first time in a sound and reasonable way. The dental hospital services have been integrated with the general hospital services. Today, medicine and dentistry cannot stand still. If they try to do so, they will go backwards. If they go forward under this Act there are tremendous opportunities of improving the health of the people and of giving the profession an opportunity of doing a really good job of work in the service of the people of the country."It is contended that there should be substituted a system of grant-in-aid, implying a fixed payment from the Ministry for each operation and freedom for an additional fee to be decided between patient and dentist 'according to the standard of skill, effort, experience and amenities provided.'"
Mr. David Eccles (Chippenham)
The hon. Member for East Wolverhampton (Mr. Baird), like other speakers from that side of the House, has not really shown us what has set the doctors' teeth on edge. The dispute is much more than a squabble between the Minister and certain representatives of the medical profession. The Minister tried to depreciate the personal factors, but we must take them into account if we are to understand why things have got to such a pass. The Minister has been unlucky. His irresistible force has bounced off the immovable force of Dr. Charles Hill. The House ought to be sorry for the right hon. Gentleman. He has had all the accidental aids to unpopularity. As my right hon. Friend has said, he has shown a complete lack of the bedside manner and he has been supported by the newspaper "Tribune," which the doctors believe represents his own views. His chief opponent is that endearing character the Secretary to the British Medical Association, whom we shall welcome on these benches in the next Parliament. All those adventitious circumstances raise the dust and impede clear judgment, and that is a grave misfortune.The negotiations between the Minister and the doctors are, or rather they might have been, a landmark in the British experiment to combine national planning with individual freedom. The whole world is watching us to see whether Great Britain can make a success of what the Government call democratic planning. The National Health Service challenges the sincerity and the competence of the democratic planners. Here is a great common enterprise to provide care and treatment for everyone when they are sick. In fairness to the doctors—the Minister mentioned it himself—one must remember that for 25 years they have wanted to make big changes in the Health Service. When the Act came before the House the general public welcomed it wholeheartedly. That Act, as my right hon. Friend has said, declares that the doctors are free to enter or to stay out. It therefore lays upon the Minister the obligation, which at the time he welcomed, to negotiate the terms on which the doctors are to serve. Everyone believed that those terms would be settled with good will on both sides. The only reason we are having this Debate is that the Minister has not done his job in the manner and in the spirit which the House and the public had a right to expect. How should he have conducted these negotiations? I would refer hon. Members to the Economic Survey for 1947 where this kind of democratic procedure is set out with the authority of the Prime Minister:
"The Government alone cannot achieve success. Everything will depend upon the willing co-operation and determined efforts of all sections of the population. … The Government therefore invites the attention of industry and the public to its plan. It intends to arrange discussions with both sides of each industry. … It will welcome constructive criticism and it is ready to modify its plans if a case for doing so is made out."
The Secretary of State for Scotland (Mr. Woodburn)
The hon. Gentleman has repeated what has been said several times in this Debate, that the fault lies with the Minister, but no evidence has been produced from that side of the House on which to found that judgment. Could we have some of the evidence?
I hope that that will be the matter of my speech. To provide evidence is exactly why I am intervening in this Debate. The essence of democratic planning laid down by Ministers opposite is to give those who are to carry out the plan a share in its making and to persuade them of their own free will to devote themselves to its success. What applies to economic policy applies to the National Health Service. This is a test of the Government's ability to achieve that reconciliation between liberty and order which the Prime Minister says is an ideal of Socialism.
Will the hon. Gentleman allow me?
If the Government fail to bring the doctors willingly into its service, Socialist Ministers will have to stop pretending that they know how to plan democratically. I do not doubt that the Prime Minister has great faith that it is possible to plan democratically in this country. I thought that the Chancellor of the Exchequer had it also, until I read his remarks in Edinburgh. It is clear from the course of the negotiations and from his speech here today that the Minister of Health does not have the same faith. He has not shown that it really makes a difference to him whether the Health Service starts off with the doctors on his side or against him. All that his words amount to is that the plan must go through on his terms.He says that because Parliament has given him the power to make these regulations the doctors must accept them exactly as he chooses to make them. I ask the House to notice that in the one concession which the Minister has made he said that if he is proved wrong about the practices arrangement he will introduce amending legislation. Therefore he does not rule out the possibility that the Act might have to be amended.
Mr. S. Silverman
Surely that point is different from the other point. What is in issue between the B.M.A. and the Minister on this point is not the intention, but whether the words of the Act are appropriate to carry out the intention. If it turns out that the words are inappropriate then amending legislation would be a reaffirmation of the original intention.
That is so. But the Minister also gave the Negotiating Committee clearly to understand at the beginning of the negotiations that amending legislation of wider scope was not ruled out from his mind. I listened to the Minister, and I still do not know why he has acted as he has and has refused to meet the doctors halfway on two or three of these points. He had to make only two concessions to them, and most of them would have come into the service willingly. He should have given them a firm assurance that it was not the desire of the Labour Party sooner or later to turn the profession into a full-time salaried service, and he should have met them on the question of appeals. By his statement today the Minister makes the position on appeals better, but the doctors feel so strongly on this point that some further step to meet them would be well worth while.Having listened to the Minister, I remain unconvinced that either of those concessions would have struck at a vital part of the National Health Service, as laid down in the Act, or that they would have made it administratively more difficult. On the contrary, by not making the concessions, it is probable that a majority of doctors will vote against the Minister and that that act of no confidence will inevitably lessen the prospect of bringing in the National Health Service smoothly and efficiently. I ask the House to consider what the Minister will gain by his obstinacy. [HON. MEMBERS: "What will the doctors gain by theirs?"] As we saw today, the right hon. Gentleman will gain some cheers from his back benchers but nothing more. The sick and suffering will not cheer because, obviously, their interest is that the largest number of doctors should come into the service determined to make it a success. In so plain an issue between the public interest and the pugnacious pride of the Minister, why is it that the public interest goes down? We want to get to the bottom of this business. What was the Minister up to when he behaved like a dictator to the doctors? Was he, as the song says, simply:
or was he deliberately picking a quarrel? There was a letter in "The Times," which has been referred to by the hon. Member for Oldham (Mr. Hale), from Dr. Guy Dain describing the course of those negotiations. The Minister never challenged the accuracy of that description. The conclusion from that letter is clear. Sometime last autumn the Minister changed his mind and decided deliberately to pick a quarrel with this great section of the independent middle class. Listening today to the Minister's Jacobin eloquence, I found every confirmation of that conclusion. I was reminded that in history, in the early stages of all great revolutionary movements, stormy characters have thrust themselves forward who have known that they thrive best on trouble. They have known that to catch big fish they must first muddy the water. I judge the right hon. Gentleman to be a champion angler in troubled waters, and I leave it to the House to speculate on the nature of the fish which may come into his net. If the Minister is looking forward to fresh trouble, as I believe he is, the doctors are looking back to their professional traditions. That is an attitude which ardent Socialists, even Socialist doctors, are not likely to understand. If the medical men on the other side of the House will allow me to say so, they never appear to represent or greatly to sympathise with the general practitioner. I do not know if that is because of the kind of medical service they have had, but I think it may be the reason why they have said that their medical colleagues outside this House who do not agree with them are suffering from hysteria. I expect the Minister also considers that opposition to his proposals is evidence of temporary lack of mental balance. Whether that is so or not, it appears that the right hon. Gentleman does not very much worry about the strength of the doctors' attachment to their traditions. Indeed he calculates that, if not before the plebiscite is over, at any rate before 5th July, the doctors will come to their senses. We must face the fact that a general practitioner whose conscience tells him to stay out of the service stands to lose a capital sum which in most cases would be of great importance to himself and his family. The capital value of his practice will disappear. A Minister with a keen sense of worldly values might well calculate that by 5th July most of these practitioners will have counted the pounds, shillings and pence and will sign upon his dotted line; but supposing this mixture of bribes and threats does not come off? Supposing that a large majority of the doctors prefer their professional traditions to the Minister's money? What happens then? Then the Health Service, which in conciliatory hands might have been launched in an atmosphere of general good will, will get off to a prejudiced and embittered start. No one ought to make light of professional standards and traditions. It is very dangerous to play with standards of conduct by which men have learned to govern their daily actions. We do not behave well by nature. When we behave well, it is because we have accepted certain standards, as rules of thumb for our action. Destroy those standards, and there is no telling where the deterioration in conduct will stop. The professional standards of British medicine have been built up, tried by experience, honoured and greatly loved for very many years, incidentally for far more years than there has been a Conservative Party and therefore still more than there has been a Labour Party. At the very centre of these traditions is the family doctor's conception of the proper and intimate relation between himself and his patient. I know it is possible to make a debating attack on the doctor-patient relation. The hon. Member for Maldon (Mr. Driberg), writing in the Sunday papers, described it as all nonsense which could easily be debunked. If the hon. Gentleman wants to make such an attack, let him wait until he is sick and then it will be odds beyond arithmetic that he will pray the doctor to think of no one but his patient. When the profession's whole future is not in danger we do not hear much about their traditions and we hear still less about their politics, but I agree with one hon. Member who said that doctors—I would say, successful doctors—have very little time for politics. My father used to say that a doctor only went on the hustings when he had not enough patients to keep him in his surgery. I think there are honourable exceptions to that, but by and large it is true, and therefore it is all the more significant that this dispute between the Minister and the profession should have aroused such intense feelings of a political kind. I would like to examine those feelings. First and foremost the doctors are thinking of their patients to whom they give their working lives. This representative committee—which is after all a much wider body than just the little B.M.A. clique which is constantly being talked about; most of the leaders of the profession whom we honour are either on it or have said they agree with it—is convinced that the Health Service would be a better service if its counter proposals were accepted. [HON. MEMBERS: "What are they?"] They are in the documents. Any hon. Member can read the comments on the Minister's proposals, they have all been published. They believe in their opinions with deep sincerity. No one knows that better than the Minister, and if he were here I would put this point to him: the Minister might have all the logic in the world on his side but even then, how could he make a success of the Health Service without the goodwill of the medical profession? It is worth his while to be reasonable and see if he can meet the doctors on one or two of these points. I want to say a word about the one which to me seems to be the most important, the basic salary. The Minister has said that £300 a year is a modest sum and justified because he wants to give a basic income to young people entering the profession and to some people who are only able to do part-time work. I agree, provided that this salary is payable only to the extent that the capitation fees do not reach the £300. I commend that to the House as a solution of the main problem between the Minister and the doctors. After all, hon. Members who write books are familiar with the method of payment by a guaranteed minimum. A publisher offers so much down and then royalties until the sales rise above the number that would bring in royalties to a sum equal to the lump sum advanced. That is a recognised method of payment, and the Minister could adopt that suggestion. I would be in favour of his giving a larger guaranteed minimum than £300 a year as a method of positive direction to the under-manned areas. Could the Secretary of State for Scotland tell us, when he replies, what are the arguments for a universal basic salary which could not be met by a guaranteed minimum? This is a serious question because, as the Secretary of State knows, there is nothing to which the doctors object so much as the prospect that they may become full-time salaried servants. They see in the Minister's £300 a year"Doing what comes naturally"—
"The baby figure of the giant mass
and their fears are well grounded. Whatever the Minister may have said today, there has never been a clear statement that Labour Party policy has abandoned its old objective of a whole-time service on a salary basis and, until that clear statement is made, this remains a political issue and it is not the slightest good thinking it can be taken out of the region of politics. I must say a word about the sale of practices on which the Minister challenged those of us on this side of the House to declare our views. The House decided that this system should be abolished. I accept that decision, and I believe that the doctors would accept it, if it were the only outstanding point between them and the Minister. Hon. Members opposite make the matter more difficult to settle when they persist in talking about this system as though patients were sold like sheep at market. The truth is that the doctor sells his goodwill, and goodwill is an asset which is capitalised in a hundred ways in trade and in other walks of life. An hon. Gentleman opposite may serve his party well for a number of years and earn enough goodwill to get a seat on the Coal Board. Why, then, should hon. Gentlemen opposite tell the doctors that they commit a sin when they do the same sort of thing? All that they are doing is to widen the breach between the profession and the Government.That is to come,"
Miss Bacon (Leeds, North-East)
He could not sell it.
I do not want to go further into the old argument about goodwill because I regard that as closed, but it is of interest to ask, why is it that since the Act was passed the opposition of the doctors on this question of the sale of practices has hardened? It is very significant, because the House of Commons voted a large sum of money to pay compensation to the doctors for the loss of their goodwill, yet it is a fact that their opposition to this part of the Act has hardened. I cannot expect the House to agree with the argument I propose to make on this subject but it is right that someone should make it.The possession of a capital asset, like a house or the goodwill of a medical practice, is a powerful aid to a man's independence. The possession of property serves sometimes as a refuge from arbitrary interference, sometimes as a platform on to which a man can climb and make his voice heard above the crowd. The doctors have a special reason of their own for valuing this kind of independence. They have found out that in their profession, when new methods of treatment or additions to medical knowledge are first brought forward, they often meet with opposition. The possibility of retreating to the independence of general practice has encouraged many a salaried worker and many a research worker to keep on in the face of hostility, not only from lay bodies, but from senior members of their own profession. That is the first reason why the doctors value this kind of independence. Secondly, the doctors have come to value their independence—which is bound up with a capital asset and payment by results—as something of great importance to the middle class. I do not think we can understand why the opposition of the doctors to the Minister has increased unless we see the Minister's recent obstinacy as one of a series of blows delivered by this Government against the middle class. Houses are not to be built for sale; the purchasing power of professional incomes goes steadily down—[An HON. MEMBER: "So does everybody else's]—the basic petrol ration is abolished; university seats in this House are to disappear; and now there is talk of a capital levy which will hit those people for whom the Secretary of State for War does not care a "tinker's cuss." All this looks like a concerted attack upon the middle class. A month or two ago in Washington I was discussing this problem with a wise American. I wish I had been able to ask him if I might use his name. He was showing me how, even in the United States, the middle class is being squeezed out between high taxation and high prices, and he summed up his anxiety by saying that a democracy which consisted only of a proletariat and civil servants would cease to be a society of free men.
