National Health Service (Amendment) Bill
Order for Second Reading read.
I beg to move, "That the Bill be now read a Second time."The purposes of this small but complicated Bill are broadly three. First, to clarify and as far as is necessary to amend the application to partnerships of those sections of the National Health Service Acts which prohibit the sale of practices by doctors in the Service, and which compensate them for the resulting loss of the selling value of the goodwill. Secondly, to carry out certain promises of amendment made to the medical profession in the discussions on the application of the Acts, both before and since the beginning of the Service. Thirdly, to make certain minor administrative changes which experience has shown are desirable for the smooth working of the machine. The Bill is essentially a minor Measure which embodies no change of principle or policy. It makes no fundamental alterations, since experience does not suggest any respects in which major amendments are required. The sections of the Acts dealing with the sale of medical practices gave rise to certain doubts in their application to partnerships, and, with a view to clarifying the position, my right hon. Friend the Minister of Health appointed a committee under the chairmanship of Mr. Justice Slade on 20th April, 1948, to consider the whole position and to recommend what changes, if any, were required to clarify the application of the principal Act and to secure an equitable result between the partners. The committee included an eminent Scottish King's Counsel, and the position in Scotland was brought under review as well as the position in England and Wales. The committee reported in November, 1948, and my right hon. Friend announced the Government's acceptance of the recommendations on 16th December, 1948. Part I of this Bill applies the recommendations of the Slade Committee in full, and I take this opportunity of thanking that committee for the work which they did in this matter. I do not propose to go in meticulous detail into the Clauses which give effect to the Committee's recommendations, but I shall endeavour to outline the broad general principles on which the solution of the problem proceeds. I am afraid that the permutations and combinations of interests between listed, new listed and outside partners are so widespread that I require to deal very briefly with the general position of each of these classes in turn. In order to understand how the different classes are affected by the proposals in the Bill, it is perhaps desirable that I should endeavour to explain to the House exactly what is meant by each of these categories. A listed partner, as defined in Clause 1, and as extended in Clause 3, is a partner who has entered his name on a list of medical practitioners undertaking to provide general medical services either (a) before the originally appointed day, or (b) prior to a deferred appointed day, which will be two months subsequent to the passing of this Bill into law. A new listed partner, however, is a medical practitioner who has not entered his name on the list prior to this second deferred appointed day, but who has done so between that date and what is known as the relevant date, that is, the date on which an obligation to acquire a share in the partnership under the partnership agreement matures, or an option to acquire such a share is exercised. An outside partner is someone who is in neither of these two categories. It is intended that the provisions of partnership agreements should be interfered with as little as possible, and that the rights and obligations which operate in the future should be fulfilled subject to the necessary modifications entailed by the operation of the scheme. Clause 1 (3), for instance, provides that there is no prohibition on the sale of practices where that is required by partnership agreements in force before 5th July, 1948. In terms of Clause 1 (4), compensation payable to members of such partnerships under Section 36 of the principal Act should be fixed once and for all on the appointed day, without regard to future rights and obligations existing at that date. I will now turn to consider, in the first instance, the position of listed partners. In the first place, where one listed partner in the Service sells the goodwill of his share in the practice, or any part thereof, to another partner in the Service, the compensation payable under the original Act is substituted for the contract price in the partnership agreement, and becomes payable immediately or as soon as practicable on the transfer taking place. That compensation is payable out of the general fund of £66 million set up under the principal Act. In the second place, when an outside partner is obliged to buy a share of a listed partner in the Service, which may be of little or no value to that outside partner, depending on the circumstances of the case, that obligation to purchase is turned into an option to purchase. If the option is exercised, and the listed partner is paid the purchase price in respect of that share, he is no longer entitled to compensation in respect of that share out of the £66 million provided under the principal Act. Thirdly, where a partner in the Service is obliged to buy the share of a partner outside the Service—and in that case the purchaser cannot normally sell that practice again—the partner in the Service gets compensation calculated at the same rate as the original compensation would have been calculated out of a new fund which is being set up over and above the original fund. But, in that type of case, provision is made that in no case can the compensation exceed the purchase price. Again, in this type of case, the compensation is payable forthwith. It is impossible to state exactly what this particular provision will involve—the setting up of this new compensation fund—but as there are only 50 mixed practices, only one of which exists in Scotland, it is unlikely that the sum involved will be large, and, in any event, there will fall to be set off against this figure any sum saved out of the £66 million by the operation of Clause 1 (7) to which I have referred. That, I think, exhausts the various conditions under which a listed partner might be involved under the Bill. If we now come to consider the case of new listed partners, we find that they are affected in certain ways, but I would point out to the House that new listed partners do not participate in compensation. Under Clause 1 (5), however, if a new listed partner acquires the share of a listed partner, the transfer will be effected without any payment, but the seller, that is, the listed partner, will be paid forthwith the appropriate compensation allotted to that share out of the £66 million. The second type of case is where an outside partner is under an obligation to purchase the share of a new listed partner, or for that matter, of a listed partner, of the goodwill of the partnership, or where one new listed partner is under a like obligation to purchase the share of another new listed partner. In those cases, the obligation under the partnership agreement is translated into an option exercisable on three months' written notice. The reason for this is that the purchasing partner might be acquiring something less than he originally bargained for under the principal Acts, and possibly something which in certain circumstances might be of little or no value to him, and, accordingly, the obligation under the agreement is translated into an option under the agreement. Thirdly, when the share of a new listed partner or of an outside partner is bought by a listed partner in terms of Clause 1 (8), to which I have already referred, the purchase price under the agreement will be paid to the seller subject to the proviso contained in Clause 1 (8) that, in the case of a seller who is a new listed partner, the purchase price payable cannot exceed the compensation payable to the purchasing listed partner. Finally, I come to consider in this respect the position of the outside partners. With regard to these, the position is that in cases where they are under an obligation, in view of the terms of the partnership agreement, to acquire the share of a listed or a new listed partner, that obligation is translated into an option, and where they are sellers under the partnership agreement they are entitled to the purchase price referred to in the agreement. The principles which I have tried to enunciate will apply with appropriate effect where the transfer of only part of a share is involved or where more than one partner is involved in the acquisition of the share. I appreciate that this is a very complicated matter, but I have tried to reduce it to the simplest possible terms consistent with the various permutations and combinations which are liable to arise. I now pass on to the ancillary provisions of Part I of the Bill. Clause 2 provides that alterations to partnership agreements which do not substantially alter the provisions of the agreement relating to the purchase will not deprive the partners to that agreement as on 5th July, 1948, from the benefits of this Bill. In view of the uncertainty which attached to the legal position of partners at the appointed day, we feel it is only but fair to give to all members of partnerships who have not heretofore joined the Service the opportunity of doing so now. They are accordingly given a further right and opportunity to join the Service prior to the second appointed day which will be, as I have already explained, two months after the date on which this Bill becomes an Act. Those members of the profession who enter the scheme prior to that second appointed day will not be obliged to seek the consent of the Medical Practices Committee, and they will qualify for compensation in respect of loss of goodwill. Where, however, there has been a sale of goodwill under a partnership agreement between the first appointed day and before the passing of this Act, the seller under that sale will receive the price paid and the purchaser will qualify for compensation in terms of the principal Acts, but that compensation will be payable forthwith, subject to this proviso that if the compensation exceeds the purchase price under the partnership agreement the balance will be repaid to the seller. The reason for payment forthwith in this and analogous types of cases is that the purchaser has been out of pocket and it is only but right to recoup him and grant him restitution forthwith. I have already dealt with the effect of Clause 5 in so far as it converts an obligation on an outside or a new listed partner to purchase into an option. Clause 6 deals with the position of assistants. The Slade Committee recommended that assistants should be treated in the same manner as partners, and effect has been given to that recommendation in this Clause. I shall not attempt to rehearse the manner in which these cases are dealt with, as they are mutatis mutandis with the cases of partnerships. It is realised, however, that despite all our efforts to secure justice as between one party and another, there might emerge the odd case, the casus improvisus, where the party may feel that the operation of the principles to which I have referred produces hardship. Provision is accordingly made for arbitration to be available in such cases to adjudicate on the matter and to make awards. The arbitrator will be an agreed on person, and, failing agreement on the person between the parties, the issue will be referred to an arbitration committee consisting of a legal chairman appointed by the Lord Chancellor in England and the Lord President of the Court of Session in Scotland, a medical practitioner appointed by the President of the British Medical Association, and an accountant who will have the qualifications set out in Clause 7 of the Bill. The powers of the arbitration committee are very wide. For instance, they can modify the Act or the regulations made under the Act, or they can recommend the dissolution of the partnership if such courses are necessary to prevent the occurrence of hardship. They cannot, however, alter the total amount of compensation payable in respect of the partnership practice. Finally, in Part I of the Bill, to remove any doubts which exist, it is declared that Section 35 of the principal Act, or Section 36 of the corresponding Act in Scotland, does not prevent a doctor who has never been in the Service from selling the goodwill of his practice even although part of that goodwill was acquired from a partner inside the Service itself. That concludes my review of the provisions of Part I of the Bill which set out to deal with the recommendations of the Slade Committee. Part II of the Bill deals with the promised amendments and minor administrative changes to which I referred in my opening remarks. In the first place, in the early part of 1948 when there was a certain amount of opposition to entering the new Service among medical practitioners, it appeared that one factor in particular was causing the profession some misgivings, namely the fear that either immediately or by degrees a whole-time salaried service would be introduced as it is possible to do by the regulations under the principal Acts, and, in point of fact, as it has been possible to do by regulations under the National Health Insurance Acts ever since 1912. It was made quite clear in the Debates on the principal Acts that the present Government had no intention of introducing a whole-time salaried service, but in order to put the position beyond all doubt, my right hon. Friend the Minister of Health gave a pledge in this House on 7th April, 1948, that it would be made clear in legislation that a full-time service could not be instituted by regulation alone. That pledge was repeated in correspondence with the medical profession on 26th May, 1948, and it is here carried out in this Bill in relation to general practitioners by Clause 10, and in relation to specialists by Clause 11. Another point which arose in the course of the discussions was that under the principal Acts tribunals of three members are set up to consider those cases where the executive councils recommend that doctors, dentists, pharmacists or opticians should be disqualified from further participation in the Service. The tribunal consists of a legal chairman, an executive council representative and a member of the profession concerned. The medical profession urged that the professional members should be drawn from a standing panel of members of the profession selected to cover the different types of practice involved, whether it be rural, industrial or some other type, and not, as required by the principal Acts, a fixed individual. Similar considerations arise in relation to the other professions, and it was, therefore, agreed that the principal Acts should be amended to allow this change taking place. A promise to this effect was given to the medical profession in correspondence as far back as May, 1948, and this promise is now implemented by Clause 14. Another matter which gave rise to a certain amount of concern was the position of local professional committees and their expenses. The medical profession urged that, as under the National Health Insurance Acts, provision should be made that the costs of local medical committees should be met by a block deduction from the remuneration of the doctors in each executive council area. Similar requests were made by the dentists and pharmacists and a promise was given to the profession on 26th May, 1948, that this amendment would be proposed and carried into effect; and that is implemented in the Schedule to this Bill. Again, in relation to executive councils, under the principal Acts the chairmen were appointed by the Minister. It was agreed with the medical profession that, now that the scheme has settled down and the councils are effectively launched, it would be reasonable to allow the councils to elect their own chairmen from among their own members; and the promise to that effect is implemented in this Bill, once again in the Schedule. In the course of the various discussions in the matter another difficulty was pointed out to my right hon. Friend, and that is that considerable inconvenience is caused at present to everyone under the scheme by the absence of any power to take off the lists of executive councils doctors or others who have removed from the district and who are not, in fact, available, for that or any other reason, to provide services in that area. Clause 13 enables that anomaly to be dealt with and provides for the removal of such persons from the lists. In considering the relative position of various professions under the scheme, the dentists pointed out that while, under the principal Acts, doctors who were on the staffs of hospitals in the service had the right to treat private patients in private beds at the hospitals, that right was denied to the dental profession in similar circumstances, and the dental profession urged that they should be provided with a similar right. My right hon. Friend promised that effect would be given to that representation, and that promise is here carried into effect, once again in the Schedule to the Bill. There are other minor matters, such as the period for claiming fees under the Midwives' Act, which has been extended from two months to three months to meet one further complaint. I think that narration concludes the list of amendments which are made in order to fulfil the undertakings or promises made by my right hon. Friends in the course of the negotiations with the medical profession. That brings me to the third category of cases to which I originally referred. The remaining provisions of Part II of the Bill are all minor in character and are designed simply to remove doubts or difficulties that have arisen in the administration of the principal Acts or to confer additional powers necessary for the proper carrying on of the Service. The principal amendments contained in these Clauses are, first, that under Clause 12 we put the coping stone on the structure of Whitley Councils which are built up for the negotiation of the terms and conditions of service of all of the many types of officers engaged in the National Health Service by enabling arbitration machinery to be set up where disagreement arises between the official and the staff sides. The intention is to set up a tribunal for the Health Service on the lines of the Civil Service Arbitration Tribunal, the details of its constitution and procedure to be settled by the terms of an arbitration agreement made between the two sides. Then, in Clause 15, we remove certain doubts which have arisen in that the right of the Minister to make certain regulations has been challenged in relation to the regulations prescribing qualifications for opticians and others, which consist of a requirement that they must satisfy an expert committee on their competence and experience. That is manifestly a desirable manner in which to decide whether or not a person has a qualification and the right to prescribe that in regulations should be beyond any dispute at all. Provision is made for that in Clause 15. In Clause 16 we make provision for the voluntary transfer of property of nursing associations, because it might well be, in view of certain restrictions in trust deeds, that there would not be that free transfer of assets from a district nursing association, who wish to transfer their assets to a local health authority, without resorting to complicated legal processes and, as hon. Members appreciate, we always try to avoid complicated legal processes. We go on in Clause 17 to deal with the position of the mental health profession. Clause 17 requires local authorities to pay fees in certain cases for examinations and reports made by doctors in connection with admission for treatment under the Lunacy and Mental Deficiency Acts; and Clause 18 goes on to validate certain detention orders made under the Mental Deficiency Act, 1913, which have now been found to be invalid. These provisions do not extend to Scotland, which has a separate form of legislation for this type of case. Clause 19 introduces the permissive power for a charge to be made for board and lodging to hospital patients who are able, and do, go out to work and earn a remuneration. Finally, in the Schedule we make provision for a payment to members of the various bodies involved in the service for loss of earnings or travelling or subsistence expenses. It was felt that these people were entitled to receive due remuneration for loss of earnings and for travelling and subsistence expenses just as are local authority members. Accordingly, provision is made for payment to these people of remuneration on the same basis as that on which payment is made to local authority members under the recent Local Government Act. I think that surveys the ground we have set out to cover in this Bill. I do not pretend that in some respects this is a very easy Bill to follow, but I have tried to reduce, as far as possible, to comprehensible terms what exactly we are trying to do in this Measure. In effect, this Bill should go a long way not only to remove from doubt certain legal difficulties which arise out of the principal Acts, but to remove those doubts which have lingered in the minds of certain people as to the position of the medical profession under the scheme. My right hon. Friends the Minister of Health and the Secretary of State for Scotland have never spared themselves in their endeavours to create a smooth-working and harmonious scheme which would do justice both to the beneficiaries and to those who were called upon to operate it alike. This Bill is an earnest of their intention to carry on that policy and to remove obstacles or difficulties which might militate against its smooth working. In so far as it achieves this, I am confident that it will receive support from all sides of the House, because I am sure that all hon. Members, even including those who voted against the original Act, must realise that this is but a further step in the development of a scheme which, in its short span of 10 months, has already evoked the admiration and respect not only of the people of this country but of the people of the whole world.
I am sure the whole House would wish to congratulate the Lord Advocate on the fluency and speed with which he has covered the provisions of this Bill. I think I may also say "skated over" the provisions of this Bill, because there was a good deal of thin ice which he wisely passed over very quickly. I should be disingenuous if at this stage I congratulated him on the clarity of his statement. The matters with which he has dealt are so technical that it will be essential for us carefully to consider what he has said, and we hope that his comments will be invaluable when we come to consider the Bill in Committee.This Measure—one might not have supposed so from the Lord Advocate's remarks—is of an unprecedented character. Normally, an amending Bill corrects oversights and makes improvements in the machinery of the principal Act in the light of the experience of working the Act in the first year or two. This Bill is largely concerned with defects of the principal Act which were plain, not only before that Measure went on the Statute Book, but before it went to Committee upstairs. We pointed out during the passage of the National Health Service Act through this House that Sections 35 and 36 of that Act—the Sections dealing with the sale of goodwill—were unworkable. We said they were unworkable, quite apart from any question of the general principle involved, namely, the desirability of retaining or not the power to sell goodwill. I think it would be proper to say something of my views on that general principle at this stage. I personally do not feel strongly about the retention or otherwise of the power of a doctor to sell the goodwill of his practice. I do not believe that that is really a question of principle at all. I believe that is a view very generally shared by hon. Members on this side of the House. The members of some professions have been able at all times to sell and to buy the goodwill of their practices. The members of other professions have not been so able. The obvious example is the profession of the learned Lord Advocate and the profession which I myself practised at one time, that of a barrister. A barrister has never been able to buy and sell his goodwill. On the whole, I think, it is a pity that that has not been the state of affairs in the medical profession. Unfortunately, it has not been so. The question which we on this side asked ourselves, when we came to consider those two Sections, was whether or not any useful purpose was to be served by abolishing the right of a doctor to buy and sell his goodwill. Of course, the answer to that question is simple if one holds the view which is undoubtedly held by many Members opposite—if one believes that a full-time, salaried medical service is a desirable thing. Quite clearly, one cannot retain the power to buy and sell goodwill and have the full-time salaried medical service together. Our approach to this question was based on quite different principles. We said that it was essential to preserve the freedom of the patient to choose his own doctor, and we said it was essential to preserve the freedom of the doctor to work where and with whom he chose. Those were the essential principles on which we approached this question, and it was in the light of those principles that we sought to amend Sections 35 and 36 of the principal Act when the Measure was in Committee. I do not want to weary the House with technicalities in this matter, but I think it is important that the House should be reminded of the arguments put forward by my right hon. and learned Friend the then Member for North Croydon, Mr. Willink. Mr. Willink pointed out that the Sections refer only to the goodwill of a practitioner as an individual, and he pointed out that in English law—I think the same is true in the Scots law—the goodwill of doctors in partnership is not their separate property as individuals but the joint property of the partnership. He asked on that, what was to happen in the case of existing partnerships which were not covered by the principal Act at all. Mr. Willink further drew attention to the provisions of Section 35 (4), which provide that certain terms almost invariably found in partnership deeds are to be treated as the sale and purchase of goodwill. That subsection refers to all partnership agreements, and so presumably includes agreements already in force at the time of the coming into operation of the Act. Mr. Willink pointed out quite clearly that the effect of that subsection would necessarily be to make all existing partnerships illegal, and so it would be essential to dissolve them before the coming into operation of the Act. Finally Mr. Willink pointed out that there was nothing in the principal Act at all to cover the case of an assistant serving a doctor under an agreement which contained some provision which would, in effect, amount to an agreement to purchase that doctor's goodwill, or some part of it. There were other points which we raised in Committee on the principal Act. Every one of those arguments was brushed aside by the Minister of Health. Let me refer to his statements. I think they will be of interest to the House. He said during our discussions on that Section:
Later he said:"I see nothing obscure in the Clause at present. In fact, I have never before heard this Clause attacked on the ground of its obscurity."—[OFFICIAL REPORT: Standing Committee C, 20th June, 1946; c. 1658.]
That was the attitude of the right hon. Gentleman when we were discussing this matter then. We pressed the right hon. Gentleman. We said his views were wrong. We asked him to reconsider this matter, and, under pressure, the right hon. Gentleman agreed that he would reconsider the matter. This is the important point which, I think, deserves close attention. On receiving that assurance from the right hon. Gentleman the Opposition did not divide against Clauses 35 and 36 standing part of the Bill. It was because of that assurance that the right hon. Gentleman would look into these very matters. The Bill then came before the House on Report. There were certain minor Amendments, which were put down in the name of the right hon. Gentleman or of his Parliamentary Secretary, covering some of the minor points which had been raised by my right hon. and learned Friend. There was nothing done to cover the main points we raised—to cover the matters included in this Bill. The right hon. Gentleman made, if I may say so, his usual speech; I do not think that I should be discourteous if I said that he made his usual hubristic speech on that occasion. May I remind the House of his opening remarks?"What we are concerned about is whether a partner who has not got a public practice at all can buy or sell a practice without hurt to the other partner, or whether a partner who is in the public service and in partnership with a doctor who having no panel can take compensation without hurt to the other partner. I am advised there is nothing in the Bill which prevents that being done. If I thought the effect of this language would be to bring about a general dissolution of partnerships we would try to seek protection against that."—[OFFICIAL REPORT: Standing Committee C, 20th June, 1946; c. 1659.]
That was his attitude, and again he refused altogether to consider the matter further. My hon. and learned Friend the Member for the Combined English Universities (Mr. H. Strauss) pressed the right hon. Gentleman to consult with the Law Officers on these very points, and he not only did not agree, but he did not even deign to answer that suggestion."I am really astonished at the heavy weather which the right hon. and learned Gentleman is making about this. One would really have thought that we had not had a long Committee discussion on this matter."—[OFFICIAL REPORT, 23rd July, 1946; Vol. 425, c. 1956.]