Mr. Alpass (Thornbury)
Was that by a Socialist Government in America?
I believe that to be profoundly true. History teaches me that a numerous body of independent men and women, who owe the Government nothing but their taxes, and are well off enough to shape their own lives, are the leaven in the democratic lump. Where would the Labour Government be without their recruits from the middle class? I am not now concerned with the politics of these people, I want to go deeper; I am concerned with their power to resist bribery and bullying—
On a point of Order. Has this anything to do with the Motion before the House?
Mr. Deputy-Speaker (Sir Robert Young)
I was not following the remarks of the hon. Gentleman but, if he is not doing so, I hope he will keep to the subject of the Debate.
I was saying that these independent people are valuable to society because they are able to resist bribery and bullying and to initiate those experiments in thought and action which make progress possible. Instinctively the doctors have come to realise that these values, which are their values, are now in danger.So it happens that the Minister of Health, by his brutal tactics, has roused 40,000 British men and women to defend the freedom of action and the freedom of conscience of all their fellow citizens. This is a large body and whatever they may do in the plebiscite they want the service to succeed. Of that I am certain. Very few concessions from the Minister, and they would enter that service with pride and hope. All the Minister has to do is to give way over the basic salary, the appeal and the negative directions. If the Minister stands firm and if the Government insists in elbowing their way into the place of the doctor's conscience, if that conscience is no longer in the doctor's breast but in some committee room in Whitehall, then we must expect this dispute, which could be easily settled by good will, to become a political battle of historical importance. Like my right hon. Friend the Member for Saffron Walden (Mr. R. A. Butler), I hope and pray that that will not happen. We have enough trouble and enough things to divide us in this country without adding this self-inflicted wound, but if it does, and if the Minister is determined to fight, we on these benches will not leave the doctors to fight alone.
Mr. W. D. Griffiths (Manchester, Moss Side)
The House listens with respect and pleasure to the speeches made by the hon. Member for Chippenham (Mr. Eccles), but after listening to his speech tonight I am sure we will all look forward to his next contribution on economic policy. Whatever the result of the B.M.A. plebiscite, in my view the people of this country want this National Health Act and they have very scant sympathy with what I regard as B.M.A. intransigence. They also see as we on this side of the House see that the nation's needs have been disgracefully obscured by the B.M.A. in a full-blooded political attack on my right hon. Friend the Minister of Health, on His Majesty's Government, and, indeed, on the institution of Parliament itself.I should like to give two examples drawn from individuals amongst the leading speakers of the British Medical Association. This sort of thing has been going on for a very long time now. I recall that two years ago at a meeting in Manchester one of the leading figures in the British Medical Association told a meeting of health workers, firstly, that the Minister of Health was a dictator, and he then used that language that we have since become used to from the British Medical Association; secondly, that the doctors were fighting this to the last ditch; and, thirdly, that if it came to a showdown substantial funds were at their disposal, and he told his audience that those funds were not entirly derived from medical sources but that substantial contributions came from non-medical sources. I was very thankful for that frank admission of what we recognise as being nothing but a political attack, and a great opportunity in the eyes of our political opponents, to whom any stick is good enough with which to beat the Government. But such is the generosity of my right hon. Friend that the gentleman who used this fiery language at the meeting in Manchester was appointed to the Regional Hospitals Board. In other words, my right hon. Friend was not sufficiently prejudiced against him to place a prohibition upon him being appointed to that board. I am bound to say that some of our Socialist health workers in Manchester were a little disturbed about that. I come to the second example. Lord Horder, addressing a meeting of consultants and specialists of London and the Home Counties, used these words:
According to the "British Medical Journal" he was given loud applause. Would that audience have cheered so lustily if the National Union of Mineworkers had called a strike throughout the coalfields because they disagreed with some detail in the Act governing the nationalisation of coal?"I believe that the public is looking to the medical profession to be the first body of responsible citizens … to cry halt to this mad march towards totalitarianism."
Sir Wavell Wakefield (St. Marylebone)
The doctors are not proposing to strike.
These people talk about their democratic practices, and they are applauded by the hon. Member for Chippenham, who points out what he regards as the democratic deficiencies of my right hon. Friend. According to their own "Journal" that meeting had little regard for democracy because it was reported that when a minority voice, that of my hon. Friend the Member for Rochdale (Dr. Morgan) was raised, it was not allowed a hearing at all and he was shouted down. When one of his opponents, who apparently had some conscience in the matter, rose to a point of order and directed the chairman's attention to the fact that after all each man had a right to speak, the chairman ruled that my hon. Friend had had his say and had exhausted his time.The country wants the medical profession to cry "halt" to disease and to human misery, and it wants it to play its full part in providing a modern health service. I will not say anything about the points at issue in the dispute between the Minister and doctors except to remark that they have been adequately dealt with both by the Minister and by my hon. Friends during the Debate today. Too little has been said about the public point of view. The average man and woman in this country will never be persuaded that there is anything intrinsically immoral about having a basic salary. The average man and woman fight all their lives to get a basic salary, and now we are told it is all wrong. I turn from that, and, with the permission of the House, I should like to say a word about my own profession. Mention was made of it by the right hon. Member for Saffron Walden (Mr. R. A. Butler). I should like to tell him that the consulting ophthalmic opticians of this country recognise that they have a most vital part to play in the new service, and they are presumably included amongst those referred to in the Government's Motion which says:
The whole of my profession are anxious to bring to the Service the benefit of their skill and experience. It is a fact, of course, that, unlike the doctors, we are somewhat in the difficulty that we do not know as yet what our terms of service and remuneration are to be. I would ask my right hon. Friend to allow that matter to be attended to as quickly as possible, because there are a lot of quite "little" men, some of them approaching middle age, who are anxious about the future, and, after all, we are only five months from the appointed day. It is necessary, in the interests of these men, and in the interests of the public, that this matter should be remedied as speedily as possible. I believe that the terms will be generous. Certainly, the terms offered to the medical profession were most generous, but, as far as we are concerned, it is desirable that this uncertainty should be removed very soon. The majority of the people of this country obtain their optical aids through and by ophthalmic opticians, and I would direct the Minister's attention—though he is probably very well aware of it—to the fact that we have promised optical aids to all, according to their need, from July of this year. Without the full participation of the opticians in the service, that promise cannot be implemented. Therefore, it is obviously of great importance that this matter should be cleared up as quickly as possible. I should like to ask the Minister, or whoever is to reply, to give me an answer to two questions. In the first place, he must be aware of the disquiet felt by the profession of ophthalmic opticians because of their lack of statutory recognition. He must also be aware of the situation which has existed for far too long whereby, arising out of this lack of statutory recognition, the people of this country have all too often been in the hands of quacks and people who are not competent to attend to their optical needs. It must have disgusted everybody in the House to have seen, particularly in working-class districts in prewar days, people trying to provide themselves with the proper spectacles they needed by reading a chart in Woolworth's. The only way to obviate that situation, even with the implementation of this service, is by giving those opticians who are, in the eyes of the Minister, suitably qualified, a statutory recognition. My second question, and my last point, is this. I would ask the Minister whether he has any information to give us about the gigantic supply question which is involved in the implementation of this service. We are only five months from the appointed day, and my information is that the people who will be called upon to manufacture frames and lenses for this service have no knowledge at all of what the Minister requires. I think that is an unsatisfactory state of affairs, because there is a shortage of materials, both of materials for frame-making and materials for making ophthalmic lenses, and there is also a shortage of labour on the industrial side. It is obvious that the manufacturers must know in reasonable time what sort of appliances the Minister is to supply, because it takes time to make the necessary tooling arrangements in the factories. Our anxiety is that, if these people are unable to meet their obligations in the matter, and if the opticians come into the service on 5th July we shall be faced with a large and increasing demand, which cannot be met, and we shall also be faced with our constituents' reproaches arising from their disappointment. Having been obliged very largely to speak for this profession, because I am the only member of it in this House, I would like to say, in conclusion, that despite all these difficulties, I have the very greatest pleasure in supporting the Government Motion. I feel that the Minister will overcome these difficulties. I feel that we, on this side of the House, must never be led too far along sectional paths in the matter of our professions, but must always regard our interest in and duty to the whole community, and we can register that by voting for this Motion tonight."That this House … is satisfied that the conditions under which all the professions concerned are invited to participate are generous and fully in accord with their traditional freedom and dignity."
Sir Hugh Lucas-Tooth (Hendon, South)
Those who took an active part in the Debate on the National Health Service Bill have necessarily found themselves in a difficult position today, and I think this is true of hon. Members on both sides of the House. When the Bill was before the House, the general principles of the future service still remained to be worked out and decided. Very naturally, hon. Members had different views about the form of the new health service and expressed those views and voted in accordance with them. Some hon. Members on the other side held the view that a full-time, salaried service was desirable, and, no doubt, they still hold the same view, as it has been expressed here today. We, on this side, hold that a full-time, salaried service would be a disaster, not a disaster to the doctors, because I personally believe it would be very comfortable for them in most ways, but a disaster to the patients and the country as a whole. We still believe that a full-time, salaried service would be a national disaster.When the Bill was introduced, it contained a number of provisions concerning the service of doctors within the proposed scheme. Some of these provisions were precise, and others were anything but precise, but left things to be worked out either by regulations made by the Minister or by the Medical Practices Committee appointed by the Minister. The main provisions of the Bill, for present purposes, however, were three in number. In the first place, the doctors in the service were to be forbidden to sell the goodwill of their practices, subject to a certain amount of compensation. Secondly, they were to be paid partly by salary and partly by way of capitation, though the relative amounts of salary and capitation were left to the Minister to determine, and he could make them vary from 1 to 99 per cent. as he pleased under the Bill. In the third place, the Medical Practices Committee were to be given power to refuse to allow any doctor to start in practice in any area where the number of doctors was already adequate, though the meaning of the word "adequate" was left quite undefined, and the Medical Practices Committee could decide that every single area in the country, except perhaps one or two, was already adequately doctored. I think those are the only provisions of the Act with which we need concern ourselves now. I have deliberately left out any reference to the question of appeal, because I believe that to be a quite unimportant question, and that the Minister could still make a concession to the doctors by appointing a High Court Judge as chairman of the tribunal, which would dispose of that matter altogether. When the Bill became an Act, these three provisions remained virtually unaltered, and it is on them that the whole substance of the dispute between the Minister and the doctors rests. The question, on which negotiations broke down is whether or not these provisions in the Act will necessarily lead to a full-time, salaried service, or perhaps I should say whether or not these provisions are being used by the right hon. Gentleman to initiate what must necessarily become a whole-time, salaried service. That is the issue between the Minister and the doctors; it is neither more nor less than that. While the Bill was going through this House, the right hon. Gentleman said very plainly that it was not intended to set up a full-time salaried service. Indeed, the actual proposals which have been rejected by the doctors' Negotiating Committee certainly did not amount to anything of the kind. But that is not the point. The question which the doctors are asking is whether these proposals are not a substantial first step in the direction of such a service? In order to clear up this matter, I wish to put the following question to the Minister or to the Secretary of State for Scotland who, I understand, is going to reply. Does he, or does he not, believe that a full-time salaried service would be a good thing? I do not mean now or on 5th July next, the day when the Measure is to come into force. There are now all sorts of administrative and, perhaps, technical considerations which will, or might, prevail. But do the Government believe that a full-time salaried service is a desirable aim? If we could get a plain statement as to that, we should know very much more where we stood, and so would the doctors. No doubt that question is the whole fundamental cause of the trouble. The right hon. Gentleman has never made his basic long-term policy clear. Unless he does so, how can the doctors avoid fearing that there is a chance of their being double-crossed? I started by saying that those of us who took an active part in this Measure might feel in some difficulty today. The reason is, of course, that if one holds strong views on the merits or demerits of the Act recently placed on the Statute Book, it is very difficult to resist the temptation to go into them again now for the purpose of influencing opinion outside this House. But those questions ought to have been decided on the Third Reading of the Bill. It seems to me to be wrong to argue now, either that the Act is good or that it is bad. I agree with the right hon. Gentleman himself that an attempt by the Opposition to support or encourage a body of men outside Parliament, however distinguished or however deserving they might be, to set the will of Parliament at naught, would be an act of political sabotage. But the trouble is that the Minister himself has put the whole policy of the Act in issue again. It is the nature of the Health Act, and, more particularly, the Minister's actions since it was passed, which are directly responsible for the present impasse. The House has been reminded that in January last year the B.M.A. wrote to the Minister offering to enter into discussions subject to two conditions, the first of which was that the possibility of further legislation would not be excluded. There can be no doubt whatever what the doctors had in mind when referring to further legislation. They meant that the questions of the basic salary, the sale of practices, and the so-called negative power of direction were to be reopened for discussion ab initio. The right hon. Gentleman cannot say that he did not know that these were the essential questions which the doctors were stipulating to have reopened. There can be no doubt whatever that, in accepting the B.M.A.'s offer, he agreed to reopen those questions. I was astonished when I heard that the right hon. Gentleman had accepted those conditions. He was agreeing, in fact, to consider undoing, or modifying, decisions on national policy made only a month or two earlier after full Debate in Parliament. Of course, we on this side thought that those provisions of the Act were unsatisfactory, and would be better modified. However, that is beside the point; they have been duly passed into law, and, subject to our powers to control the making of the regulations and the working out of the policy, we could not properly have attempted to get the provisions of the Act disregarded. But, after the Minister had agreed to reopen the questions himself, I submit that we were entirely set free—if we cared to do so—to encourage the doctors to make whatever demands they chose. Certainly, the Minister of Health could not have complained had we done so. However, the Conservative Party did not do that. We have always been of opinion that, where terms and conditions of service are concerned, it is for those affected to make their own arrangements, both collectively and individually, within the law. That is the principle enshrined in our Amendment today. We have never interfered in these discussions, and I, for my part, will try to say nothing today which might prejudice the reopening of negotiations. I will only take advantage of the Minister having reopened the discussion on the principles of the Act to say that the reason why the right hon. Gentleman was driven to agree to that course was because the Act itself was so thin and faulty in parts that it threatened to break itself down, and that the Minister's explanations were so inadequate and so far from reassuring the doctors that they were driven to demand legislative protection. We on this side of the House did not seek this Debate, but, now that it is before the House, let there be plain speaking. I propose to say something further about the events of January, 1947, in the light of subsequent events. I have studied the reply of the Minister to the B.M.A. which was published in December, and also, as far as possible, every utterance he has made on this subject. As a result, I have come to the conclusion that the right hon. Gentleman never at any time seriously entertained the idea of modifying the provisions of the Act with a view to meeting the sort of points which everyone knew all along the doctors were worried about. I cannot help concluding that the Minister's action in accepting the B.M.A.'s offer was a piece of political duplicity, and I do not speak for myself alone. I, naturally, discussed these matters with very many private doctors, and, almost without exception, they also held the view that they had been deceived by the Minister's acceptance and did not now regard his acceptance of the conditions as an honest one.