Perhaps the hon. Gentleman will allow me to correct the statement which he is now making to the House. The investigations of Mr. Justice Slade's Committee have in fact completely vindicated the statement which I made to the Committee. The statement which I made, and which the hon. Gentleman has just read out, was that I did not think the operation of these Clauses would result in the general dissolution of partnerships. That is the conclusion which has been reached after full investigation. All that has been decided is that it is necessary to amend the old Act in order to remove doubt in about 50 cases.
I do not think that the House would desire to go into the technicalities of this matter.
Does the hon. Gentleman deny what I have said? He has in fact almost accused me of bad faith; of having made a promise to the Committee and then of not carrying out the promise on the Report stage. I made investigations, and I satisfied myself that the Clauses would not bring about the general dissolution of practices which the hon. Gentleman feared. They have not brought about the general dissolution of practices. What has been discovered is that there are about 50 types of partnership where relief of doubt is necessary.
I am quite prepared to leave this matter to the opinion of the House. The right hon. Gentleman said quite plainly that the Clause was clear beyond a doubt. I do not know whether he is suggesting that that was the decision of the expert Committee which he set up. If he is saying that, I should be delighted to hear him justify it in the course of his remarks when winding up the Debate. As a matter of fact, the right hon. Gentleman completely refused to listen to the criticisms which we made of this Bill and which are now fully justified by the expert committee which he himself set up. It was because of his refusal to listen to our arguments that we voted against these two Clauses standing part of the Bill, having agreed, without a vote, on his previous undertaking, to let them stand as a matter of principle. The right hon. Gentleman with the majority behind him can, of course, vote down all opposition in this House, but he cannot vote down the facts of life—and the fact that Sections 35 and 36 of the principle Act as originally drafted, and as they stood in the Act when it came here on Third Reading, were completely unworkable.
They have been worked.
If the right hon. Gentleman had listened to the Opposition at the time of the passing of the principal Act, Clauses 1 to 9 of this Bill could have been incorporated in that Act. That would have saved an immense amount of trouble and, what is more, the right hon. Gentleman would have prevented a great deal of heat and suspicion arising. If these Clauses had been clear at the time the Act became law, he would have found it much easier to conduct the discussions with the doctors which so nearly brought about the ruin of all his schemes.It is, I think, right to remind the House of the history of the original Bill. After the principal Act was passed, lengthy discussions took place between the Minister and the doctors. The doctors had three main objections to coming into the proposed new Service. The first was the fear of a full-time salaried service. The learned Lord Advocate, in the course of his remarks, suggested that the doctors need have no such fear. I think that he can hardly be aware of the statements of his own colleagues on the Front Bench beside him at the time of the passing of the Act. My right hon. Friend the then Member for Hillhead, now Lord Reid, quoted the policy of the Labour Party in 1943 as follows:
The right hon. Gentleman intervening in that Debate made this remark:"In the Labour Party's opinion it is necessary that the medical profession should be organised as a national full-time salaried, pensionable service."
Does the right hon. Gentleman really think that that remark was calculated to allay the suspicion of the doctors that this was intended as a step at least in the direction of a full-time salaried service? I know that the right hon. Gentleman has said that it is not his intention to introduce such a service immediately, but he has never stated that as a long-term policy he desires never to see such a salaried service introduced at all. The doctors were, of course, suspicious in the light of those remarks that it was the intention of the Labour Party to introduce such a service. Indeed, hon. Members sitting behind the Government Front Bench are still quite candid in their views that such a service is desirable."There is all the difference in the world between plucking fruit when it is ripe and plucking it when it is green."—[OFFICIAL REPORT, 2nd May, 1946; Vol. 422, c. 392.]
So are many of the doctors.
I am obliged for the interruption. It only goes to prove what I was saying. The doctors objected to the good-will provision in the principal Act. They objected on the principle—I will admit—which I myself have disclaimed this afternoon, but I do not think that they were mistaken from their point of view. They took the view that as long as they were free to buy and sell their practices it would be impossible to have a salaried service, and it was because of that they objected to the abolition of buying and selling practices. They also objected in detail for the quite specific reasons which were submitted to the expert committee, and on which the committee gave their findings which are now incorporated in this Bill.Finally, the doctors had the fear that the Clause giving power to prevent a doctor working in an area already adequately doctored, could be used in a way to direct them to serve as doctors in particular parts of the country. There were a number of other relatively minor questions into which I do not think it is necessary to go. As a result of these objections by the doctors, deadlock was reached in the discussion between them and the right hon. Gentleman. The doctors quite properly and democratically, if I may say so, held a plebiscite or ballot, or whatever you may like to call it, at which the general practitioners voted by an overwhelming majority, of the order of 12 to one, against coming into the scheme. The right hon. Gentleman at the time suggested that that vote was based on misrepresentation. One of the matters which the doctors clearly had in mind was the interpretation of the goodwill provisions of the Act. In the light of what the right hon. Gentleman is doing this afternoon, is he now really saying that anyone was misrepresenting the situation when he said that those provisions were completely unworkable and would in fact bring about the dissolution of all existing partnerships? The fact of the matter is, it was quite plain that the doctors meant business; they could not be out-voted as the Opposition can be in this House, and the right hon. Gentleman gave way: he had to give way. He set up the expert committee which is the forerunner of Part I of this Bill; he promised legislation to give effect to any necessary recommendations made by that committee; he promised legislation making a full-time salaried service impossible; and he undertook that doctors should be allowed to set up in practice in all areas which were not already over-doctored. I think that is a fair statement.
I do not understand what the hon. Gentleman is now saying. There has been no departure at all from the original Act in that respect. There is no change at all in the situation.
I am not suggesting that there has been any departure from the original Act. As I understand the matter—indeed, it has been made public on a number of occasions—the right hon. Gentleman has told the doctors that it is not his intention that Section 34 of the original Act shall be used to bring about direction of doctors by negative means.
I will answer that when I reply.
If the right hon. Gentleman would deal with that matter in the course of his reply, it would help to clear the matter up. Certainly that is what I understand.
All I am saying is that no change whatsoever is made by this Bill. Nor was any change made on that matter in the passage of the original proposals through the House of Commons. The scheme which is in existence at the moment, and operating quite smoothly, is the scheme of the original Act.
The scheme of the original Act was, as were large parts of that Act, extremely elastic in form. The original Act referred to those areas which were already adequately doctored. Those were the words in the original Bill, and indeed those in the principal Act today. If the right hon. Gentleman were to use those provisions so as to exclude doctors from going to all areas except a few, they could be used, in effect, so as to direct doctors to go to particular areas. As I understand it—indeed, it has been mentioned in public on many occasions—the right hon. Gentleman has made it perfectly plain that his intention is that those provisions shall be used only to exclude doctors from going to areas which are declared to be over-doctored.
That is not the position.
If that is not the position no doubt the right hon. Gentleman will clear it up in the course of his reply.
Is it not a fact that the law as it stood after the passing of the original Act will be the law after the passing of this Bill?
I quite agree. I am not suggesting for a moment that this Bill deals with that. What I am dealing with is what happened between the Minister and the doctors when it was a question of whether or not they would come into the Service. My point is that on every principal objection which the doctors raised the right hon. Gentleman found that he had to give way.
Yes, on every single one.
No, that is quite wrong.
The right hon. Gentleman says it is quite wrong. He will have an opportunity of refuting that in due course. Those objections were identically the objections which the Opposition had raised in the course of the discussions on the original Act. The right hon. Gentleman's colleague now comes to the House and recommends this Bill to us. What a pity it is that he did not come here and make these recommendations two years ago. There are times when we are tempted to think that the Minister of Health is anxious that the Opposition should oppose his proposals. There are times when we are driven to the conclusion that he desires to be thought of in the country as a kind of knight in shining armour slaying the dragon of Tory reaction. That is the picture the right hon. Gentleman wishes to build up for himself in the country. Perhaps I might put it another way: He is the honest huntsman who is bent on exterminating the snarling vermin. Perhaps he would prefer that. The fact is, the only foxes in the right hon. Gentleman's coverts are foxes that he has brought in a bag, bought, paid for and put there himself. This Bill is a satisfactory Measure.
If the hon. Gentleman says that, there must be something wrong with it.
Subject to detailed consideration in Committee, we think this is a good Bill, and we desire to give it our support. I propose, if I might, to draw the attention of the House to Clause 7, which deals with the removal of hardship in particular cases and, as the Lord Advocate has said, allows doctors in partnership, where hardship would be involved, to take the matter to arbitration. Subsection (2) provides:
I think that words such as those are wholly novel in any Act of Parliament. As far as I know, it is the first time that an arbitrator, an outside party chosen by private persons, is given a power to vary any Act of Parliament, and certainly the Act of Parliament enabling the arbitrator himself to be appointed. We could hardly have more definite proof of our contention in Committee on the principal Act, that that Act was unworkable, because these words have been inserted on the express recommendation of the expert committee. They had to be inserted, because even the expert committee itself was unable to devise words to give precise and fair effect to what was intended. We could hardly find better evidence to show that what we contended is the fact, and that the original Act, and the Act as amended by these Clauses, would be unworkable without some wholly exceptional and extraordinary powers. Clause 10 is perhaps the most important Clause from our point of view. It deals with the prohibition of a full-time salaried service. I do not for a moment suggest that that Clause does not fully give effect to the right hon. Gentleman's aims. I think it does. But it would be convenient and of great interest if he could deal a little more fully with that Clause. It says:"On any such reference, the arbitrator or committee shall have power to modify the provisions of the agreement or the operation in relation thereto of the Act of 1946 or this Act or any such regulations as aforesaid in any such manner as he or they may think equitable for the purpose of removing or preventing such hardship, including a power to direct the payment or repayment of money by any such party to the agreement as aforesaid."
I think that effect would be given to those words if the fixed salary did not exceed half the total emoluments. I imagine that "mainly" would limit the fixed salary element to not more than a half. I should like to know whether that is the opinion of the Government in this connection. Further, I should like to know when this Clause becomes law if it is the intention of the Government to alter the present arrangements with regard to fixed salaries. I am not for a moment pressing the right hon. Gentleman in favour of an alteration. As I understand the present scheme of salaries, it is regarded by the right hon. Gentleman as something of a temporary measure, and we should like to know whether it is his intention to change his policy in this matter in the immediate future."the remuneration to be paid … shall not … consist wholly or mainly of a fixed salary."
To which fixed salary is the hon. Gentleman referring?
To the £300 salary.