Mr. Rankin (Glasgow, Tradeston)
Will the hon. Gentleman allow me to interrupt him? He alleges that there was duplicity on the part of the Minister. Will he make it clear that, in making that statement, he is not in any way referring to the Scottish service about which agreement was reached with the profession, both on the hospital side and on the general practitioners' side, and that any alleged deception is confined to the English Act?
Sir H. Lucas-Tooth
I cannot possibly accept what the hon. Gentleman says, because I have no knowledge of it whatsoever. I can assure him that I was not referring to anything that happened in Scotland. Whether the doctors and I are right or wrong is perhaps not so very important. What is vital is that a very large proportion of the medical profession are of the opinion that the right hon. Gentleman is politically not to be trusted. That is the fact. That fact is the greatest stumbling block to the satisfactory initiation of the new Health Service. The Minister himself is the greatest incubus on the nation's health.I will refer to another aspect of this matter which will show that the aspect of the doctors, whether right or wrong, is sincere and spontaneous. Much has been said about the British Medical Association. That is, perhaps, natural. They are the immediate cause of this Debate. There have also been discussions, which have been referred to this afternoon, with another great profession, the dentists. I have been at pains to inquire into these discussions. I am sorry that I missed the speech of the hon. Member for East Wolverhampton (Mr. Baird) who spoke for the dentists earlier. The position of the dentists, of course, is somewhat different from that of the doctors. It is not proposed to nationalise the dentists' goodwill; and, of course, the Spens Committee has not yet reported on the dentists' remuneration. The chief matters at issue between the Minister and the dentists have been the questions of clinical freedom and the choice between fixed fees and grants-in-aid. These are somewhat technical matters with which I do not think it is necessary to weary the House. I think I can put the issue briefly and fairly. Under the scheme, are the dentists to be paid a uniform flat rate for treating each patient in accordance with the decisions laid down by some third party deriving authority from the Minister, or are they to be paid in accordance with the results of their work, untrammelled by outside interference? That is the issue between the Ministry and the dentists. There appears to be plenty of room for a satisfactory compromise for all parties. But the negotiations with the dentists have also broken down and, on the face of it, the reason again is that the Minister has remained completely intransigent. He has shown no sympathy and no elasticity whatsoever. Again I find among private dentists with whom I have had conversations exactly the same sort of distrust regarding the right hon. Gentleman's intentions. They believe that all his words and actions point to one conclusion, that his ultimate aim is the creation of a full-time salaried service for dentists. The dentists as a whole are not rich men. Many of them have been badly paid in the past; moreover, they are certainly not peculiarly susceptible to Conservative propaganda of a kind which has been insinuated this afternoon in the case of the doctors. Yet this body of men have adopted exactly the same attitude as their fellow profession. It is impossible to dismiss all these apprehensions as groundless figments of the imagination. The law of England has always refused specifically to enforce a contract of service. No doubt, the underlying reasons for this judge-made rule have been that effective enforcement would be contrary to English ideas of freedom. Indeed, it would be halfway to slavery. Anything less than such slavery would be ineffective because there would be nothing to ensure that the person obliged to render the service would do so properly if compelled against his will.
Mr. McAdam (Salford, North)
On a point of Order, Mr. Deputy-Speaker. May I move that you accept the hon. Gentleman's speech as read?
Sir H. Lucas-Tooth
The hon. Member may do so in a few minutes' time. I have necessarily had to speak at some length. In the case of the doctors and dentists, the Minister is going even further than seeking to enforce a contract of service voluntarily entered into. It seems that he is seeking to force many members of the profession to enter the service against their will, and he is using cajolery, threats and very generous expenditure of public money to gain his end. I know that the right hon. Gentleman and some of his hon. Friends set administration higher in value than justice, but I would ask the right hon. Gentleman not to despise the accumulated wisdom of the English judges. If he forces the doctors and the dentists into service against their wishes and consciences, he will either destroy the service or betray the cause of English freedom
Mr. Somerville Hastings (Barking)
All who have listened to this Debate and have the welfare and happiness of the people at heart must be gratified by its tone. With one exception, that of an hon. Member who exulted in the number of doctors who had signified their decision not to enter the service, hon. Members on both sides of the House seem to wish the service to come into operation and be carried out with a spirit of good will. I would like to add my word in the same direction.A doctor politician is in a very difficult position. All his former colleagues, when they have any grievance against the Government in power, write to him and seem to regard him as personally responsible. I have had a great number of letters from members of the medical profession, and they divide themselves into two groups. One group dislikes the scheme, dislikes the Government's social security provisions even more, and dislikes the Minister most of all. It reads into this Bill everything that hon. Members on this side have ever said, whether wisely or foolishly. I believe that group to be small and decreasing in size. There is, however, a large number of doctors who feel genuine misgivings about this Act. They are not yet satisfied. I would like to address my few remarks mainly to them. Many doctors in this class have been doing excellent medical work all their lives. They are quite certain that their patients have been well treated. What they do not realise is that there are many other patients who, because of the lack of organisation in the present Health Services and because they cannot afford to pay doctors' fees have not been getting such good treatment. These same doctors who have written to me know that they are trusted and respected by their patients. On medical matters their word is regarded as law, and quite rightly so, and they feel that their patients ought to regard their word as gospel as regards the organisation of the Health Services as well. My experience in administration—and for many years I was chairman of the Hospitals Committee of the London County Council—is this: that a doctor may be a very good clinician but he is not necessarily for that reason a good administrator, and very often one gets a more useful opinion from a layman or laywoman than from a doctor, even in regard to the organisation of medical or health services. There is one further point. Doctors are busy people. They read the newspapers and the scientific medical journals. Where the newspapers talk about medical matters, and purport to give discoveries of new treatments they are almost invariably wrong and the doctor has learned to discredit the ordinary newspapers but to believe what he reads in the medical Press. When that medical Press switches over from scientific truth to political matters, the doctor is apt to fail to realise the change and to take at their face value everything which is written in these journals. Nevertheless, many of my doctor friends have genuine misgivings; they fear that their clinical freedom—that is to say, their freedom to treat their patients according to what they have learned and discovered by experience—may be interfered with. I would like to say that, it has been my experience at any rate that I am able to do better work for my hospital patients than for my private patients because at the back of me in the hospital there is an organised service and one is able to get advice regarding one's patients much more readily from one's colleagues. It is quite evident that most doctors feel the same way because there is pressure on all sides for pay beds in hospitals so that doctors may be able to treat all their patients under the same advantageous conditions. I also find that if I get my patients in a hospital, as part of an organised service, I am able to persuade them to undergo the treatment which I think is necessary in their interests much more easily than when they are paying directly and individually for advice and treatment; they seem to think that because they are paying the piper it is their bounden duty to call the tune. Therefore, I cannot see why there should be less clinical freedom under the new Act than as things are today. I cannot see what practitioners really have to fear nor can I see how clinical freedom would be increased if their demands were granted—that is to say, the sale and purchase of practices, the abolition of medical direction, thus permitting a doctor to practice wherever he likes, and no basic salary. As the Minister has reminded the House, these three matters have been discussed for many years in the profession. As recently as 1944, in reply to the B.M.A. questionary, the profession voted on these matters. This questionary was a very tendentious document, aimed at getting accepted by the profession the B.M.A's. decision against the White Paper. I do not intend to weary the House with figures, but on the question of the sale and purchase and the question of negative direction—that is to say, permitting doctors to practice only where there was need for their help—on these questions the profession decided by majority on the point of view put by the Minister today. On the question of a basic salary they were divided. They recommended that there should be basic salary and capitation in practices in health centres, but in separate practice there was a small majority in favour of capitation only. Only two years earlier the medical planning Committee of the B.M.A., of which I was a member, recommended that the payments of doctors should be by a small basic salary and capitation. May I, in a word or two, analyse some of these contentions? May I deal with the sale and purchase, although it has been dealt with fully today? In fact, what happens today is that where a young man wishing to start in a practice has not the necessary capital he borrows £2,000 or £3,000 to purchase it. The alternative is to do what we call "squat." In the past, the man who started a practice expected to be able to pay back the sum he borrowed perhaps at the rate of £200 or £300 a year. That cannot be done today with the present rate of Income Tax and there is, therefore, an increasing feeling amongst all the younger, and not a few of the middle-aged, practitioners that they are in increasing difficulties about the repayment, especially when their children reach the age when they have to be educated. More than ever they are desirous of getting rid of this serious difficulty in starting a practice. May I say a word about the question of negative direction? We all want these services, in some form or other, to be a success. What is going to be the main difficulty, even with all the goodwill in the world? It is going to be shortage—shortage of doctors, shortage of dentists, shortage of nurses. The members of the medical profession have complained to the Minister that it is going to be very difficult for a doctor to be responsible for the health of 4,000 people and here they are on very sound ground. I realise that in connection with the new scheme there will be certain advantages; there will be no trouble in keeping accounts and it will be easy to get a consultant's services for their patients, but even with these great advantages it will be difficult for a practitioner to deal effectively with the health of 4,000 people. How can it be that in the same breath the profession objects to negative direction—that is to say, refusing permission for a practitioner to start practice in an area where there are already sufficient doctors? If our resources are scanty, surely, we must use them to the best advantage. As soon as there are sufficient doctors, as soon as there are no under-doctored areas, then the problem of negative direction will solve itself. This brings me to my last point, and that is, basic salary. I can speak from experience of the terrible problem that, as things are today, besets a young doctor when he wants to start in practice. He is unable to marry. He has to adopt all sorts of unpleasant methods of making himself known to the people around. He has to do the most unpleasant thing of all—entice away other doctors' patients in order to make a living. I cannot but feel that the doctor who wants to start in practice will be very much better off if there is a small basic salary allowed to him. There is good reason for this basic salary, because the overhead expenses of a small practice per patient must inevitably be much greater than they are in a large practice. I can conceive only one reason against the basic salary, and that is that the old and established practitioners may rather fear the competition of the young man coming into the district. I should like to remind the House that the Minister very rightly desires that the young practitioners should be trained as assistants by older practitioners; but, as fat as I see it, he is going to permit the usual clause in such contracts, that the assistant agrees not to practise within so many miles of his principal. That means that where the assistant is to some extent known he will not be able to start his own practice, but that he will have to go somewhere else where his work is entirely unknown. If that is so—and, indeed, it is—it does seem that there is a very good reason for this basic salary. If the name "basic salary" is considered undesirable by the profession, why should it not be called "settlement allowance"? If the profession are so sensitive about it, I would agree to the suggestion that has been made from the other side that this settlement allowance should be in the form of a guarantee of the first 300 or 400 patients. I do not mind how it is arranged, but I do feel that it is very important that the young practitioner with money should not have an advantage over the young practitioner who has not money behind him. I do hope that after this Debate my profession will think again, to see if they cannot join with the Minister in endeavouring to make this the best Health Service that the world has ever known.
Sir John Graham Kerr (Scottish Universities)
I propose to de vote the few minutes left to me, not to making debating points, not to speaking as a party man, but to offering some comments as a representative of the teaching given at medical schools. Were I asked exactly what were the qualifications justifying my speaking for the medical schools, I would say that I have had very intimate relations with the two largest and, as some believe, greatest medical schools in the country. In one of them, I was a student of medicine and later an examiner; in the other, I was a member of the medical faculty and a teacher of medical students, my principal job being to lay a sound biological foundation for the superstructure of more specialised subjects later on. I was also a member of the inner circle—that is, of the medical committee—of one of the greatest of our voluntary hospitals, that hospital which is known the world over as the birthplace of modern surgery. I was also a governor of the biggest extramural medical school in the City of Glasgow.What is a medical school? The medical schools of our country are the great centres of teaching and research in medical science. It is their teaching activities which make the officers who will have to carry out any Health Service, whether the present service or the one that is impending. It is the centres of research which enable medical science to make progress. The great teacher in medical science, as in other branches of biological science, is not the conscientious, industrious man who gramophones off a great array of facts which can be obtained from any textbook. The great teacher is the man who has a great personality, who grips the attention and enthusiasm of the young student, inspiring him to great things. Under present conditions the medical profession is able to attract the very best young men. The able young man is one who, as we say in Scotland, has a good conceit of himself, who believes in his own power to get on, and who sees, under present conditions, great possibilities by which he may reach comparative wealth, dignity and honour. Now, the threat of a salaried service will bar out these young men; the best of them will turn to other activities; they will go into business, or some other profession, such as the law—
Or the Civil Service.