I beg the hon. Gentleman's pardon, it should be the basic rate.The Title of this Bill is one which would allow any hon. Member to put down Amendments to cover a great deal of the ground which was covered in the original discussions on the National Health Service Bill. We could raise a number of those issues over again, but that Measure is now law and has started to operate. We do not regard this as an occasion to seek to make fundamental changes. If we tried to do so the only effect would be to delay the passing of the Bill, which we are most anxious to see on the Statute Book. Besides, tradition and necessity require that the Opposition of this country should accept schemes which they find in operation, and seek to amend and improve them as occasion permits. The fundamental trouble which we find in the Health Service Acts is that under the principal Acts the choice of priorities is all wrong. The Acts in our opinion are founded on two fallacies. The first is that unlimited money would be available and the second that it is only expenditure which is needed to provide a good health service. The hon. Member for South Tottenham (Mr. Messer) has said:
I do not think that I can do better than to refer to what was said on this subject in "The Economist":"If it is money or life that matters, then in our regard life must have priority."
"This argument in terms of absolutes—money or life, tuberculous people dying because the estimate is wrong and so on—is superficial, vulgar and dangerous."
Yes, but they did not prove it.
That is a matter of opinion.
That is our view of the attitude of hon. Members opposite, and the way that this scheme is being developed. Our view is that where money is limited, its expenditure on matters of life must have priority over other matters, even though these are more popular."It may be politically effective, but it is the kind of thing which will quickly undermine the foundations of the Health Service itself."
That is what I intended.
We say these Acts are working the other way about. Free spectacles are admirable things, but are very rarely matters of life. The trouble with these Acts is the more free spectacles are available to the people the longer and longer become the queues at the hospitals. It is the hospitals which are the matters of life in this connection. That is our attitude. We appreciate that this Bill does not provide an opportunity for dealing with that. This change must be dealt with partly by administration and only partly by amendments, which must be made not by this Government but by some other Government which has a better attitude to these matters.
Subject to the Ruling of the Chair, it is perfectly competent for the Opposition to put down an Amendment to the Bill removing from the range of free issues any part of the Health Service. If they wish to do so they ought to take the opportunity now. There is laid upon the Minister of Health a statutory obligation to provide a free range of services. Until that Act is amended that obligation must be carried out. If the Opposition wish to constrict the range of free health treatment it is quite open to them to put down an Amendment.
I am very grateful to the right hon. Gentleman for that assurance. We shall look with the greatest interest to the series of Amendments which will be put down by the Chancellor of the Exchequer and the reactions to them of the hon. Member for South Tottenham (Mr. Messer).
I shall not detain the House long, but I think hon. Members will agree with me that we have heard a very interesting, if not surprising, contribution from the hon. Member for South Hendon (Sir H. Lucas-Tooth). I take it that this is a landmark in the history of the Conservative Party. They are now trying to escape from the blunder they committed in voting against the Second and Third Readings of the National Health Service Act. I do not blame them. It will take some time to get away from that stigma. I did not expect them to oppose this Measure in any way today.I do not think it does much good to indulge in recriminations about the National Health Service at this time, particularly if those recriminations are not accurate. I believe that what we want more than anything else is an atmosphere of national good will towards this National Health Service. We shall have some very difficult problems to solve in it. They will not be solved in one year or five years. This is a long-term project affecting the health of the nation for generations, and the sooner we get away from futile recriminations the better. Certainly, in my recollection, there was no giving in to the doctors on the question of buying and selling goodwill, or what was wrongly called direction of doctors. There never was, in my opinion, a case for the buying and selling of goodwill. If the Minister had given in on that, it would have had a very bad effect on the Service itself. The question of the direction of doctors, as far as I remember, was used as a sort of political propaganda stunt, when in fact it was probably the only way to ensure that, without positive direction, there should not be under-doctoring of one area and over-doctoring of another.
The hon. Member means negative, not positive, direction?
I am referring to the machinery for getting the doctors in the right places without infringing their liberty.I was very interested in the latter part of the speech of the hon. Member for South Hendon, when he was dealing with priorities. It is possible that priorities will have to be revised. That is always possible in any scheme, but I am not at all sure about the suggestion of abandoning the issue of free spectacles, or of any complete aspect of the National Health Service, in order to reduce the total expenditure on the scheme. Perhaps the hon. Member did not mean that the total expenditure on the National Health Service should be reduced at all. Perhaps he meant that the money saved by not issuing free spectacles should be used to assist other parts of the scheme, thus keeping the total expenditure the same. Can he give us some indication of which course he meant? Does he want to get rid of reckless expenditure or does he want to cut down the issue of free spectacles in order to spend the same amount of money on hospitals and other things?
What I was saying was simply that if we wish to increase expenditure on hospitals and are not able to obtain more money for the Service as a whole, it will be necessary to reduce expenditure in other directions within the Service. I am not advocating any particular increase or reduction of the total expenditure. That is a financial matter which we ought not to discuss this afternoon.
In that case I am very glad that the Conservative Party's view is that we are spending the right amount of money on the scheme, but that we are spending it in the wrong way. In that case, can we have an end to this ceaseless propaganda which goes on in every constituency saying that we must cut down the expenditure on the Health Service?
The hon. Member is trying to put words into my mouth. What I said was that if it is wished to spend more money on particular aspects of the Health Service without increasing the total expenditure, then reductions must be made on other items. The question of the total amount spent on the Health Service is a financial question which cannot be pursued on the Second Reading of this Bill; it is a purely administrative question.
No, it is not an administrative question; it is a statutory matter.
I am not putting words into the mouth of the hon. Member for South Hendon. I never said that the hon. Member said anything of the sort. What I am saying is that the Conservative Central Office, throughout the whole of the country—at any rate, in my constituency and in many others—are supporting a campaign of saying that there is reckless Government expenditure. They are linking that with the National Health Service and giving the impression that we should cut down the total expenditure on the National Health Service because we cannot afford it.
The hon. Member has no right to say that. We have done no more than the Chancellor of the Exchequer did on the Second Reading of the Finance Bill.
I have a perfect right to say that. Look at the dishonest posters:
Whom did they fight They fought themselves. They were not fighting Socialists or Liberals. They fought for it—I have never heard of such nonsense. To return to the question of amending the Health Service, the Minister is right in the decision not to amend seriously the Health Service until it has been working for some time. There are adjustments which undoubtedly will have to be made, some of them by administrative action and some by legislation. On the whole, although there have been undoubted abuses by doctors, dentists, opticians and patients, considering the magnitude of the scheme those abuses are a relatively small minority. They will have to be dealt with in some way, but we have not yet sufficient experience to decide which is the right way to deal with them. On the general question of amendment, I should like to ask the Minister whether he can obtain the fullest possible information—if possible, impartial information—as to the working of the Health Service itself. There are many of us who do not agree with the Government on many other matters of politics but are vitally concerned that the scheme should work out properly. We should welcome an honest exposition of the weaknesses which are occurring, the suggested ways of dealing with them, and so on. That is another reason why I am so anxious that we should stop this tendency to use the Health Service as a political football."The Conservatives fought for the National Health Service."
If the Health Service is to be used purely as a political football, there will be a tendency on the part of any Government to cover up the weaknesses and not to give the fullest possible information to enable us to get everybody working in the scheme to put it right.
The hon. Gentleman himself should begin now.
The right hon. and gallant Gentleman will have plenty of opportunity and I have no doubt that he will take advantage of it. The Conservative Party must make up their minds exactly where they stand—[Interruption.] Has it occurred to them that just now I have in the House about the same percentage of representation as they have? I have 10 per cent. of my party here, and there is about 10 per cent. of both the other parties.It is important that in this Debate we should get from the Conservative Party a statement of their attitude to the National Health Service and its Amendment, for this is a vital matter to the whole nation. At present the Conservative Party are trying to ride three horses. First, they want the National Health Service as a political slogan—they must have that in order to have something to put on their posters. Secondly, they do not want any money spent on it because they say it is reckless expenditure. Thirdly, every time there is a cut, they put Questions on the Order Paper. It is remarkable, when we get these suggestions that we must not spend so much money on the National Health Service, that as soon as a cut in expenditure is introduced, Questions appear on the Order Paper. I can remember the Question which was put immediately on one occasion by the hon. Member for Oxford (Mr. Hogg): "Will the Minister reconsider any cuts which he is proposing to impose on the Oxford Regional Hospital Board?"—and so on. When we come to look at the development of the scheme, we shall have to face the fact that it will cost money. [Interruption.] It is all very well for the lunatic fringe of the Conservative Party to act in this way. I would rather be without a policy than be saddled with theirs. We must seriously face up to the fact that this scheme will seldom be likely to cost less than it is costing today. We have got to face that. Any economies which are made in the administration of the scheme—[Interruption.]
Cannot hon. Gentlemen opposite listen to an intelligent speech once in a while?
I have noticed with in-interest, and have remarked outside the House—and I shall continue to do so—upon the extraordinarily ill-mannered behaviour of what claims to be the best educated party in the House.I was about to say that we shall have to face up to the fact that if we are to deal adequately with the health of the people, any economy we can make in the scheme—and undoubtedly we can do that, by eliminating waste—will have to be used to build things like health centres and to carry out otherparts of the scheme, so that we can get on to the preventive side of medicine quicker than we otherwise would do. Any idea of slashing the Estimates for the Health Service will merely retard the arrival of that period when we can reduce the cost naturally because we have put the preventive side of medicine into good working order. It is not a question of five or 10 years' time, but of 20, 30, or even 40 years hence. That is why I say it is a long-term project. Let us have constructive criticism by all means, but this irresponsible political sniping at the Health Service and the Government in their administration of it, using it as a political slogan on posters and so on, will serve only to conceal the weaknesses and lower the morale of the people in the Service. I say quite frankly that many things will have to be amended. The position of the rural doctor must be looked at again, not only from the point of view of his remuneration, but also because of the large lists to which he has to attend and the large area he has to cover. On the other side, I think that the position of the dentists will have to be fully investigated. I believe there has been a miscalculation. I do not know whether it requires legislation or whether it can be done by administrative action. I am quite sure that the sooner we take this scheme out of the field of party politics and get down to constructive criticism, the better. This Bill ought to be called the National Health Service (Amendment No. 1) Bill, because we shall want amending Bills Nos. 2, 3 and 4, and then a consolidating Bill. Do not let us go in for recriminations, but let us work together to see that the scheme is properly amended. I welcome this Bill as a contribution towards that end.