Sir J. Graham Kerr
If they are determined to stick to medicine they will go overseas, and we shall lose them. Up to the present we have been getting these brilliant people, educating them, and inspiring them with enthusiasm; and they, in their turn, have become leaders of the profession. It is these leaders who today are the great teachers of medical students in the voluntary hospitals. When and if the time comes when the officers of these great hospitals are on a salaried basis, the leading men will be lost to the hospitals. I do not suggest for one moment that the salaried officers in such hospitals—and we already have some in the great municipal hospitals—do not do their work conscientiously and well, but they are not great outstanding personalities; indeed outstanding personalities would be a great nuisance in the teamwork of a salaried service. Without outstanding personalities, the teaching of our future medical men would unquestionably go down and down.In regard to research, I often wonder whether hon. Members realise that the people of our race and country have been the great leaders in all the big advances in medical science. Three centuries ago there was published a little book, which I saw described the other day in "The History of Medicine" as the greatest book on medical science in the whole of its history. That was the little book by William Harvey, which described for the first time the circulation of the blood. It shows that the blood circulates all over the body, and that it is pumped round and round by the heart. His fundamental work was followed up by younger colleagues, who showed how this circulated blood carries throughout the tissues of the body the oxygen necessary to keep them alive. What a great discovery that was. I must not go on to give a catalogue of the great men of our race who have continued the development of science, but I would remind hon. Members of Joseph Lister, the founder of modern surgery, Patrick Manson, so well known in the field of tropical medicine, and that little country doctor, Jenner, in Gloucestershire, who laid the foundations for all immunisation, which plays such a great part in our life today. These voluntary hospitals, while they are voluntary, are centres of charitable effort. The people of their regions are proud of them, and give their wealth to keep them going. I know many of my friends look down upon charity, and think that it is a dreadful thing that people should subsist on charity, or should even benefit by it. I can only say that I have a rather different view. I remember as a lad being taught that old saying:
Charity nowadays is simply another word for human kindliness, and human kindliness is surely one of the most beautiful things in the whole of our spiritual outlook, and should be allowed to flow in all its fullness."Faith, hope, charity, these three; but the greatest of these is charity."
Mr. Richard Law (Kensington, South)
Last Thursday, when the Business for this week was announced, my right hon. Friend the Member for Warwick and Leamington (Mr. Eden) asked the Leader of the House whether this Debate might not be postponed. He asked that question because he, and we on this side, felt that to have a Debate at this time, while members of the medical profession were making up their minds on the great issues we have been discussing today, could only have the effect of muddying the waters and injecting a further infusion of party politics into issues which have already been sufficiently bedevilled by party politics. I still regret that we have had this Debate. There have been a number of detached, dispassionate, and sincere speeches, such as the one to which we have just listened, from my hon. Friend the Member for the Scottish Universities (Sir J. Graham Kerr), and the hon. Member for Barking (Mr. Hastings). But "the raucous speech of a politically poisoned person" if I may quote the Minister of Health—to which we listened at the beginning of the Debate—has done incalculable harm to the cause we all have at heart.That cause as, I think, the whole House will agree, is this: on whatever side of the House we sit we are hoping that the National Health Service Act will be made effective, and will become effective on the appointed day. The violence, however, of the Minister's attempt to drive a wedge into the medical profession, to make them disloyal one with another, is not likely, I fear, to bring about a reconciliation between him and the medical profession. The Minister was very anxious that we on this side should make our position clear. My right hon. Friend the Member for Saffron Walden (Mr. R. A. Butler), and my hon. Friend the Member for Putney (Mr. Linstead) and others, have made that position abundantly clear—
What is it?
—but, especially in the light of that interruption, I will try to summarise the position of those of us who sit on these benches.We did not seek this Debate. We believe that it is wrong to attempt to influence, on political grounds, a decision on the part of the medical profession which ought to be come to on the grounds of judgment and of conscience alone. We have not sought to influence that decision, and in nothing I am saying now do I intend to seek to influence it. I say that the more emphatically because of one fact we all have to remember. If the doctors, in the exercise of their independent judgment, decide to take a certain course, and to stay out of the National Health Service, they will undoubtedly be accepting a financial risk, even if it is only a temporary risk. I think it would be extremely wrong for any Member of this House, for whatever reason, to try to egg on people outside this House to take risks of that kind.
I cannot give way. The Minister made a long and provocative speech without one interruption from this side. He had an infinity of time at his disposal, but I am tied to time. Therefore, I must ask hon. Members to forgive me if I do not give way to every interruption.The Minister of Health besought us to remember the middle class, as though we were likely to forget either the middle class or any other class of the community. I think that the right hon. Gentleman is inclined to forget that it is that side of the House which speaks and acts for the "tinker's cuss." It is this side that tries, at any rate, to consider the interests of the community as a whole. From that point of view alone, we are sincerely anxious that the Minister and the medical profession should reconcile their differences, and that this Act should become effective on 5th July. In saying that I am making no recantation. When the Bill was before the House we held very strong views on certain parts, of it, and we thought then, as we think, now, that the Act would have been a much better one if our views had been accepted. The decision of Parliament, however, went against us, and we are not seeking to exploit the most unhappy situation that has arisen outside of Parliament in order to get that decision reversed. It will be open to another Parliament to reverse it, if it thinks fit, but we are not seeking to reverse the decision of Parliament by stirring up any extra-Parliamentary action. We are not seeking, to use the eloquent phrase of the Minister, to, "sabotage the will of Parliament." There is one question that I think we ought to ask ourselves, both in order to clarify our own minds which on that side of the House, at any rate, seem to be in some confusion, and in order to clarify the minds of the public to whom, after all, we owe some responsibility. What is the will of Parliament? There is very great confusion about that. I think that anybody sitting in the Gallery or, indeed, on the Floor of the House who listened to the Minister this afternoon, would have come to the conclusion that it was the will of Parliament that the doctors and dentists should be compelled to enter the National Health Service. Anyone who read the speech of the Chancellor of Exchequer in Edinburgh on Saturday would come to the same conclusion—that Parliament had laid it down that doctors were under compulsion to enter the National Health Service. [HON. MEMBERS: "Nonsense."] It is all very well for hon. Members opposite to say "Nonsense," but let them listen to what the Chancellor, in fact, said:
He went on to say:"If democracy is to survive in this country, the minority must conform to the reasonable wishes of the majority and we must all subordinate our own interest to those of the nation."
It cannot possibly be maintained in the light of what is contained in the National Health Service Act, and in the light of the repeated pledges which the Minister himself has given, that if the doctors refuse to go into the national health service on grounds of judgment and of conscience, they are flouting the will of Parliament. In fact, they are only exercising a right to a freedom of choice which Parliament has expressly guaranteed to them. It is of importance that hon. Members opposite, and the great general public outside, should realise that fact. It would be a different matter if there was any question of the doctors refusing to succour the sick. There is no question of that. It cannot be said from any reading of the Act or any interpretation of the various undertakings that the Minister has given us, that if one, or 1,000 or 50,000 doctors refused to accept service under the scheme, they are flouting the will of Parliament. I would like to discuss the attitude of the Minister on this point, because it seems to be a little ambiguous. The burden of his speech this afternoon was that the British Medical Association did not represent the doctors and were gulling and deceiving the doctors and pulling the wool over the doctors' eyes. [HON. MEMBERS: "Hear, hear."] If hon. Members opposite really believe that the medical profession of this country is so gullible that it cannot form a judgment on an issue of this kind, complicated as it is, I must say that it is a bad look-out for the health service in any case. The right hon. Gentleman made some play with this question of the open poll. He said that it was the antithesis of democracy. I am not sure whether I have used his exact words. He said that it was undemocratic and that it laid the way open to intimidation. In reply to my right hon. Friend the Senior burgess for Oxford University (Sir A. Salter) he repeated the answer which he gave in the House of Commons the other day. If it is not unparliamentary for me to do so, I say that when the Minister takes that attitude it is really the most absolute humbug. If the Minister thinks that the open ballot is undemocratic, I would ask him how otherwise the collective opinion of the medical profession could be discovered. Would he think it more democratic to have a ballot that was not signed? If the British Medical Association had issued ballot forms to be returned without any signature or means of identification, surely the right hon. Gentleman would have said that the ballot was cooked? And he would have been quite right, because it would have been open to anyone to get hold of a form and to fill in the answer they liked. The reason that I say the Minister's whole attitude is humbug rests on something else also. A year ago the right hon. Gentleman entered into negotiations with the British Medical Association on various assumptions One assumption was that he did not exclude an amendment of the Act and another was that when the negotiations were over, whatever the result, there would be a ballot of this kind."There is a dangerous spirit abroad among certain groups who seem to think their own interests and opinions ought to overrule the decisions of the nation. Such an attitude appears to be adopted by the leaders of the doctors at this moment. …"
The right hon. Gentleman shakes his head, but let me remind him that on 28th January, 1947, the representative body of the British Medical Association passed a resolution running:
That was another plebiscite with an open ballot, so the Minister knew all about the habit of the B.M.A. in having open ballots—"The association, having considered the final results of the plebiscite."—
The Minister must have known perfectly well that the plebiscite would be in this form."and the Minister's letter of 6th January … is willing that discussions be entered into with the Minister to that end, provided that such discussions are comprehensive in their scope and the possibility that they may lead to further legislation is not excluded, and that after the conclusion of those discussions, a second plebiscite be taken on the issue of entering the service."
Oh, no. The former plebiscites taken by the B.M.A. have been for the purpose of collecting opinions. This present plebiscite is for the purpose of determining action.
That really is a distinction without a difference, from the point of view of this argument, and it is a confession, out of the Minister's own mouth, what sheer humbug this point on which he has laid so much stress really is.The Minister said there were four main points at issue. They are the buying and selling of practices, the question of partnerships, the question of the capitation fee and the appeal to the High Court. The Minister advanced a number of arguments, some of them, I agree, arguments of force, why his view was right and the view of the B.M.A. was wrong; but the arguments he advanced were not conclusive. He said that the buying and selling of patients was repugnant to the people of this country. I do not think anybody would deny that. He did not, however, point out that in the view of the B.M.A., in the view of doctors as a whole, and in the view of very large numbers of people in this country, it is not a question of the buying and selling of patients but of the buying and selling of goodwill, and that goodwill has to be justified in the event by the patient himself, and no matter what money passes, if the patient does not like the doctor, the patient will leave him. If the Minister and his supporters behind him are really so stirred morally by the purchase of practices—of goodwill—why is it that in the Act dental practices are not interfered with? Surely a moral wave of that kind should sweep away dental practices as well as medical practices? In the Minister's view it must still be the buying and selling of patients.
Major Bruce (Portsmouth, North)
There is no parallel.
They are still human beings. The fact is that the British Medical Association regard the buying and selling of practices as a convenient method for the distribution of practices. They may be wrong in saying that it is the best method, but at least it can be said that that method is free from any element of direction, and they argue that the complicated and cumbersome method which the Minister has proposed contains an element of direction, and it is that element of direction of which they are afraid—
Mr. S. Silverman
Will the right hon. Member tell us what he is afraid of?
Then there is the question of partnerships. In his speech this afternoon the Minister made great play with the experience of previous Ministers of Health with the B.M.A. He said it was quite clear from the experiences of Mr. Willink, Mr. Ernest Brown and others, that it was not he as Minister of Health who was at fault but the B.M.A. I wonder whether anyone who listened to his violent, passionate speech this afternoon could have believed that he was a good negotiator? He said that the doctors had been confused by the B.M.A. about the whole partnership business. It was not only the doctors who were confused by the B.M.A., it was so eminent a counsel as Sir Cyril Radcliffe who gave it as his opinion that the B.M.A. were right and the Minister was wrong. The Minister now says that he has made a concession on that—he still thinks he is right, but he will refer the matter to an impartial tribunal at once. When did the Minister make that concession?
A fortnight ago—
Then did he make it in negotiation with the B.M.A.?
—as a result of the fact that the B.M.A., in its discussions and propaganda, had so confused the minds of the general practitioners as to make it necessary to reassure them.
The Minister has not answered my question. The Minister was negotiating with the B.M.A.—
I have already explained that the B.M.A. had said, before the discussions started, that they had decided to reject the whole Act. No negotiations, obviously, could take place.
I do not think that will hold water. I was extremely surprised and, if I may say so, shocked when I heard the Minister this afternoon say that while he was still negotiating, he was presented with a printed circular rejecting the Act, ending the negotiations—
That printed circular to which he referred is simply the statement of the case put forward by the B.M.A.—[HON. MEMBERS: "Oh."] Yes, it is—
The right hon. Gentleman should read page II which says:
They then include a list."In many respects the Act as it now stands is unacceptable to the medical profession. The main points which need modification, in most cases by amendment of the Act, to secure the approval of the majority of the profession include:"
Yes, the Minister meets the B.M.A. on the basis of negotiating with them the terms on which they will come into the service, and he does not exclude from those terms the amendment of the Act. All that document was—which the Minister represented this afternoon as an ultimatum to him, a rejection of all negotiations—was a perfectly plain and, I should have thought, relatively mild statement of the B.M.A. case. [Laughter.] It would be a good idea if hon. Members opposite who are so amused by what I have just said would read that statement. It is not only in the Library but also in the "British Medical Journal."The point I was making before the Minister interrupted me was that he made a concession on this point, not with those with whom he was negotiating, but in a newspaper interview. If that is the Minister's idea of negotiating with the profession it is little wonder that his negotiations have failed. Then there is the question of the capitation fee. The right hon. Gentleman says, "Why do they worry, because, after all, at any time in the last 30 or 40 years it was possible for the Minister of Health to impose a basic salary on the profession and it did not worry them? Why, therefore, does it cause them anxiety now?" It causes them anxiety now because they are in the National Health Service in which they were not then, and they are in the process, as they fear, of becoming a nationalised health service. Thus, this question of capitation fee and basic salary assumes an entirely different importance in their minds. It is, I am sure, in the minds of all of us a great tragedy that this difference remains unresolved. It is a great tragedy not for the Minister, not for the British Medical Association, not even for us in this House, but it is a great tragedy for the people of this country. I would ask the Minister whether it is not as yet too late for him to seek some accommodation with the medical profession. The hon. Member for Northern Dorset (Mr. Byers), who is the Chief Whip of the Liberal party—the only person I have seen him whip is himself—did make the same kind of appeal both to the Minister and to the P.M.A., but he said the onus was on the B.M.A. I do not agree, not because I am supporting the B.M.A. against the Minister—though I would not hide from the House the fact that in my opinion on most points the B.M.A. is right and the Minister is wrong—but because the Minister is in a very strong position. He has this immense Parliamentary majority behind him, a majority which would nationalise the medical profession at the flick of his fingers. He can afford to be generous. There is another reason why I think the onus is on the Minister. I said just now that the medical profession attach more importance to the capitation fee within the context of this Act than they did before. It would probably be fair to say that the medical profession attach more importance to every one of those things within the context of this Act than they did before, and if the Minister could give way on one of them he might find—[HON. MEMBERS: "Which one?"] I do not know. I am not speaking here for the British Medical Association; I am speaking for His Majesty's Opposition. If the Minister could give way on one thing—any one thing—he might find that he had broken the long jam. Hon. Members may know that very much the same thing happened in Northern Ireland, where they had a comprehensive Health Service Act like this one, and the Minister, as he is here, was negotiating with the medical profession, which felt strongly on all these points. When the Minister showed some willingness to give way, and he did once on the question of the courts, for example, he found that the whole atmosphere of the medical profession had changed and he was able to come to an agreement with them. I tell the Minister now what I believe to be the truth. I think the public is not particularly pleased either with the British Medical Association or with the Minister. I think it is felt generally that, if the B.M.A. have been stubborn, so has the Minister; and I think it is also felt that it is in the power of the Minister to break this log jam, because he is the stronger party and because it is in his power to give and to make Amendments to the Act, and it is not in the power of the B.M.A.