The hon. Member for South Hendon (Sir H. Lucas-Tooth) referred to a speech of mine in which I said, "If it is a question of money or life, then life should come first." That was taken up by the famous or infamous paper, "The Economist," in an article which attempted to read into what I said the meaning that money did not matter. No reasonable person, even on this most important service, is going to suggest that we should unnecessarily pour out money. That was never intended when I used those words. What I said was that so important is this Service that when it is a question of economising, it is the last thing on which we should do so. One cannot foresee what is to be the future economic position of this country, but if it is to be such that we cannot maintain the standard of life of the people as it is at the present time, then the last thing we should reduce is the standard of the Health Services, which is what I intended to convey. What "The Economist" did not say, in quoting me, was that I said the wealth of a nation is in the health of its people which has its economic value.I hope I have been able to disabuse the hon. Member's mind of any idea of false economics on my part. We have not got a bottomless purse, and I referred to that fact when I spoke last week on the Finance Bill. I am hoping that we shall be able to get a system of finance for this service which will not permit it to be a target for any future Chancellors of the Exchequer. It may be—one never knows what the people of this country are going to do, because sometimes they are most irresponsible—that at some future time there will be a Tory Government, and what a magnificent target it is, if we have a service like this, costing about £300 million. The hon. Member for South Hendon was most ungenerous to the Minister of Health. The Minister piloted through the House one of the most important Bills that has been introduced in modern times. Everyone agrees that he acquitted himself magnificently and showed a grasp of his subject. He gave explanations that were understandable, which had he been a professional lawyer would, no doubt, not have been quite so clear. The hon. Member for South Hendon said that his profession has no goodwill. Well, we know that.
I did not suggest that there was no goodwill, but that there was no goodwill which could be sold.
The hon. Member says that the profession has no goodwill to sell, but there is goodwill the profession can show if they are prepared to do so. The Minister got the Bill through, and throughout the proceedings he said he was prepared to listen when the need came, and that there would be inquiries made. We cannot have an immense service of this description and of such complexity without going through an experimental period which will show need for changes here and there.The Minister has gone to the length in this Bill of giving the doctors more than most people would consider necessary. He gave an undertaking that he would not introduce a salaried service. One would have thought that that undertaking was enough; there was nothing beyond the possibility of a salaried service in the Act. But the Minister has now put into this Bill a statement that there will not be a salaried service. He makes that plain in Clause 10, and Clause 11 clearly states:
Where is the need to say that something is not to be done? One would have imagined that the situation as it was in the Act would have been sufficient. This shows that the Minister has been prepared to concede that to those who had fears that were groundless, and there is nothing more in it than that. I want to say a word about the part-time specialist services. It will not do to imagine that the medical profession as a whole are completely agreed as to the encouragement of part-time specialists. During this week I received a letter which shows how clearly the part-time specialist services are tied up with the paid beds provision. One cannot help feeling that when they criticise the paid beds provision there is a danger that the position might be exploited. There were those of us who thought there would be a "freezing" of beds to the exclusion of the general public, that there would be hospital management committees that would set aside a certain number of private beds to which the public could not get admission. The Minister said quite rightly that we have it in the Bill that these paid beds can only be occupied when they are not required by people who need them for medical services."Provided that regulations made under this section shall not contain any requirement that all specialists employed for the purpose of hospital and specialist services shall be employed whole-time."
The hon. Member is speaking of Section 5?
Yes. The letter I wish to quote was received from a doctor in my own locality. He is a general practitioner and is not a Socialist. The letter is dated 13th May and states:
The letter goes on to speak of the distress of parents and continues:"I feel I ought to call your attention to a practice which seems to me to be becoming very common, and as nothing could discredit the National Health Service more, I should be very glad to have your views on the subject. On several occasions recently, I have sent children who require tonsillectomy to various local hospitals, their names have been put on the waiting list and the parents have been told that it may be anything from nine months to two years before the operation can be done."
That is one of the dangers of the part-time specialist. It means that the specialist on the staff of the hospital can take his paying patients in the hospital. I do not mind him doing that; if someone can afford to pay a high fee for an operation I see no reason why he should not pay, provided there is no hindrance to other cases which are awaiting operation. As I received this letter only recently I have been unable to go more fully into this case, but inquiries will be made. In my region we do our best to safeguard this position, but I suggest to the Minister that this case shows the need for regional boards to have rather more authority over management committees. It may well be that in the course of our experience we shall be able to establish co-operation which will enable us to exercise a greater degree of influence than at present. Full-time specialists in hospitals are by no means in complete agreement that the part-time specialist is the right solution to the problem. I can see that point of view. But I can also see the value in part-time specialists, especially those of character who are doing work of a type which is so important, and of whom there are so few. Take the type of man who is a specialist in thoracic surgery. Probably the most important operation that can be performed upon a tuberculous patient is thorocoplasty, lobectomy, or neumectomy. It is a very narrow speciality. There are not enough of these specialists, and it would be wrong of us to insist that every specialist should be full-time, for that would mean that we could not distribute his skill and ability over a wide area. That does not mean, however, that we should encourage the view that the part-time specialist service is the best we can provide. Members of the medical profession working in hospitals, who have considered this matter, feel that they are suffering from a comparison between their own position and that of the part-time specialist. They point out that there is a lot of travelling time for which the part-time specialist is paid at the rate at which he would be paid for doing his specialised work in hospital. They contend that that is a misuse of the time of the specialist. They also point out that the part-timer is allowed to undertake work which entitles him to 9½/11ths of the salary he would earn as a full-time specialist. He is also entitled to up to 800 guineas per annum for domiciliary visits; he is entitled to make special visits on behalf of the regional board, with whom he is not under contract, at 5 guineas per visit; he is entitled to work as a locum tenens at 5 guineas per half day; and he is entitled to work as a practitioner in his own private practice. There are other matters with which I will not weary the House, such as Income Tax allowances for expenses that the full-time specialist is not able to get. I mention these things because I think too much importance is being placed on the proviso in the Clause that in no circumstances will there be introduced a regulation which will make all specialists full-time specialists. The specialists' position is a very important one in the Health Service—and here I would like to have the ear of the Minister. Before the coming into operation of the Act the Ministry of Health were very generous in encouraging post-graduate study, the idea being that we should have potential specialists. The regional boards have a special interest in the specialist service because they are the authorities for providing that service. In a hospital, all the staff up to the rank of registrar are appointed by the management committee. Above the rank of registrar and specialist they are appointed by the regional board. The management committee appoint staff including supernumaries—those surplus to medical establishment requirements. It is of interest to the regional board that these post-graduate studies should continue, and I suggest that consideration might be given to putting on to the regional board the responsibility for the provision of facilities for post-graduate study. There is no question of one body wishing to obtain authority or superiority over another. But we have found, in certain areas of the country which are under-hospitalised, that a patient suffering from a complaint requiring immediate attention might have to travel 50 to 60 miles. Anyone in Wisbech who has appendicitis has to go 50 miles to Norwich or 60 miles to Cambridge. In the hospitalisation of these under-hospitalised areas there will be need for more specialists. The regional board, because it sits in a position from which it can take a wider view than the management committee, and a less centralised view than the Ministry of Health, is the right body to be entrusted with this task. As the Health Service expands, we must face the fact that it is very doubtful whether expenditure will decrease. Costly though it is now, we have not by any means got the service which is required. In 1944, there were 4,000 people waiting to get into tuberculosis sanatoria, in December, 1948, the number had risen to 9,000. My medical friends will agree with me when I say that if it is possible to deal with a lesion when it first shows, there is the possibility of the patient being restored to industry, or at least of his life being saved. If the cavity develops, and the infiltration gets bigger and deeper, so that the disease gets a greater hold, no medical skill will avail. Tuberculosis, unlike cancer, is primarily a young people's complaint; its victims are mainly those between the ages of 14 and 35 to 40. We cannot look for contraction; there must be expansion. The Minister has embarked on what is probably the most important social experiment of modern times. I am sorry that the hon. Member for South Hendon was so small-minded in his attempt to use the Bill as an opportunity for saying, "I told you so." Even if it had been true, surely the Minister is right in having the courage to introduce an Amending Bill. If he had not done so, he would have been wrong and would rightly have been criticised for not doing so? This Bill does not alter the Act fundamentally. There will need to be amending Bills. There will need to be Bills giving some greater measure of elasticity to the different administrative bodies engaged in this work. We have the problem of the old people. At present there are in their own homes old people who cannot get a bed in hospital, and they are in homes which are not fit for people to be ill in. We find that problem in the case of hospitals where these old people can be discharged by virtue of the magnificent work done by the medical profession. I have in mind a hospital where there is a magnificent geriatic clinic. The woman doctor in charge of that unit is able to get out of bed 40 per cent. of the old people who go into the hospital, but when they are out of bed we cannot send them anywhere for there is nowhere to send them. The difficulty about admitting these old people into hospitals arises largely because we cannot discharge them from hospital. The Minister will have to turn his attention to this and many other problems. This is an expanding service, and it is the noblest service to which any Minister could put his hand."They have been told in the office of the hospital, 'Oh, yes, of course the operation can be done at once if it is done privately by Mr. So and So' (the surgeon who has just seen them in the out-patients department under the National Health Scheme). The cost of the operation done privately varies from £30 to £50, which in most cases is outside the possibility of payment by the parents."
The House always listens with interest and attention to what the hon. Member for South Tottenham (Mr. Messer) has to say on the subject of health services. He speaks with exceptional knowledge over the whole range of the subject. Whatever "The Economist" may or may not have said about it, we on this side of the House appreciate his sincere desire to see this service improved. Whatever justification there might have been for the criticism of "The Economist," I think the hon. Member put it right in his opening remarks.He recognised, as everybody else does, that there is a danger to the Health Service in the mounting costs which are involved. That is a danger which we are to some extent seeing already in the cuts which have necessarily had to be made in some of the hospital estimates and which everybody regrets. I think that he recognises, as we all recognise, that if we are to enjoy a National Health Service in this country, no matter whether there is a Tory Government, a Liberal Government or a Socialist Government in power, in the long run we have to earn as a nation the benefits we seek to enjoy. I shall not follow the broad line of argument which has been developed about the cost of the Health Service, nor shall I enter into the more detailed matters to which the hon. Member for South Tottenham referred about part-time specialists and so forth. I make no complaint about the introduction of this Bill; indeed I rather welcome it, for a variety of reasons. In the main, the Clauses deal with matters which were to a considerable extent debated on the Committee stage of the main Act. These are second thoughts, and they are probably better thoughts. Nobody need apologise for having second thoughts about the various aspects of this Service. I agree with others who have said that we are bound to have a number of amending Bills. The Health Service covers a vast range of circumstances and details. If I have a criticism of the Bill, it is not so much about what is in it as about some of the things which have been left out. My regret is somewhat mitigated by the fact that the Title is so wide and the Financial Resolution so generously drawn, that it will be possible to urge the inclusion of various other matters. I have no doubt that on the Committee stage we shall be able to discuss such things as whether appliances ought to be made available to foreigners entering the country. There are arguments on both sides in some cases, and these matters can well be debated at some other stage in the proceedings. There is one matter to which I particularly want to refer, a matter which I raised with the right hon. Gentleman the Minister of Health a few days ago at Question Time. It is not analgesia in childbirth. It concerns firms who, under the Factory Acts, are compelled to have their employees under 17 years of age medically examined. At the present moment they are outside the scope of the Service. Not only have they to pay the insurance contributions, but they have also to pay privately an outside doctor to come and examine their juveniles. Nobody questions the propriety of the examination—it is very necessary that these young workers should be medically examined—but when I put down a Question to the right hon. Gentleman the other day he very kindly said that it would be impossible to do it without an amendment of the Act. It seems to me that this may be an opportunity—I hope the Minister will give due consideration to it—for some amendment of that kind which will overcome that anomaly.
And increase the cost?
I shall not make debating points about increasing the cost. Such a firm seems to be paying twice and the costs are going straight on——
The hon. Member makes the same mistake as is made over and over again. The employer makes no more payment in contributions than he has made over the last 30 or 40 years. He makes exactly the same contribution as was made before. He makes it like everybody else as a taxpayer. He makes no additional payment for the employee through insurance contributions.
I do not think that the right hon. Gentleman has quite followed the point I made. The complaint is not the amount of the contribution but that the firm is paying twice. I do not want to debate this at length now—it is more appropriate to the Committee stage—but I hope the right hon. Gentleman will look at it, because it is something upon which we might well improve the main Act. He rather suggested that amendment would be necessary.I now turn to a matter which concerns the provisions in the main Act with regard to analgesia in childbirth. The desire of all of us who have been associated with that matter has always been to have introduced a limited but, as we think, useful reform in the law on that matter. I am not in the least interested to make any personal or party point about this matter, and I believe that those of all parties who have been associated with me in this matter would concede that. I want to make a proposition to the right hon. Gentleman. There are two new Clauses on the Paper in the name of the hon. Lady the Member for Epping (Mrs. Manning) concerning the provision of analgesia to women in childbirth. If the right hon. Gentleman could see his way to accept these on the Committee stage, I should be perfectly prepared to withdraw the Analgesia in Childbirth Bill. The proposed Clauses do not give me everything I could wish to have, but they deal substantially with some 75 per cent. of what we were seeking to do in that Bill. The Clauses to which I refer are not the earlier ones dealing with the provision of all necessary services. For 100 years people have been debating whether analgesia really was a necessary service and who on earth would decide whether it was a necessary or reasonably necessary service? The two proposed new Clauses would place a duty upon the local authority to provide analgesia and transport and drugs, and place the duty upon hospitals to have the apparatus there and in good working order. We contend now that in the principal Act, to which so much reference has been made this afternoon, while many duties are placed upon local health authorities, there is no duty to provide any service for analgesia. Section 23 of the principal Act says this:
It seems to us that that is a limited duty to impose upon a local authority. It would not appear that there is any duty to give the service which we demand, and we think that some such duty ought clearly to be imposed. One can always argue, and lawyers often do, as to the interpretation of a statute, but in order to check our own opinion I took the opinion of an outside counsel upon the interpretation of the original Act. I do not say for a moment that it is conclusive—no lawyer's opinion is ever conclusive—but I thought it was something which it was proper to do to fortify my own opinion and the opinions of those with whom I was associated. I am sorry that the Minister has gone, but I have no doubt that my remarks can be repeated to him. I shall read the conclusion that this independent counsel gave. He said:"It shall be the duty of every local health authority to secure … that the number of certified midwives so employed … is adequate for the needs of the area."
"(1) There is no clear and specific duty imposed on local health authorities in the National Health Service Act, 1946, to provide analgesia services.
(2) The general duties imposed on local health authorities under sections 22 and 23 of the Act are not in my opinion wide enough to include a duty to provide analgesia services. But even if this is not accepted it must in any event be open to very grave doubt whether the duties are wide enough to include analgesia services.
(3) If a duty to provide analgesia services is not specifically, or otherwise, imposed on local health authorities under the Act, the Minister has no power to require these services to be provided.
(4) If, contrary to the views I have expressed, the Minister was entitled to require analgesia services to be provided, it would certainly be within his discretion whether he required that provision to be made or not.
We thereupon took the opinion of a well know Scottish K.C. on the position in Scotland. He went even further. He said that not only was there no obligation to provide these services but he doubted whether, strictly interpreting the sections, there was even any power to do so. Those are the opinions of those counsel on this matter. The position appears to be as follows: first, there is no duty under the main Act to provide analgesia services imposed upon the local health authorities, secondly there is no power on the part of the Minister to make them carry out those services, thirdly, even if there was a power, it is entirely optional to the Minister whether he exercises it or not. That is the law as far as I have been able to ascertain it. I may be wrong; people often are; lawyers do not always agree. I am not deriding the lawyers, for I am one myself. Surely, however, it is not even necessary for me to say that this is bound to be right. Surely, with that weight of legal opinion on that side, it is plain that such doubt must exist in this matter as to warrant the introduction of legislation in order to clarify the position. The Minister may say, of course, that it does not matter what the law is, that it is the performance which counts. And he will be able to say that since he has been in office, through his local health authorities and so forth, he has made considerable improvements in many areas as to the amount of analgesia which is being administered. I concede that straight away, I do not challenge it at all. I pay my tribute to the energy with which the right hon. Gentleman has been pursuing this matter, and to the energy with which everybody has been pursuing this matter, especially to some extent since attention has been called to it. There is no doubt about that but, equally, I think he would be inclined to concede—at least I hope he would—that the position even now is far from being satisfactory. The best areas are exceedingly good but some of the bad areas are very bad indeed. I think I can appropriately take Wales as an example. I asked the Minister of Health for the figures of the last convenient period, and I was given them for the period from 5th July to 31st December, 1948—that is for a six months period to the beginning of this year. In Caernarvon not one solitary woman had any relief whatever from analgesia. In Merioneth and Merthyr, not a solitary woman. There were others in which the percentages were very small indeed, such as Cardigan, eight women, Pembroke, 30 women. In parts of East Anglia the position is bad, in parts of the South-West it is bad. In Scotland it is almost tragic. I want to make it clear that the figures I was given are for 1947, the last ones which the Secretary of State for Scotland had conveniently. There, in area after area, no analgesia whatever was given.I have dealt with the position in England. The position would, so far as I am aware, be the same in Scotland, although the sections are not in all respects identical."
Will the hon. Gentleman permit me to interrupt? I do not think he realises the position in Scotland. We do not have midwives. We have an Act in Scotland that permits mothers to have doctors and anaesthetics, not midwives and analgesia, as in England.
I am much obliged to the hon. Lady for her intervention. She has drawn attention to the perfectly fair point that there is a difference in treatment between England and Scotland. However, I have been meticulously careful to get figures for those cases where the midwife only was employed. Though I could argue the case of the doctor, I am not concerned with it because, if one considers the time during which the doctor is able to be present, it is not long. In these cases, no doctor was concerned, the midwife only was in charge, there were 26,000 of them, and only 120 had analgesia.
Not in Scotland.
Yes, these are in Scotland. These are the figures provided by the Scottish Office. In Aberdeen County, not a solitary woman. In Argyll, not a solitary woman.
May I ask the hon. Gentleman if the midwives were in entire charge, or were they acting only as maternity nurses to the doctor as sometimes happens?
Both in England and Scotland, quite clearly, there is a doctor who sees the patient beforehand and has to be technically in charge, at any rate to the extent that no analgesia must be administered unless there is a certificate that it would not do injury to the patient. No one would ever seek to challence that position. These were cases where only the midwife was in a position to administer the relief, that is to say, no doctor was there to give any other form of anaesthetic.
May I finish my point and then I will give way? In those cases in 1947 there were only 120 out of 26,000. I want to be meticulously fair about this. In reply to a recent Question, I understood that the position improved somewhat in Scotland in 1948 because the figures for that year showed that as many as 800 out of 26,000 received some relief of this kind. Really, 800 is a very small number out of such a very large number of lives.I am not therefore saying, and I am not quoting these figures to indicate, that the Ministry of Health or the Minister of Health has been backward in efforts or exhortations. That is not my case. My case is that in some of the backward areas very little has been done. If a clear and specific duty were laid upon some of these areas I think the advance would be quicker than if we relied merely upon exhortation.
Is the hon. Member making any distinction between the services available and the services used? I ask that question because in one area which I know very well, where 100 per cent. of the midwives are trained and where all the facilities exist, the actual percentage used was only 40.
The figures I am quoting are for the cases used. As the hon. Lady is aware, one can never be entirely accurate with statistics of this kind. The inquiry was held to ascertain the average number of women who refused the service when it was offered. The figure given was some 6 per cent. It is extraordinarily unlikely that in county after county and burgh after burgh in Scotland not a solitary woman used the service if she could have got it. That is stretching the case too much.I must now say one or two things about transport. An independent Government inquiry was held on this subject. In their report, the recommendation was clear and specific. It was:
A car is necessary for the transport not only of the apparatus but of the midwife to the patient, particularly in some of the large areas. It is not being done. I thank the right hon. Gentleman for coming back into the House. I can assure him that I have been most kind to him in his absence. I am not saying that the Minister has been inactive. In fact, the other day he was successful in getting an improvement whereby there might be more priority for midwives than otherwise in respect of cars, but until we order the cars we shall not get them. If one looks in the nursing journals one will realise that it is not unusual to see advertisements for midwives or maternity nurses specifying that ownership of a motorcar is essential to the appointment. People talk about the lack of midwives and of maternity nurses, but if one is to seek for them solely among the classes of the community that own their own motorcars, it is limiting the opportunities from the start. In these matters we would seek to place the duty upon local authorities to make this necessary transport available. The idea here is not to be critical of the Minister or of the Government. The idea is to strengthen the hands of the Minister. I would refer to and emphasise one point on which I touched earlier. The right hon. Gentleman is very energetic. We can all say that, whether we agree with his policy or not. He may not always be Minister of Health. Some local health authorities are admirable, but they do not always remain under the same management. If we are to get any continuity of policy in this matter surely it is better to have a clear duty imposed rather than to leave the matter in the air. If cuts are to be imposed, where are they most likely to be imposed? Not where Parliament has said that a clear duty is to be laid down. The cuts are most likely to be imposed where everything is all permissive, anyway. If the House feels seriously about the need to provide women with this relief from pain, at least let us put the matter in the same category of duty obligation as we do the dental care of mothers and young children. The only other matter is the question of the hospitals. We want to lay a duty on the hospital to have the apparatus there and to see that the apparatus is in working order. I am bound to say that I should have thought that was not asking too much. I want to quote one letter on that subject. It is a letter from two doctors. One is Dr. Minnitt, the inventor of the Minnitt apparatus, who has probably done as much as any other man in the furtherance of this branch of medicine. The other doctor is Dr. Elam of the Wellhouse Hospital, Barnet. Both of them are well-known in this field. This letter they wrote the other day to "The Times." I do not know whether "The Times" has published it yet, but I think I may quote it. It says:"The right answer seems to us to be that every midwife, whether in town or country, ought to be provided with a car and given sufficient financial help to run it."