Mr. Scollan (Renfrew, Western)
What is wrong with the Act, anyway?
What is wrong with the Act? We are not debating the Act; we are debating the question of the Health Service coming into effect on the appointed day. On this side of the House we hope that it will come into effect on 5th July, and we welcome its coming into force on that date, but what we cannot accept is satisfaction that the conditions under which the doctors are to participate are
We cannot accept that proposition for two reasons. The first is that none of us, either on this side of the House or the other, know what these conditions are. The second reason is that we believe that, in present circumstances, the only people who can decide whether these conditions are in accordance with their traditional freedom and dignity are the members of the profession themselves. Therefore, I beg to move, to leave out from "people" to the end of the Question, and to add:"generous and fully in accordance with their traditional freedom."
"but declines to prejudice in any way the right of individuals in all the professions concerned to express their opinions freely, according to their traditions, and in the interest of their patients, upon the terms and conditions of service under the proposed National Health Scheme."
The Secretary of State for Scotland (Mr. Woodburn)
As Secretary of State for Scotland, I came into these negotiations at a very late time in their development. Indeed, my first meeting was in the famous negotiations over the last two days. I came in with a fairly objective mind, and with a considerable sympathy for the doctors, who are facing a great change in their lives. Therefore, I could look at the whole proceedings with a certain amount of impartiality as between the Minister and the doctors. I would like to say that I was shocked that negotiations which were to last for two days were opened by a statement from the chairman of the Negotiating Committee that they had issued the draft statement of their position, that it could not be altered, and that 50,000 had already been printed before the negotiations started. That seemed to me to be a ridiculous point from which to start negotiations.Throughout these negotiations, I never saw the slightest sign of the British Medical Association and the Negotiating Committee being willing to accept the position put forward by the right hon. Member for South Kensington (Mr. Law)—that, if any concession were given, they would be willing to work the scheme with good will. That was entirely absent from the whole negotiations, as viewed by me. Therefore, I can honestly state that I saw no sign whatever that the British Medical Association and their associates are prepared to work the scheme. In my view, they seemed to be more keen on having a fight than getting a settlement. Therefore, it is a rather difficult—
Sir H. Morris-Jones
On a point of accuracy, the right hon. Gentleman refers to the last two days of the negotiations at which he was present. Is it not a fact that negotiations have been going on for months, and that the Minister has never made any attempt to meet the doctors' point of view?
I am only speaking about the last two days when I was present. It is quite untrue—and I state this categorically—to say that the Minister was contemptuous in these negotiations. He asked right away whether that was the final word of the B.M.A., and the chairman said, "Yes." All that happened—and all that could happen—was that the B.M.A. and their party wanted to hear the reply of the Minister verbatim to what they had put down. That was eventually compiled and issued to the doctors throughout the country. This Debate might not have been necessary, and the doctors might have been left free to pass their judgment on these questions, had it not been for the fact that the whole discussion had been muddied and blurred by a propaganda campaign initiated by the B.M.A. which has perverted the whole discussion.There are two issues with which I want to deal as calmly as I can. There has already been far too much heat and emotion engendered throughout the country on this matter. The first issue is the Opposition Amendment. Quite frankly, I think it is entirely irrelevant to this discussion. [An HON. MEMBER: "Why accept it then?"] If it pleases hon. Members opposite, we are quite ready to add it to the Motion. The point is that this discussion is taking place in order that Members may have an opportunity of saying to the doctors of this country, "This is an Act of Parliament passed by this House. We want you to help to bring it into force with good will and co-operation. If any difficulties arise, this House will be prepared to take steps to put them right." That is the message we wish to send to the doctors from this House of Commons. The real issue is whether it is in the public interest that doctors should be misled and pressed to boycott and refuse to carry out an Act of Parliament. The question has been raised today whether the doctors are free to come in or to keep out of the service. There are two separate questions which are confusing people today. The first is that it is quite right that the doctor should have the conscientious right to say, "I shall not enter the scheme; I shall stay out and preserve my private practice." On the other hand, it is certainly not within the bounds of liberty to say, "I shall conspire with the B.M.A. to prevent the scheme being inaugurated." Had the clear issue been honestly presented, the doctors would have accepted the new Health Service with good will and enthusiasm. But this B.M.A. campaign has blurred the truth, and misrepresentation and suspicion have made many decent doctors so confused that they do not know where they are. Moreover, they have now been presented with an entirely false issue; whether they shall be loyal to the British Medical Association and the Negotiating Committee, or loyal to the country. If it is a question of loyalties they ought to be loyal to the community and to the patients whom they serve, even if it means disloyalty to this campaign of the British Medical Association. Let us examine the British Medical Association's case. The weakness of that case is proved by the necessity to import abuse, misrepresentation and misstatements to secure support for the boycott. The first and greatest abuse has been about the Minister. The Minister, as he said today, has not made any public statements about this matter at all, and, therefore, he has imported no prejudice into the discussion. [Laughter.] That is absolutely true, and I challenge anybody to deny it. As the Minister pointed out, he is not the first Minister who has been negotiating with this body, and it is common knowledge that Mr. Ernest Brown was at loggerheads with them and that at the last they were hardly on speaking terms. In the case of Mr. Willink, even after he had given way to them and brought forward a scheme that seemed to meet them, they even rejected that scheme. There is no justification for saying that it is the particular Minister who is now in charge of the negotiations who has caused this revulsion. It has obviously existed before. The hon. Member for London University (Sir E. Graham-Little), who represents the doctors, with two of his colleagues wrote in the "Daily Telegraph" this morning:
He was putting that forward to prove that they were not favourable to the Conservatives as against the Socialists, but it proves just the same that they are prepared to oppose any scheme unless they get their own way on every point. Unfortunately, the British Medical Association case has varied at every stage of the negotiations. When a concession is made on one point they go on to a new point and, therefore, it is difficult to keep track of what their case really is. The hon. Gentleman presented the case as the British Medical Association is presenting it to the doctors throughout the country, with all its prejudice and colour; and, therefore, from the point of view of presenting the case to the House for the British Medical Association, he did it very well. So far as I can see, there are about five real points which they bring forward: the element of fixed salary, the abolition of sale of practices, what they call negative direction, the legal obscurity about partnerships, the dismissal procedure, and the appeal to the courts. The point concerning partnerships was made at the negotiations when we met, and the doctors certainly put forward cases in which doctors were in considerable doubt as to what would happen in regard to the partnerships. The Minister gave an explanation of his interpretation of the law, and said that if it was proved by any court to be wrong the Government would undertake to introduce legislation to put it right. That seemed to me to be an absolute assurance to the doctors, but they are still not satisfied. Therefore, since the negotiations, the Minister has gone further to meet them by appointing an independent legal body to go into this question and propose what should be done to satisfy them. I agree that all these points could give rise to legitimate differences of opinion in negotiation, but if the doctors and the medical people had adopted a spirit of negotiation there is no reason at all why they could not have been investigated in a calm fashion to ascertain whether there was any way out of the difficulty. If any serious problem still afflicts the doctors in relation to the working of the Act, the Government will certainly be prepared to examine it at any time. I have said there has been misrepresentation. That has evidently been met by scoffing from some hon. Members and I therefore propose to provide some instances. The Minister has already quoted some papers where he is described as a would-be dictator and a would-be Fuehrer. Why? What has the Minister been doing? He has been carrying out an Act of Parliament; the Minister has done nothing but try to carry out an Act as passed by this House, and I suggest that it is an ill-service to democracy to describe a Minister obeying the will of this Parliament as a dictator or Fuehrer. The B.M.A. said in the document sent out to the doctors that there were organisations in conflict with the members of the profession, and it goes on to say:"… the proposals for a similar but less mischievous scheme laid before Parliament by the Coalition … in 1944 was opposed by the medical profession in nearly as universal a measure as now."
I ask you—the profession has a conviction! How does the B.M.A. know the profession has this conviction? They have not yet taken a fresh ballot, and the previous ballot, as my hon. Friend the Member for Barking (Mr. Hastings) showed, gave an exactly opposite view. They start with a conviction they know nothing about—about "the Act leading unmistakably towards a whole-time State medical service"—which is pure conjecture, suspicion and fear—"The conflict is based on the profession's conviction that the Act leads unmistakably towards a whole-time State medical service."
Why are the powers there?
The powers have been there for 36 years and are still there, this Act will not make any difference. A second document sent to the doctors from the Insurance Acts Committee says:
Who are they to say what is the best interests of the public? That is what the House of Commons is here to say—not the doctors. They advise the insurance practitioners formally to reject it in the forthcoming plebiscite. I am glad the right hon. Gentleman the Member for South Kensington was very cautious. He said he was not going to advise the doctors to resist this scheme, largely on the grounds, I gathered, that it might cost them something financially. That seemed to be a kind of negative direction to the doctors in regard to this scheme and I hope they will take this negative advice and be positive in accepting the scheme. A question has arisen about the secrecy of the ballot. It is suggested that the ballot is secret, but there is a good deal of evidence to show that it is not quite so secret. Actually, the ballot itself and what is following from it shows a considerable degree of conspiracy to prevent the doctors having a free choice. I have a document which has been sent out to doctors in at least one area:"The Committee condemns the National Health Service Act, 1946, in its present form as contrary to the best interests of the public."
"It is urgently requested that if you have not already done so you will return the completed plebiscite form to London to arrive not later than Monday, the 9th instant, owing to later developments. Kindly inform any non-member of your acquaintance regarding this request."
Squadron-Leader Sir Gifford Fox (Henley)
Which branch was that?
It was from the Gloucester branch of the B.M.A. In another area it was said:
They ask the member to tell them whether he is going to vote "Yes" or "No" and what his reply will be to the various questions and also:"Before calling another meeting of our group to discuss the B.M.A. plebiscite I think it will be very helpful if you would please fill in the enclosed form."
Not only that; but in the document sent out to the doctors the doctors are informed that local committees are to be set up to watch that doctors do not change their minds. They say they want to advise doctors in good time if there is any change. These little groups—these security groups, although that is an ugly name—[HON. MEMBERS: "Shop stewards."]—are to safeguard the position and see that doctors do not change their minds. This is also becoming to some extent a political campaign. I agree that the right hon. Member for South Kensington did not take up that attitude, but the right hon. Member for Saffron Walden (Mr. R. A. Butler) certainly gave it that aspect. He indulged in a political campaign against my right hon. Friend without arguing the merits of the scheme at all. I really think that, in a serious national issue of this kind, where there is a challenge to an Act of Parliament, it ill behoves the right hon. Gentleman to use this Debate for purposes of that kind; and I am sure it ought to be foreign to his nature, and would be in the normal way. Let me give some evidence of how this is turning into a political campaign. The B.M.A. say:"I promise to inform the members of my group immediately if at any time before 5th July I change my mind."
If hon. and right hon. Gentlemen opposite take that attitude they raise a very ugly argument. What will their attitude be if and when they come into power here again—which I doubt—and they carry Acts of Parliament which the workers regard as dictatorship of the State? The B.M.A. go on to say that it is their conviction that this scheme leads unmistakably to a whole-time medical service and that those who enter it will be whole-time State medical servants. My right hon. Friend has already made clear that, so far as the Government are concerned, they do not accept the Coalition proposition of a full-time salaried service, and that what we have done is to accept the proposition that, largely—not wholly—in accordance with the desires of the medical profession, there is to be a basic salary element in the payment. The B.M.A. case says:"We are faced today with that recurring historical phenomenon, the dictatorship of the State."
They want an assurance about that. While we cannot pledge future Parliaments, the Government give the assurance here and now, and the point to remember is that that was put on the Statute Book 36 years ago; and if it is to be another 36 years before another change takes place I do not think the doctors need worry about that—not the present lot, anyway. In any case, before such a change were made the doctors would have an opportunity of expressing their views. They would have the opportunity of doing so then without making all this fuss in anticipation of something that may never arise. The B.M.A. say that doctors like all other workers should be free to choose the form and place and type of work they prefer, without Government or any other direction. I am not quite clear what other workers they are referring to. I have never met those workers. They are certainly not the teachers, and certainly not the lawyers, because even lawyers have to go where the law is. Everybody has to go where there are jobs. I am surprised to hear that the doctors have any other point of view. Moreover, in practice today doctors have to go to those places where there are empty practices, otherwise they would be described by their colleagues as blacklegs. This question of negative direction is closely bound up with this. As my hon. Friend the Member for Barking pointed out, the doctors in their votes approved of this to the proportion of 57 per cent. to 39 per cent. against. Even the general practitioners voted 51 per cent. for and 45 per cent. against. Therefore, the Government have a majority of doctors in favour of this, in the last free ballot without any intimidation. [HON. MEMBERS: "No."] Well, the ballot was taken for the doctors by the British Institute of Public Opinion, and we accept the vote then taken as a legitimate and fair vote."The medical profession is in the public interest opposed to any form of service which leads directly or indirectly to the profession as a whole becoming a full-time salaried service of the State or local authorities."