I quote from these two reputable doctors. Of course, in all these cases statistics are apt to be not very accurate. I am not saying that in criticism of the Minister or of anybody else. That woman mentioned in the letter is counted as having had analgesia in childbirth. Anybody who has had a whiff of gas in any stage is counted in. I am not going to keep the House any longer. I thank hon. Members for listening to me on a subject upon which I feel rather strongly. I would make an offer. I am prepared to drop my Bill if the Minister will accept the proposed new Clause of the hon. Member for Epping. I shall be sorry to lose my Bill because I have become rather attached to it in recent months, but if one wishes to get a reform through, what has to be studied is getting it through. I am not in the least interested, I ask the House to believe me, whether the reform is achieved by means of a Conservative Member's Private Bill or through a Socialist Member's new Clause in this Bill. If we get the new Clause we shall have made an important step towards removing some part of this suffering in this country. I hope that the right hon. Gentleman will be big enough to take that step tonight."The Medical Research Council has set up a committee to investigate methods for producing relief from pain in maternity. It would appear from our experience, that a more urgent necessity, is the proper supervision of present approved methods. A letter recently received by one of us, described the experience of a patient in a Metropolitan hospital. 'I was kept,' she says, 'in Ward S, until 10 minutes before the baby came. By the time I was taken to the labour ward and given the machine, my baby was born, after only one more pain. That means I was in labour from 8 p.m. on Sunday night until 12.50 p.m. on Monday. I entered the labour room at 12.40; baby was born at 12.45. The previous young girl was still there resting, and she told me the machine did not work for her, as it was empty.' This letter is not the only one we have received. About two years ago, we sent to the Ministry of Health a number of similar letters. We would like to suggest then, that as an immediate measure, it shall be an established rule in every hospital, that a staff anaesthetist shall be appointed to supervise the administration of analgesia, and that in domiciliary midwifery, the local authority shall make a similar appointment to enable the midwives to obtain the assistance they need."
After the excellent speech which we had from my hon. Friend the Member for South Tottenham (Mr. Messer) it would be a pity if the Debate were to degenerate into a discussion merely on the question of analgesia. Though I am going to follow immediately the arguments of the hon. Member for Monmouth (Mr. P. Thorneycroft) I hope we realise that there is much more in the Bill than the subject which the hon. Member has so ably raised. One might describe this Bill as a psychological Measure. It is concerned with psychiatric treatment applied by the Minister of Health and administered by him to the medical profession to relieve them of their unjustified anxieties. That was disclosed to us by the hon. Member for Monmouth, whose speech implied that everything would be quite all right so long as the present Minister is in that office—but who knows? He may be promoted.If the Minister is to go out, is it not really in the back of the hon. Gentleman's mind that he would like to insure the Health Act against the possibility of his own party being returned to power? He would like to re-insure it against an event which is unlikely to happen. There is no harm in indulging in such re-insurance if we are certain that it does not harm this Act. There are many arguments in favour of various sorts of relief and, indeed, before he got on to the subject of relieving pain in childbirth the hon. Member spoke of relieving the expenses of employers from the services which it is necessary for them to carry out in connection with the Factories Act. Those are two things which we may have to consider, but, whether we are considering employers' liability or childbirth, we should make the words wide enough for the purpose we have in view. We all have the greatest respect for my hon. Friend the Member for Epping (Mrs. Manning) but the words she and other Members use in the proposed new Clause attempt to prescribe by Act of Parliament and to write into an Act of Parliament exactly what should be done in childbirth. They have dealt with one specific thing; instead of making the words of the Act as broad as possible they have made them as narrow as possible. This is a question which has received considerable popular discussion, but what we should attempt in this House is to make certain that not only analgesia but any other services which it is necessary to administer should be available. If it is necessary to deal with it, let us deal with the whole issue once and for all. This is not the time to discuss it, but some hon. Friends and I have put down a proposed new Clause dealing with the duty of local health authorities in connection with midwifery. I was glad to see that the first part of that new Clause secured the approval of the hon. Member for Monmouth, because he followed the first part of the wording. But, at a later stage, he branched off and differentiated very sharply in order to keep to the analgesia issue, while we tried to make it embrace other services. Actually I do not think any Clause is necessary because, although never before has there been such talk of the illegality or impropriety from a legal point of view of analgesia, there has never been at the same time such an amount of actual practical administration of it. If it is true, as suggested, that the Minister of Health is a law breaker, he has broken the law on a quite unbelievable scale in my own county and in the county of my hon. Friend the Member for Epping. In one half year after the introduction of the Health Act there have been more cases of administration of analgesia in England and Wales than in the whole period of 1939. If that can be done under the existing law, it does not seem that there is anything we need remedy from that point of view. But what there is a need to watch for is the administration. Already in Essex there is talk of economy in all sorts of services. The political power has passed from one party to another and I hope that the hon. Member for Monmouth will use some of his eloquence on the Essex County Council to try to persuade them not to cut down on services on which analgesia depends, not to cut down on ambulance services and to economise in all these ways because there is already great talk in Essex of his party standing for reform and retrenchment. I do not know where they picked up the phrase, but if those reforms and retrenchments are going to affect not only the medical service but everything which goes with it, ambulance service and the like, they will put an end to analgesia——
What a strangely illogical speech.
My hon. Friend will have an opportunity to deal with that particular aspect of it later and, knowing her, I am certain she will take full advantage of the opportunity. It would be very unfortunate if we were divided on any barren dispute as to form of words. It seems to me that it should be possible to devise a form of words which will embrace, not the narrow, but the broad issue. I do not say that the form of words of my hon. Friends and myself is ideal, but I cannot say that of the form of words of the hon. Member either. We should wish to remove all doubt on this subject and to make the Clause watertight from all points of view.
I trust that the hon. Member for Horn-church (Mr. Bing), whose speeches I always enjoy, will forgive me if I do not follow him on the question of analgesia, because I have other matters to mention. One is tempted to ask the Minister to eat some of his own words, but it is very easy to ask him to do that and I do not propose to do so. However, I hope he feels he has learnt a valuable lesson, which has been a useful part of his political education, in the experience he has had over the original Act and this amending Bill.Hon. Members no doubt will recollect that when the National Insurance Bill, which became an Act in the same year as the Health Service Act, was before the House, it received a unanimous Second Reading. I think there were only two hon. Members who even called out against it. The whole question of National Insurance has been above party throughout this Parliament; and I wish that the Health Service had also been above party. I express the hope that now that we have this amending Bill, which cures the serious defects in the original Act, we can approach the question of the Health Service on a non-party basis. I welcome the provisions of Part I of the Bill, as I do other parts of the Bill, and should like to join in the tribute and to the work of Mr. Justice Slade and the committee over which he presided. I do that with great pleasure because 17 years ago I happened to be his pupil in my early days at the Bar and the report of his committee is typical of his orderly legal mind. In regard to Part II of the Bill, I speak as the son of a general medical practitioner, who also in his long medical life, was a surgeon, and I welcome the fact that in Part II we have some security for the future that the medical profession will be placed in a position in which it is in the best interest of their patients that they should be. There was a tag spoken three or four years ago, of which I would remind hon. Members. It was said to have been spoken by a general practitioner and was as follows:
That would indeed be a very serious position, if it became established; but so long as we preserve a high degree of independence in the members of the medical profession, I think that undesirable situation can be avoided. I welcome the provisions of Part II of the Bill because they are likely to preserve to a great extent the independence of the medical profession. I sincerely hope, however, that during the Committee stage the vagueness of the proviso which is to be found in Clause 10, and which is to be added to the original Act, will be removed. Meanwhile, it would be most valuable if the right hon. Gentleman, in winding up the Debate, were to give the House some idea of what he at least has in mind when he says that in special circumstances the proviso with regard to there being no fixed salary or not mainly a fixed salary shall not prevail, because if these "special circumstances" are to be interpreted too broadly by a Minister with particular whims, the whole effect of this amendment will obviously go by the board. So much for the comments I have to offer on the Bill itself. I hope that I shall not be out of Order if I make one or two remarks about the way the principal Act is working out at the moment. I understand that hospital management committees and regional hospital boards have been asked to apply their minds to the question of reducing expenditure. No instructions given to these bodies have come our way, as Members of Parliament. It is time that the Minister told the House exactly what he has asked the hospital management committees and regional hospital boards to do. I look forward to enlightenment on that matter because I know that a great deal of anxiety is being felt by some members of these committees as to what these economies will involve. I shall endeavour to rebut the suggestion which is often made by the Minister and the Chancellor of the Exchequer, and made with reason, that hon. Members are asking for expensive improvements in public services and at the same time are crying out for economy. There are many Departments for which the right hon. Gentleman is not responsible, and some part of the work for which he is responsible, in which economies could certainly be made and improvements of the service thereby carried out. In particular—the Minister has already been told about this in this House, but I should greatly welcome something more from him about it tonight, for he has had further time to consider the matter since it was last raised on the Supplementary Estimates—this service is obviously carrying heavy overhead costs of administration. That is well known, and the right hon. Gentleman has had time in which to apply his mind to the question of how those costs can be reduced. We want to know if he has made a serious effort to consider the matter; and, if so, what are the results of his deliberations. This service was originally proclaimed as being a service which was free to the individual in all cases, irrespective of contributions. There are two respects in which I have found, through experiences of my constituents, that it is not free. In the first place, people living in remote rural areas are often having to pay high transport charges to get to a hospital for treatment. Only three days ago I received a letter from a lady in a remote village; in fact it is scarcely a village, it is just a small hamlet, too small to be served by a bus service now or probably for many years to come. She was told by her doctor when he visited her, that she ought to go to hospital 10 miles away three times within one week for X-ray treatment. She has considered the matter, and she and her husband find that it will be necessary for them to hire a car costing in all £3 for the three visits in order that she may have that treatment. In other words, the service is free if one can afford to go and get it. That is how it works out for quite a number of people in rural areas. I understand that regulations have been made for the reimbursement of fares paid on public transport; but where private transport is necessarily hired, it appears that there can be no reimbursement whatever. That matter will have to receive attention. Then the families of men serving in the R.A.F. and living in Service quarters are in a most unusual position. In their case freedom of choice of doctor appears to be excluded. They are told, "You can receive the attention of the one doctor serving the station, but if you do not want his services and desire the services of another doctor living in the neighbourhood, you cannot have them, even though he is within the Health Service." Further, even though they go to the Service doctor they are told, so I am reliably informed, that they will have to pay for the medicines which he prescribes for them. If I am wrong about these facts, I shall be only too happy to learn that that is so; but, if I am right about them, it seems that an exception is being made to the general principle that the Service is free to the individual. A strange position has arisen in regard to pay beds. When the Minister took over the hospitals, he found that they had their private wards, etc. He was quite willing to make provision for pay beds when it was possible to do so. At least he has done so, but a condition has been attached that, if a patient entitled to all the rights of the service accepts pay bed accommodation, he or she must also pay full private fees to the medical practitioners and specialists attending. In some cases of which I know, that has worked out as a considerable hardship to members of the middle classes. I know a young professional man earning from £600 to £700 per year whose wife, while away from home, was taken ill with appendicitis and had to go into hospital quickly. When telephoned, he said, "Get her a private ward, if you can." He never for a moment expected that he would have to pay very substantial fees for the specialist and the other doctors attending her. He assumed that apart from the payment due for the private ward accommodation, his wife would be treated as a member of the public entitled to the services available under the National Health Service Act. Instead of that he has had a bill amounting to £70 or £80 for private ward accommodation and the specialist's fees. Nor am I blaming the doctors in this case, because the doctors, whether they wish to or not, are, according to the Minister's own regulations, as I understand them, being compelled to charge their usual private fees."I am the servant of my patient, while I'm master of my fate; but I'll be master of my patient, when I am a servant of the State."