Colonel Gomme-Duncan (Perth and Kinross, Perth)
Is there not intimidation now?
I turn to the so-called "negative direction." Today, every industrialist who wants to start up a factory has to submit to some negative direction from the Minister of Town and Country Planning. Today, nobody is prepared to say that people should be allowed to start building where they like.
Sir G. Fox
Another "police State."
Moreover, the location of industry is not a free thing today. In London, nobody is allowed to start up—[Interruption.] There is certainly not freedom to make the mess of the country permitted by hon. Members opposite. In the location of industry, it is not permitted in an area already overbuilt and over-populated, such as London, to allow new industries to flock in and to make the place into an even greater octopus. That is not to say that they will not go anywhere they like outside, provided they find a place where there is room to start up, and where there is labour to employ. That can also be described, in the same way, as negative direction. Even under the Education Act of the right hon. Member for Saffron Walden teachers have to go where the jobs are.Let me now deal with the appeal to the courts. I can imagine nothing more fantastic than this dispute over the appeal to the courts. In 36 years, in Scotland three doctors were sacked and in England 46 doctors were sacked. If we take one in 50 as a reasonable proportion of mistakes that might be made in the dismissal of people, it means that there is a million to one chance of any particular doctor being unjustly dismissed in any year. Yet, on the basis of that million to one chance of a doctor being dismissed, the doctors are, presumably, prepared to wreck a great National Health Scheme. The thing is too ridiculous to argue.
There was a very considerable vote, although not a majority, in favour of the basic salary. Even now, the doctors accept the principle of the basic salary as applied to special areas. I have been asked the reason for the basic salary. One of the reasons is that it helps young doctors—which is admitted by everybody; secondly, it is a convenient basis for an inducement to people to go to difficult areas; and, thirdly, it reduces the temptation to build big lists; and, more than that, as a doctor's practice tapers off, it is made easier for him to give up patients as he reaches old age.The Beveridge Report, which gave birth to this scheme, thrilled not only this country but the world. The social security adumbrated in that Report is now on the statute book. We have family allowances, school feeding, adequate benefits for the maimed, the sick and the ageing, and the abolition of the Poor Law is on the way. Here we have a great National Health Scheme. No Measure had greater unanimity in the British Parliament than this. The appointed day, 5th July, is the V-Day, when we are to attack the five giant social evils. Everyone—civil servants, teachers, local authorities, and communities throughout the country—is involved, and is striving with every effort to be ready on 5th July to introduce this great scheme—with one important exception: the British Medical Association, which is prepared to wreck the scheme, and to refuse to carry out this Act of Parliament on grounds which, when we consider the great measure of agreement over 99 per cent. of the scheme, are really trivial, based on conjecture, and utterly misconceived. The B.M.A. are telling the doctors that if they do not carry out the scheme, the Minister may as a result postpone the appointed day, and that if he does not he will be unable to promise a comprehensive service. They say that whatever final settlement follows, the Association will insist on a non-victimisation clause covering inter alia capital value, and that if a sufficient number of general practitioners stand firm, all will retain their capital values. They go on to say that if the general practitioners stand out and depend on patients' fees, they will see that the Government cannot allow such a situation to continue. I say very solemnly to the doctors that the B.M.A. have no authority and no knowledge which will justify them giving such a pledge to the doctors. I certainly cannot, on behalf of the Government, see that there is any merit or foundation in that promise they give to the doctors. The law clearly lays down that doctors who do not come in on 5th July do not share in the £66 million which is granted towards capital values. [HON. MEMBERS: "Intimidation."] It is a simple statement of fact. The doctors' position, according to the Act, is that if they do not come in on 5th July, then they cease to be doctors under the National Insurance Scheme, and depend entirely on private patients. No one can alter that, unless a new Act of Parliament is passed. On the other hand, if a doctor comes into this scheme, he has one of the finest jobs in the world. He has a basic salary, plus capitation fees. He is left free to carry out his clinical work with the greatest freedom. He gets right away, every year, interest at 2 per cent. on the capital value of his practice. He gets a capital sum on retirement, and a retirement allowance or gratuity. His widow gets a right to a pension, and he has the right to divert part of his pension to his dependants; and he can receive fees for other work. Can anyone point to anyone else in the community who has conditions which compare to that? The purpose of this Debate is not to force injustice on the medical profession, but to make clear that doctors are being asked to injure, at its birth, the greatest Health Service in the world, on the basis of unfounded, suspicious and unreal fears, and hypothetical injustices. On the other side, there is service to health and healing, security for the doctor and his wife, now and in retirement, unfettered opportunity for specialist co-operation in treatment of their patients. No Government will ever refuse to redress real grievances, and the
Division No. 72.]
|Acland, Sir R.||Cocks, F. S||Gaitskell, Rt. Hon. H. T. N.|
|Adams, Richard (Balham)||Coldrick, W||Ganley, Mrs. C. S.|
|Allen, Scholefield (Crewe)||Collick, P||George, Lady M. Lloyd (Anglesey)|
|Alpass, J H.||Collindridge, F.||Gibbins, J.|
|Anderson, A. (Motherwell)||Collins, V. J.||Gibson, C. W.|
|Anderson, F. (Whitehaven)||Colman, Miss G. M.||Gilzean, A.|
|Attewell, H. C.||Comyns, Dr. L.||Glanville, J. E. (Consett)|
|Attlee, Rt. Hon. C. R.||Cook, T. F.||Gooch, E. G.|
|Austin, H. Lewis||Cooper, Wing-Comdr. G.||Granville, E. (Eye)|
|Ayles, W H.||Corbet, Mrs. F. K. (Camb'well, N.W.)||Grey, C. F.|
|Ayrton Gould, Mrs. B.||Corlett, Dr J.||Grierson, E.|
|Bacon, Miss A.||Cove, W. G.||Griffiths, D. (Rather Valley)|
|Baird, J.||Crawley, A.||Griffiths, Rt. Hon. J. (Llanelly)|
|Balfour, A.||Cripps, Rt Hon. Sir S||Griffiths, W. D. (Moss Side)|
|Barnes, Rt. Hon A. J||Crossman, R. H S.||Gunter, R. J.|
|Barstow, P. G.||Daggar, G.||Guy, W. H.|
|Barton, C||Daines, P.||Haire, John E. (Wycombe)|
|Battley, J. R.||Dalton, Rt. Hon. H.||Hale, Leslie|
|Bechervaise, A. E.||Davies, Clement Rt. Hon. (Montgomery)||Hall, Rt Hon. Glenvil|
|Bellenger, Rt. Hon F. J.||Davies, Edward (Burslem)||Hamilton, Lieut.-Col. R.|
|Benson, G.||Davies, Ernest (Enfield)||Hannan, W. (Maryhill)|
|Berry, H||Davies, Harold (Leek)||Hardman, D. R.|
|Hardy, E. A.|
|Beswick, F.||Davies, Haydn (St. Pancras, S.W.)||Harrison, J.|
|Bevan, Rt. Hon. A (Ebbw Vale)||Davies, S. O. (Merthyr)||Hastings, Dr. Somerville|
|Bevin, Rt. Hon. E (Wandsworth C.)||Deer, G.||Haworth, J.|
|Bing, G. H. C.||de Freitas, Geoffrey||Henderson, Rt. Hn. A. (Kingswinford)|
|Binns, J.||Delargy, H. J||Henderson, Joseph (Ardwick)|
|Blackburn, A. R||Diamond, J.||Harbison, Miss M.|
|Blenkinsop, A.||Dobbie, W.||Hewitson, Capt. M.|
|Blyton, W. R.||Dodds, N. N.||Hicks, G.|
|Bottomley, A. G.||Donovan, T.||Hobson, C. R.|
|Bowden, Flg.-Offr. H. W||Driberg, T E. N.||Holman, P.|
|Bowles, F. G. (Nuneaton)||Dugdale, J. (W. Bromwich)||Holmes, H. E. (Hemsworth)|
|Braddock, Mrs. E. M. (L'pl, Exch'ge)||Dumpleton, C. W||House, G.|
|Braddock, T. (Mitcham)||Durbin, E. F. M.||Hubbard, T.|
|Bramall, E A.||Dye, S.||Hudson, J. H. (Ealing, W.)|
|Brook, D. (Halifax)||Ede, Rt. Hon. J. C||Hughes, Emrys (S. Ayr)|
|Brown, George (Belper)||Edelman, M.||Hughes, Hector (Aberdeen, N.)|
|Brown, T. J. (Ince)||Edwards, John (Blackburn)||Hughes, H. D. (W'lverh'pton, W.)|
|Bruce, Maj. D. W. T.||Edwards, W. J. (Whitechapel)||Hutchinson, H. L. (Rusholme)|
|Buchanan, Rt. Hon. G.||Evans, A (Islington, W.)||Hynd, H. (Hackney, C.)|
|Burden, T. W.||Evans, E. (Lowestoft)||Hynd, J. B. (Attercliffe)|
|Butler, H. W (Hackney, S.)||Evans, John (Ogmore)||Irvine, A. J. (Liverpool)|
|Byers, Frank||Evans, S N. (Wednesbury)||Irving, W J. (Tottenham, N.)|
|Callaghan, James||Ewart, R.||Isaacs, Rt. Hon. G. A|
|Carmichael, James||Farthing, W J.||Janner, B.|
|Castle, Mrs B. A.||Fernyhough, E.||Jeger, G. (Winchester)|
|Chamberlain, R. A.||Field, Capt W. J.||Jeger, Dr. S. W. (St. Pancras, S.E.)|
|Champion A. J.||Fletcher, E. G. M. (Islington, E.)||Jones, D. T. (Hartlepools)|
|Chater, D||Foot, M. M.||Jones, Elwyn (Plaistow)|
|Chetwynd, G. R||Forman, J. C.||Jones, J. H. (Bolton)|
|Cluse, W. S.||Fraser, T. (Hamilton)||Jones, P. Asterley (Hitchin)|
|Cobb, F. A.||Freeman, Peter (Newport)||Keenan, W.|
sensible thing I suggest is for the doctors to start this scheme with good will, see how it works, and then let us review it, and if there are defects, the Government will then put them right. Let the House of Commons make this a unanimous appeal to the doctors to come in with good feeling and generosity, and work this scheme when 5th July comes as it was meant to be worked by the great spirits which gave it its initiation.
Mr. R. J. Taylor (Lord of the Treasury)
rose in his place, and claimed to move, "That the Question be now put."
Question put, "That the Question be new put."
The House divided: Ayes, 341; Noes, 177.
|Kenyon, C||Paling, Rt. Han Wilfred (Wentworth)||Strauss, Rt Hon. G (Lambeth, N.)|
|Key, C W||Paling, Will T. (Dewsbury)||Stress, Dr B|
|King, E. M.||Palmer, A. M. F.||Stubbs, A E|
|Kinghorn, Sqn.-Ldr. E.||Pargiter, G. A.||Summerskill, Dr. Edith|
|Kinley, J.||Parker, J.||Swingler, S.|
|Kirby, B. V.||Parkin, B. T.||Sylvester, G. O.|
|Lang, G.||Paton, Mrs. F (Rushcliffe)||Symonds, A. L.|
|Lawson, Rt. Hon. J. J.||Paton, J (Norwich)||Taylor, H B. (Mansfield)|
|Lee, F. (Hulme)||Pearson, A.||Taylor, R. J. (Morpeth)|
|Lee, Miss J. (Cannock)||Perrins, W.||Taylor, Dr. S. (Barnet)|
|Leonard, W.||Platts-Mills, J. F. F.||Thomas, D. E (Aberdare)|
|Leslie, J. R.||Poole, Cecil (Lichfield)||Thomas, Ivor (Keighley)|
|Lever, N. H.||Popplewell, E.||Thomas, I. O. (Wrekin)|
|Levy, B. W.||Porter, E. (Warrington)||Thomas, John R. (Dover)|
|Lewis, A. W. J. (Upton)||Porter, G. (Leeds)||Thomas, George (Cardiff)|
|Lewis, J. (Bolton)||Price, M. Philips||Thurtle, Ernest|
|Lewis, T. (Southampton)||Proctor, W. T||Tiffany, S.|
|Lindgren, G. S.||Pursey, Cmdr. H.||Timmons, J.|
|Lipton, Lt.-Col. M.||Randall, H. E.||Titterington, M. F.|
|Longden, F.||Ranger, J||Tolley, L.|
|Lyne, A. W.||Rankin, J.||Tomlinson, Rt. Hon. G.|
|McAdam, W.||Rees-Williams, D. R.||Turner-Samuels, M|
|McEntee, V. La T||Reeves, J.||Ungoed-Thomas, L|
|McGhee, H G.||Reid, T. (Swindon)||Usborne, Henry|
|Mack, J. D.||Richards, R.||Vernon, Maj. W. F.|
|McKay, J. (Wallsend)||Ridealgh, Mrs. M.||Viant, S. P|
|Mackay, R. W. G. (Hull, N.W.)||Robens, A.||Wadsworth, G.|
|Maclean, N. (Govan)||Roberts, Emrys (Merioneth)||Walkden, E.|
|McLeavy, F.||Roberts, Goronwy (Caernarvonshire)||Walker G. H.|
|MacMillan, M K. (Western Isles)||Roberts, W. (Cumberland, N.)||Wallace, H. W (Walthamstow, E.)|
|McNeil, Rt. Hon. H.||Robertson, J. J. (Berwick)||Warbey, W. N.|
|Macpherson, T. (Romford)||Rogers, G. H. R.||Watkins, T. E.|
|Mainwaring, W. H.||Ross, William (Kilmarnock)||Webb, M. (Bradford, C.)|
|Mallalieu, J. P. W.||Royle, C||Wells, P. L. (Faversham)|
|Manning, Mrs. L. (Epping)||Sargood, R.||Wells, W. T. (Walsall)|
|Mathers, Rt Hon. G.||Scollan, T.||Westwood, Rt. Hon. J|
|Medland, H. M.||Scott-Elliot, W.||Wheatley, J. T. (Edinburgh, E.)|
|Mellish, R. J.||Segal, Dr. S.||White, C. F. (Derbyshire, W.)|
|Messer, F.||Sharp, Granville||White, H. (Derbyshire, N.E.)|
|Middleton, Mrs. L.||Shawcross, C. N. (Widnes)||Whiteley, Rt. Hon W.|
|Mikardo, Ian||Shawcross, Rt. Hn. Sir H. (St. Helens)||Wigg, George|
|Millington, Wing-Comdr. E. R.||Shinwell, Rt. Hon. E.||Wilcock, Group-Capt. C. A. B.|
|Mitchison, G. R.||Shurmer, P.||Wilkins, W. A.|
|Monslow, W.||Silkin, Rt. Hon. L.||Willey, F T. (Sunderland)|
|Moody, A. S.||Silverman, J. (Erdington)||Willey, O. G. (Cleveland)|
|Morley, R.||Silverman, S. S. (Nelson)||Williams, D. J. (Neath)|
|Morgan, Dr. H. B.||Simmons, C. J.||Williams, Rt. Hon. T (Don Valley)|
|Morris, Lt.-Col. H. (Sheffield, C.)||Skeffington, A. M.||Williams, W. R. (Heston)|
|Morris, P. (Swansea, W.)||Skeffington-Lodge, T. C.||Williamson, T.|
|Morrison, Rt. Hon. H. (Lewisham, E.)||Skinnard, F. W.||Wills, Mrs. E. A.|
|Smith, C. (Colchester)||Wilmot, Rt. Hon. J.|
|Mort, D. L.||Smith, Ellis (Stoke)||Wilson, Rt. Hon. J. H.|
|Moyle, A.||Smith, H. N. (Nottingham, S.)||Wise, Major F. J.|
|Murray, J. D.||Smith, S. H. (Hull, S.W.)||Woodburn, A.|
|Naylor, T. E.||Solley, L. J.||Wyatt, W.|
|Neal, H. (Claycross)||Sorensen, R. W.||Yates, V. F.|
|Nichol, Mrs. M. E. (Bradford, N.)||Soskice, Sir Frank||Younger, Hon. Kenneth|
|Nicholls, H. R. (Stratford)||Sparks, J. A.||Zilliacus, K.|
|Noel-Baker, Capt. F. E. (Brentford)||Stamford, W|
|O'Brien, T.||Stewart, Michael (Fulham, E.)||TELLERS FOR THE AYES:|
|Oliver, G. H.||Stokes, R. R.||Mr. Snow and|
|Paget, R. T.||Strachey, Rt. Hon, J.||Mr. George Wallace.|
|Agnew, Cmdr. P. G.||Butcher, H. W.||Dodds-Parker, A. D.|
|Aitken, Hon. Max||Butler, Rt. Hon. R A (S'ffr'n W'ld'n)||Dower, Lt.-Col. A. V. G. (Penrith)|
|Amory, D. Heathcoat||Carson, E||Dower, E. L. G. (Caithness)|
|Assheton, Rt Hon. R||Challen, C.||Drayson, G B.|
|Baldwin, A. E.||Channon, H.||Drewe, C.|
|Beamish, Maj. T. V. H||Clarke, Col. R. S.||Dugdale, Maj. Sir T. (Richmond)|
|Beechman, N. A.||Clifton-Brown, Lt.-Col. G.||Duthie, W. S.|
|Bennett, Sir P.||Cole, T L.||Eccles, D. M.|
|Birch, Nigel||Conant, Maj. R. J. E.||Eden, Rt Hon. A.|
|Boles, Lt.-Col. D. C. (Wells)||Cooper-Key, E. M.||Elliot, Lieut.-Col., Rt. Hon. W|
|Boothby, R.||Corbett, Lieut.-Col. U. (Ludlow)||Erroll, F. J.|
|Bossom, A C.||Crockshank, Capt. Rt. Hon. H. F. C.||Fleming, Sqn.-Ldr. E. L.|
|Bower, N.||Crosthwaite-Eyre, Col. O. E.||Fletcher, W. (Bury)|
|Bracken, Rt. Hon. Brendan||Crowder, Capt. John E.||Foster, J. G. (Northwich)|
|Braithwaite, Lt.-Comdr J. G.||Cuthbert, W. N.||Fox, Sir G.|
|Bromley-Davenport, Lt.-Col. W.||Darling, Sir W. Y.||Fraser, H. C. P, (Stone)|
|Brown, W. J. (Rugby)||Davidson, Viscountess||Fyfe, Rt. Hon. Sir D. P. M|
|Buchan-Hepburn, P. G. T.||De la Bère, R.||Gage, C.|
|Bullock, Capt. M.||Digby, S W.||Galbraith, Cmdr. T. D|
|Gammans, L. D.||Mackeson, Brig. H. R.||Renton, D.|
|Glyn, Sir R.||McKie, J. H. (Galloway)||Roberts, H. (Handsworth)|
|Gomme-Duncan, Col. A||Maclean, F H R.||Roberts, Peter (Ecclesall)|
|Graham-Little, Sir E.||Macmillan, Rt. Hon. Harold (Bromley)||Robertson, Sir D. (Streatham)|
|Grimston, R. V||Maitland, Comdr. J. W.||Ropner, Col. L.|
|Hannon, Sir P. (Moseley)||Manningham-Buller, R. E.||Ross, Sir R. D. (Londonderry)|
|Harvey, Air-Comdre. A. V.||Marlowe, A. A. H.||Savory, Prof. D. L.|
|Haughton, S. G.||Marquand, H. A.||Scott, Lord W.|
|Head, Brig. A. H.||Marsden, Capt. A.||Shephard, S. (Newark)|
|Henderson, John (Cathcart)||Marshall, D. (Bodmin)||Shepherd, W. S. (Bucklow)|
|Hogg, Hon. Q.||Marshall, S. H. (Sutton)||Smith, E. P. (Ashford)|
|Hollis, M. C.||Maude, J. C.||Smithers, Sir W.|
|Holmes, Sir J. Stanley (Harwich)||Medlicott, F.||Spearman, A. C. M.|
|Hope, Lord J.||Mellor, Sir J.||Stewart, J. Henderson (Fife, E.)|
|Hulbert, Wing-Cdr. N. J.||Molson, A. H. E.||Stoddart-Scott, Col. M.|
|Hurd, A.||Moore, Lt.-Col. Sir T.||Strauss, H. G. (English Universities)|
|Hutchison, Lt.-Cm, Clark (E'b'rgh W.)||Morris-Jones, Sir H.||Sutcliffe, H.|
|Jarvis, Sir J.||Morrison, Maj. J. G. (Salisbury)||Taylor, C. S. (Eastbourne)|
|Jeffreys, General Sir G.||Morrison, Rt. Hon. W. S. (Cirencester)||Taylor, Vice-Adm. E. A (P'dd't'n, S.)|
|Joynson-Hicks, Hon. L. W.||Mott-Radclyffe, C. E.||Teeling, William|
|Keeling, E. H.||Neven-Spence, Sir B.||Thomas, J. P. L. (Hereford)|
|Kerr, Sir J. Graham||Nicholson, G.||Thornton-Kemsley, C. N.|
|Kingsmill, Lt.-Col. W. H.||Nield, B. (Chester)||Touche, G. C.|
|Lambert, Hon G||Noble, Comdr A. H. P.||Vane, W. M. F.|
|Lancaster, Col C. G.||Nutting, Anthony||Wakefield, Sir W. W.|
|Langford-Holt, J.||Odey, G. W||Walker-Smith, D.|
|Law, Rt Hon R. K.||O'Neill, Rt Hon. Sir H.||Ward, Hon. G. R.|
|Legge-Bourke, Maj. E. A. H.||Orr-Ewing, I. L.||Watt, Sir G. S. Harvie|
|Lennox-Boyd, A. T.||Osborne, C.||Webbe, Sir H. (Abbey)|
|Lindsay, M. (Solihull)||Peaks, Rt. Hon. O.||Wheatley, Col. M. J. (Dorset, E.)|
|Linstead, H. N.||Peto, Brig. C. H. M.||While, Sir D. (Fareham)|
|Lipson, D. L.||Pickthorn, K.||Williams, C. (Torquay)|
|Lloyd, Selwyn (Wirral)||Pitman, I. J.||Williams, Gerald (Tonbridge)|
|Low, A. R W.||Poole, O B. S. (Oswestry)||Willoughby de Eresby, Lord|
|Lucas, Major Sir J.||Prescott, Stanley||Winterton, Rt. Hon. Earl|
|Lucas-Tooth, Sir H.||Price-While, Lt.-Col. D.||York, C.|
|Lyttelton, Rt. Hon. O.||Prior-Palmer, Brig. O.||Young, Sir A. S. L. (Partick)|
|MacAndrew, Col. Sir C.||Raikes, H. V.|
|McCallum, Maj. D.||Ramsay, Maj. S||TELLERS FOR THE NOES:|
|McCorquodale, Rt. Hon. M S.||Reed, Sir S. (Aylesbury)||Mr. Studholme and|
|Macdonald, Sir P. (I. of Wight)||Reid, Rt. Hon. J. S. C. (Hillhead)||Lieut.-Colonel Thorp.|
Question put accordingly, "That the words proposed to be left out stand part of the Question."
Division No. 73.]
|Acland, Sir R.||Braddock, Mrs. E. M. (L'pl, Exch'ge)||Crossman, R. H. S.|
|Adams, Richard (Balham)||Braddock, T. (Mitcham)||Daggar, G.|
|Allen, Scholefield (Crewe)||Bramall, E. A.||Daines, P.|
|Alpass, J. H.||Brook, D. (Halifax)||Dalton, Rt. Hon. H.|
|Anderson, A. (Motherwell)||Brown, George (Belper)||Davies, Clement (Montgomery)|
|Anderson, F. (Whitehaven)||Brown, T. J. (Ince)||Davies, Edward (Burslem)|
|Attewell, H. C.||Bruce, Maj. D. W. T.||Davies, Harold (Leek)|
|Attlee, Rt. Hon. C. R.||Buchanan, Rt. Hon. G.||Davies, Haydn (St. Pancras, S.W.)|
|Austin, H Lewis||Burden, T W||Davies, S. O. (Merthyr)|
|Ayles, W H||Butler, H. W (Hackney, S.)||Deer, G.|
|Ayrton Gould, Mrs. B.||Byers, Frank||de Freitas, Geoffrey|
|Bacon, Miss A.||Callaghan, James||Delargy, H J.|
|Baird, J.||Carmichael, James||Diamond, J.|
|Balfour, A.||Castle, Mrs. B. A.||Dobbie, W.|
|Barnes, Rt. Hon. A. J||Chamberlain, R. A.||Dodds, N. N.|
|Barstow, P. G.||Champion, A. J.||Donovan, T.|
|Barton, C||Chater, D.||Driberg, T. E. N.|
|Battley, J. R.||Chetwynd, G. R.||Dugdale, J. (W. Bromwich)|
|Bechervaise, A. E.||Cobb, F. A.||Dumpleton, C. W|
|Bellenger, Rt. Hon. F. J.||Cocks, F. S.||Durbin, E. F. M.|
|Benson, G||Coldrick, W.||Dye, S.|
|Berry, H.||Collick, P.||Ede, Rt. Hon. J. C.|
|Beswick, F.||Collindridge, F.||Edelman, M.|
|Bevan, Rt. Hon. A. (Ebbw Vale)||Collins, V. J.||Edwards, John (Blackburn)|
|Bevin, Rt Hon. E. (Wandsworth, C.)||Colman, Miss G. M.||Edwards, W. J. (Whitechapel)|
|Bing, G. H. C.||Comyns, Dr. L.||Evans, A (Islington, W.)|
|Binns, J.||Cook, T F.||Evans, E. (Lowestoft)|
|Blackburn, A. R.||Cooper, Wing-Comdr. G.||Evans, John (Ogmore)|
|Blenkinsop, A.||Corbet, Mrs. F. K. (Camb'well, N.W.)||Evans, S. N. (Wednesbury)|
|Blyton, W. R.||Corlett, Dr J.||Ewart, R.|
|Bottomley, A. G.||Cove, W. G.||Farthing, W. J.|
|Bowden, Flg.-Offr. H. W.||Crawley, A.||Fernyhough, E.|
|Bowles, F. G. (Nuneaton)||Cripps, Rt. Hon. Sir S.||Field, Capt. W. J.|
The House divided: Ayes, 337; Noes, 178.
|Fletcher, E. G. M. (Islington, E.)||McEntee, V. La T.||Silkin, Rt. Hon. L.|
|Foot, M. M.||McGhee, H G.||Silverman, J. (Erdington)|
|Forman, J. C.||Mack, J. D||Silverman, S. S. (Nelson)|
|Fraser, T. (Hamilton)||McKay, J. (Wallsend)||Simmons, C. J.|
|Freeman, Peter (Newport)||Mackay, R. W. G. (Hull, N.W.)||Skeffington, A. M.|
|Gaitskell, Rt. Hon. H. T. N.||Maclean, N. (Govan)||Skeffington-Lodge, T. C.|
|Ganley, Mrs. C. S.||McLeavy, F.||Skinnard, F. W.|
|George, Lady M. Lloyd (Anglesey)||MacMillan, M K. (Western Isles)||Smith, C. (Colchester)|
|Gibbins, J.||McNeil, Rt. Hon. H.||Smith, Ellis (Stoke)|
|Gibson, C. W.||Macpherson, T. (Romford)||Smith, H. N. (Nottingham, S.)|
|Gilzean, A.||Mainwaring, W. H.||Smith, S. H. (Hull, S.W.)|
|Glanville, J. E. (Consett)||Mallalieu, J. P. W.||Snow, J. W.|
|Gooch, E. G.||Manning, Mrs. L. (Epping)||Solley, L. J.|
|Granville, E. (Eye)||Mathers, Rt. Hon. G.||Sorensen, R. W.|
|Grey, C F.||Medland, H. M.||Soskice, Sir Frank|
|Grierson, E.||Mellish, R. J.||Sparks, J. A.|
|Griffiths, D. (Rother Valley)||Messer, F.||Stamford, W.|
|Griffiths, Rt. Hon. J. (Llanelly)||Middleton, Mrs. L.||Stewart, Michael (Fulham, E.)|
|Griffiths, W. D. (Moss Side)||Mikardo, Ian||Stokes, R. R.|
|Gunter, R. J.||Mitchison, G. R.||Strachey, Rt. Hon. J.|
|Guy, W. H.||Monslow, W.||Strauss, Rt. Hon. G. (Lambeth, N.)|
|Haire, John E. (Wycombe)||Moody, A. S||Stross, Dr. B.|
|Hale, Leslie||Morley, R.||Stubbs, A. E.|
|Hall, Rt. Hon. Glenvil||Morgan, Dr. H. B.||Summerskill, Dr. Edith|
|Hamilton, Lieut.-Col. R.||Morris, Lt.-Col. H. (Sheffield, C.)||Swingler, S.|
|Hannan, W. (Maryhill)||Morris, P. (Swansea, W.)||Sylvester, G. O.|
|Hardman, D. R.||Morrison, Rt. Hon. H. (Lewisham, E.)||Symonds, A. L.|
|Hardy, E. A.||Mart, D. L.||Taylor, H. B. (Mansfield)|
|Harrison, J.||Moyle, A.||Taylor, Dr. S. (Barnet)|
|Hastings, Dr. Somerville||Murray, J D||Thomas, D E. (Aberdare)|
|Haworth, J.||Naylor, T. E.||Thomas, Ivor (Keighley)|
|Henderson, Rt. Hn. A. (Kingswinford)||Neal, H. (Claycross)||Thomas, I. O. (Wrekin)|
|Henderson, Joseph (Ardwick)||Nichol, Mrs. M. E. (Bradford, N.)||Thomas, John R. (Dover)|
|Herbison, Miss M.||Nicholls, H. R. (Stratford)||Thomas, George (Cardiff)|
|Hewitson, Capt. M.||Noel-Baker, Capt. F. E. (Brentford)||Thurtle, Ernest|
|Hicks, G.||O'Brien, T.||Tiffany, S.|
|Hobson, C. R.||Oliver, G. H.||Timmons, J.|
|Holman, P.||Paget, R. T.||Titterington, M. F.|
|Holmes, H. E. (Hemsworth)||Paling, Rt. Hon. Wilfred (Wentworth)||Tolley, L.|
|House, G.||Paling, Will T. (Dewsbury)||Tomlinson, Rt. Hon. G.|
|Hubbard, T.||Palmer, A. M. F.||Turner-Samuels, M.|
|Hudson, J. H. (Ealing, W.)||Pargiter, G. A.||Ungoed-Thomas, L.|
|Hughes, Emrys (S. Ayr)||Parker, J.||Usborne, Henry|
|Hughes, Hector (Aberdeen, N.)||Parkin, B T.||Vernon, Maj. W. F.|
|Hughes, H. D (W'lverh'pton, W.)||Paton, Mrs. F. (Rushcliffe)||Viant, S. P.|
|Hutchinson, H. L. (Rusholme)||Paton, J. (Norwich)||Wadsworth, G|
|Hynd, H. (Hackney, C.)||Pearson, A.||Walkden, E.|
|Hynd, J. B. (Attercliffe)||Perrins, W.||Walker, G. H.|
|Irvine, A. J. (Liverpool)||Platts-Mills, J. F. F.||Wallace, G. D. (Chislehurst)|
|Irving, W. J. (Tottenham, N.)||Poole, Cecil (Lichfield)||Wallace, H. W. (Walthamstow, E.)|
|Isaacs, Rt. Hon. G. A.||Popplewell, E.||Warbey, W. N.|
|Janner, B.||Porter, E. (Warrington)||Watkins, T. E.|
|Jeger, G. (Winchester)||Porter, G. (Leeds)||Webb, M. (Bradford, C.)|
|Jager, Dr. S. W. (St. Pancras, S.E.)||Price, M. Philips||Wells, P. L. (Faversham)|
|Jones, D. T. (Hartlepools)||Proctor, W T.||Wells, W. T. (Walsall)|
|Jones, Elwyn (Plaistow)||Pursey, Cmdr. H.||Westwood, Rt. Hon. J.|
|Jones, J. H. (Bolton)||Randall, H. E.||Wheatley, J. T. (Edinburgh, E.)|
|Jones, P. Asterley (Hitchin)||Ranger, J.||White, C. F. (Derbyshire, W.)|
|Keenan, W.||Rankin, J.||While, H. (Derbyshire, N.E.)|
|Kenyon, C.||Rees-Williams, D. R.||Wigg, George|
|Key, C. W.||Reeves, J.||Wilcock, Group-Capt. C. A. B|
|King, E. M.||Reid, T. (Swindon)||Wilkins, W. A.|
|Kinghorn, Sqn.-Ldr. E.||Richards, R.||Willey, F. T. (Sunderland)|
|Kinley, J.||Ridealgh, Mrs. M.||Willey, O. G. (Cleveland)|
|Kirby, B. V.||Robens, A.||Williams, D. J. (Neath)|
|Lang, G.||Roberts, Emrys (Merioneth)||Williams, W. R. (Heston)|
|Lawson, Rt. Hon. J. J.||Roberts, Goronwy (Caernarvonshire)||Williamson, T.|
|Lee, F. (Hulme)||Roberts, W. (Cumberland, N.)||Wills, Mrs. E. A.|
|Lee, Miss J. (Cannook)||Robertson, J. J. (Berwick)||Wilmot, Rt. Hon. J.|
|Leonard, W.||Rogers, G. H. R.||Wilson, Rt. Hon. J. H.|
|Leslie, J. R.||Ross, William (Kilmarnock)||Wise, Major F. J.|
|Lever, N. H.||Royle, C.||Woodburn, A.|
|Levy, B. W.||Sargood, R.||Wyatt, W.|
|Lewis, A. W. J. (Upton)||Scollan, T.||Yates, V. F.|
|Lewis, J. (Bolton)||Scott-Elliot, W.||Younger, Hon. Kenneth|
|Lewis, T (Southampton)||Segal, Dr. S.||Zilliacus, K.|
|Lindgren, G. S.||Sharp, Granville|
|Lipton, Lt.-Col. M.||Shawcross, C. N. (Whines)||TELLERS FOR THE AYES:|
|Longden, F.||Shawcross, Rt. Hn. Sir H. (St. Helens)||Mr. William Whiteley and|
|Lyne, A. W.||Shinwell, Rt. Hon. E.||Mr. Robert Taylor.|
|McAdam, W.||Shurmer, P.|
|Agnew, Cmdr. P. G.||Grimston, R. V.||Noble, Comdr. A. H. P.|
|Aitken, Hon. Max||Harmon, Sir P. (Moseley)||Nutting, Anthony|
|Amory, D. Heathcoat||Harvey, Air-Comdre. A. V.||Odey, G. W.|
|Assheton, Rt. Hon. R||Haughton, S. G.||O'Neill, Rt. Hon. Sir H.|
|Baldwin, A. E.||Head, Brig. A. H.||Orr-Ewing, I. L.|
|Beamish, Maj. T. V. H.||Henderson, John (Cathcart)||Osborne, C.|
|Beechman, N. A.||Hogg, Hon. Q.||Peake, Rt. Hon. O.|
|Bennett, Sir P.||Hollis, M. C.||Peto, Brig. C. H. M.|
|Birch, Nigel||Holmes, Sir J. Stanley (Harwich)||Pickthorn, K.|
|Boles, Lt.-Col. D. C. (Wells)||Hope, Lord J.||Pitman, I. J.|
|Boothby, R.||Hulbert, Wing-Cdr. N. J.||Pools, O. B. S. (Oswestry)|
|Bossom, A. C.||Hurd, A.||Prescott, Stanley|
|Bower, N.||Hutchison, Lt.-Cm. Clark (E'b'rgh W.)||Price-White, Lt.-Col. D|
|Boyd-Carpenter, J. A.||Jarvis, Sir J.||Prior-Palmer, Brig. O|
|Bracken, Rt. Hon. Brendan||Jeffreys, General Sir G.||Raikes, H. V.|
|Braithwaite, Lt.-Comdr. J. G.||Joynson-Hicks, Hon. L. W.||Ramsay, Maj. S|
|Bromley-Davenport, Lt.-Col. W.||Keeling, E. H.||Reed, Sir S. (Aylesbury)|
|Brown, W. J. (Rugby)||Kerr, Sir J. Graham||Reid, Rt. Hon. J. S. C. (Hillhead)|
|Bullock, Capt. M.||Kingsmill, Lt.-Col. W. H.||Renton, D.|
|Butcher, H. W.||Lambert, Hon G||Roberts, H. (Handsworth)|
|Butler, Rt. Hon. R A (S'ffr'n W'ld'n)||Lancaster, Col C. G.||Roberts, Peter (Ecclesall)|
|Carson, E||Langford-Holt, J.||Robertson, Sir D. (Streatham)|
|Challen, C.||Law, Rt. Hon R. K.||Ropner, Col. L.|
|Channon, H.||Legge-Bourke, Maj. E. A. H.||Ross, Sir R. D. (Londonderry)|
|Clarke, Col. R. S.||Lennox-Boyd, A. T.||Savory, Prof. D. L.|
|Clifton-Brown, Lt.-Col. G.||Lindsay, M. (Solihull)||Scott, Lord W.|
|Cole, T. L.||Linstead, H. N||Shephard, S. (Newark)|
|Conant, Maj. R. J. E.||Lipson, D. L.||Shepherd, W. S. (Bucklow)|
|Cooper-Key, E. M.||Lloyd, Selwyn (Wirral)||Smith, E. P. (Ashford)|
|Corbett, Lieut.-Col. U. (Ludlow)||Low, A. R. W.||Smithers, Sir W.|
|Crookshank, Capt. Rt. Hon. H. F. C.||Lucas, Major Sir J.||Spearman, A. C. M|
|Crosthwaite-Eyre, Col. O. E.||Lucas-Tooth, Sir H.||Stewart, J. Henderson (Fife, E.)|
|Crawder, Capt. John E.||Lyttelton, Rt. Hon. O.||Stoddart-Scott, Col. M.|
|Cuthbert, W. N.||MacAndrew, Col. Sir C.||Strauss, H. G. (English Universities)|
|Darling, Sir W. Y.||McCallum, Maj. D.||Studholme, H. G.|
|Davidson, Viscountess||McCorquodale, Rt. Hon. M. S.||Sutcliffe, H.|
|De la Bère, R.||Macdonald, Sir P. (I. of Wight)||Taylor, C. S (Eastbourne)|
|Digby, S W.||Mackeson, Brig H R||Taylor, Vice-Adm. E. A (P'dd't'n, S.)|
|Dodds-Parker, A. D.||McKie, J H. (Galloway)||Teeling, William|
|Dower, Lt.-Col. A. V. G. (Penrith)||Maclean, F H. R.||Thomas, J P. L (Hereford)|
|Dower, E. L. G. (Caithness)||Macmillan, Rt. Hon. Harold (Bromley)||Thornton-Kemsley, C. N.|
|Drayson, G B.||Maitland, Comdr. J. W.||Thorp, Lt.-Col R. A. F|
|Dugdale, Maj. Sir T. (Richmond)||Manningham-Buller, R. E||Touche, G. C.|
|Duthie, W S.||Marlowe, A. A. H.||Vane, W. M. F|
|Eccles, D. M.||Marples, A. E.||Wakefield, Sir W. W.|
|Eden, Rt. Hon. A.||Marsden, Capt. A.||Walker-Smith, D.|
|Elliot, Lieut.-Col., Rt. Hon. W.||Marshall, D. (Bodmin)||Ward, Hon. G. R.|
|Erroll, F J||Marshall, S. H. (Sutton)||Watt, Sir G. S. Harvie|
|Fleming, Sqn.-Ldr. E. L.||Maude, J. C.||Webbe, Sir H. (Abbey)|
|Fletcher, W (Bury)||Medlicott, F.||Wheatley, Col. M. J (Dorset, E.)|
|Foster, J. G (Northwich)||Mellor, Sir J.||White, Sir D. (Fareham)|
|Fox, Sir G||Molson, A. H. E||Williams, C. (Torquay)|
|Fraser, H. C P. (Stone)||Moore, Lt.-Col. Sir T.||Williams, Gerald (Tonbridge)|
|Fyle, Rt. Hon. Sir D. P. M.||Morris-Jones, Sir H.||Willoughby de Eresby, Lord|
|Gage, C.||Morrison, Maj. J. G. (Salisbury)||Winterton, Rt. Hon Earl|
|Galbraith, Cmdr. T. D.||Morrison, Rt. Hon. W. S. (Cirencester)||York, C.|
|Gammans, L. D.||Mott-Radclyffe, C. E.||Young, Sir A. S. L. (Partick)|
|George, Maj. Rt. Hn. G. Lloyd (P'ke)||Neven-Spence, Sir B.|
|Gomme-Duncan, Col. A.||Nicholson, G.||TELLERS FOR THE NOES:|
|Graham-Little, Sir E.||Nield, B. (Chester)||Mr. Buchan-Hepburn and|
Main Question put, and agreed to.
"That this House takes note that the appointed day for the National Health Service has been fixed for 5th July; welcomes the coming into force on that date of this measure which offers to all sections of the community comprehensive medical care and treatment and lays for the first time a sound foundation for the health of the people: and is satisfied that the conditions under which all the professions concerned are invited to participate are generous and fully in accord with their traditional freedom and dignity."