There is nothing in the Act of Parliament which compels a doctor to charge anybody a brass farthing.
Then why is it that the Minister's regulations have been so worded that, if a patient accepts pay bed accommodation, he or she must do so on condition of not getting the rest of the Health Service attention free? It has to be paid for.
The hon. Member is quite wrong.
I am at the moment in correspondence with the Minister about such a case. I shall look to a happy conclusion of that case if the practice is what the Minister says it is.It must be a great attraction to foreigners to come to this country hoping that they will get all the services free. They have not contributed to them, but that is beside the point if it is to be an attraction to foreign tourists. But we must make quite sure that it will be an attraction. We do not want foreign tourists to encounter any of the snags and difficulties which our own people have experienced, and on balance I should have thought that this was not a very wise provision, at any rate just yet. And in any event, if we want to attract the foreign tourist it would be far better to sack the Minister of Food. Now that we have got this matter of the original Act, which was obviously a bad one, thoroughly squared up—it is to be well amended as we can understand if we look at this Bill and at the Schedule in particular—let us hope that from now onwards both sides of the House can co-operate in making the National Health Service the success it ought to have been from the very beginning.
I welcome this Bill designed to weave loose threads into the fabric of the National Health Service Act. Some opponents of the Government claim that these amendments should have been included in the 1946 Act, and declare them to be omissions of hurried legislation. I cannot share that view. For years the country was in need of a comprehensive health service, but had to wait a long time before a Government would deal with the problem. The Conservatives talked about it, but took no practical steps towards its realisation. True to name and tradition, they conserved the old disorder. On this side of the House hon. and right hon. Members who knew the urgent need for reform are agreed that the National Health Service Act was not passed too quickly, nor was it brought into operation too soon.Not yet a year old, the Service suffers the inevitable troubles of infancy, and now my right hon. Friend promptly prescribes the remedies. Part I of the Bill clarifies the position of general medical practitioners practising in partnership, and should relieve their anxieties. About two years ago I heard an official of the British Medical Association speak on this particular matter and explain the complexity of some partnership agreements. I am sure he did not exaggerate, but I gained the impression that the problem affected many practitioners. It is now stated in the Financial Memorandum to this Bill that about 50 practices are involved and about 150 doctors concerned. Many must have settled their financial difficulties, but it is worth while devoting the first part of this Bill to the benefit of the remainder. Further comment on this part of the Bill would require expert knowledge of law and accountancy. Part II of this Bill begins with Clause 10 and prohibits a full-time salaried practitioner service. I was not satisfied with the reasons given by the learned Lord Advocate why this Clause was inserted. My right hon. Friend the Minister of Health has had a very difficult task in dealing with representatives of the medical profession. He has had the good sense to know that the general medical practitioners are the commandos of the National Health Service. He wants to be reasonable, fair and just, and he has made compromise after compromise. But has not he now gone too far in trying to meet the demands put forward by that section of the profession which are most opposed to his political views? Let me quote a few extracts from the leading article in the "British Medical Journal" of Saturday, 21st May:
Also:"The B.M.A. conducted a campaign against the introduction of a whole-time salaried medical service.…"
Also:"It did not accept the assurance of the Minister that this was not the Government's intention.…"
The medical profession does not want a full-time salaried service, and the Government have not tried to force one on to it. The Act of 1946 was arranged so that the Minister could by regulation conform to the wishes of the medical profession and the best interests of the country. The day may come when the medical profession wants a full-time salaried medical service and will have difficulty in obtaining one if this Clause becomes law. I suggest that my right hon. Friend is pampering a section of the profession which is most politically prejudiced and panic stricken. I should like him to hear some of the comments on this Bill taken from that same recent leading article in the "British Medical Journal" to which I have already referred:"Mr. Bevan once more bowed before the storm.…"
And another sentence:"The Minister of Health, may, of course, argue that an amending Bill at this stage should be free of controversial matters so that it may be passed quickly, or at least before the end of the life of the present Government."
I think my right hon. Friend ought to know of that. The only other criticism which I wish to make of this Bill is with regard to a part of the Schedule, and it relates to local medical committees. There it is proposed that subsection (3) be added to Section 32 of the 1946 Act. Perhaps I might draw the attention of the House first of all to Section 32 of the 1946 Act which states that local medical, dental and pharmaceutical committees may be formed in the area of any executive council. Subsection (2) of that same section states:"He has again committed a breach of trust with a profession that has loyally collaborated with the Government in operating a service full of imperfections."
Thus the committees can be told what they have to do, and the executive councils are forced by law to consult with them. Surely this clearly acknowledges the importance of these committees. I admit that they are of value to doctors, dentists and pharmacists, but I suggest they are of even greater value to the Minister himself; forming as they do liaison between the administrative and general duties branches, and being essential for the efficiency of the service. This Bill proposes that:"The executive council shall … consult with the said committees … and the said committees shall exercise such other functions as may be prescribed."
Why should the administrative expenses of these committees and the travelling and subsistence allowances of the members have to be met by compulsory deductions from the salaries of doctors, dentists and pharmacists? Why is this not a public expense? I suggest that this has been incorporated in the Bill because voluntary payment by the people concerned has been a failure. Although the amount is only quite small, some object on principle and others feel that they cannot afford any reduction of income. I resent this niggardly nibbling at the pay packets of doctors, dentists and pharmacists, and I ask the Minister to reconsider the matter. When he reconsiders it I ask him to bear in mind that doctors are not wealthy men. They must not be judged by their gross incomes because many of them have heavy practice expenses. They do not seek wealth but they ask that their remuneration shall be sufficient to allow them to give freely their self-sacrificing service in accordance with the traditions of an honourable profession. I hope that the Minister appreciates that after the storm he has weathered, we sail in calmer seas with the majority of medical men and women, bringing welfare to the people and world renown to the Service. I hope also that the passage of this Bill through Parliament will bring home to all medical practitioners the fact that we have a Minister of Health and a Government willing and anxious to aid them in their vital work."The executive council may, on the request of the local medical committee or the local pharmaceutical committee or the local dental committee … allot to that committee out of the moneys available to the council for the remuneration of persons of whom that committee is representative … such sums for defraying the administrative expenses of the committee, including travelling and subsistence allowances payable to members of the com- mittee.. and the amount of any such sums shall be deducted … from the remuneration of the persons aforesaid."
I trust that the hon. Member for Batley and Morley (Dr. Broughton) will not mind if I do not follow him into the detail of his argument, but I do not wish to detain the House for very long. In fact, Mr. Speaker, I had not intended trying to catch your eye, because I wanted to speak on one particular aspect of the National Health Service which has already been dealt with by two hon. Members who were more intent than I to speak on it. I wish to answer the arguments put forward by the hon. Member for Hornchurch (Mr. Bing) who, unfortunately, is no longer with us.I refer to the proposed new Clauses dealing with analgesia, which we will not discuss in detail today but to which I hope the Minister will pay attention. I trust that he will consider accepting them, and I hope that he will give some indication to that effect when he replies to the Debate. The hon. Member for Hornchurch supported his own new Clause because he felt that it was necessary that we should not try to be too specific when we are amending the Act. I would suggest that his Clause is really far too wide. At the end he suggests that it should be made a duty to provide for all women in childbirth
I suggest that the words:"all services reasonably necessary for the proper care of the women.…"
are too wide. Who is to decide?"all services reasonably necessary"
One ought not to discuss in detail new Clauses which are going to be put down on the Committee stage. One may refer to the subject in general, but I think that it would be wrong to discuss in detail the wording of the Clauses now.
I accept your Ruling, Sir. Therefore, I will say, speaking in a general manner, that those new Clauses in the names of the hon. Member for Hornchurch and the hon. Member for Coatbridge (Mrs. Mann), are too wide in their interpretation. I trust that the Minister, who has again departed from our proceedings, will perhaps pay attention to those new Clauses which are put down in the names of my hon. Friend the Member for Monmouth (Mr. P. Thorneycroft) and the hon. Member for Epping (Mrs. Manning). It is important that we should be clear in our own minds as to the exact interpretation of the National Health Service Act. My hon. Friend the Member for Monmouth has read out counsel's opinion, both English and Scottish, as to the interpretation of the original Act. We seek to amend it through this Bill and through our new Clauses because we are not satisfied that in fact the local authorities have a duty imposed upon them to provide these necessary services of drugs, transport, apparatus, etc., to the midwives in the discharge of their duty.It has been said that by trying to impose a duty on local authorities one tries to take away their responsibilities. But this argument was answered by the then Parliamentary Secretary on the Second Reading of the National Health Service Bill, when he said, referring to the responsibility of local authorities:
By our new Clauses we seek to ensure that it becomes a duty and not the option of local authorities, to provide the necessary analgesia services. I thought that the hon. Member for Hornchurch was perhaps a little wide of the mark when he said that it was a pity that we should have a barren dispute on the form of words. The interpretation of an Act is extremely important. It is most necessary that local authorities should have a perfectly clear idea of what are their duties so that they should not have to refer to legal opinion to know exactly what they are. For instance, we do not want to feel that the situation is as described by the Minister himself when, in answer to a Question in this House, he said that he had the power to change, enlarge or modify any of the duties imposed upon local authorities at any time. I submit that that is a very serious statement. Surely, the local authorities do not like to feel that their duties can be changed, enlarged or modified at any moment by the Minister. Surely it is far better that Parliament should discuss what is to be their specific duty and make it clear by Act of Parliament. Finally, I should like to make reference to one interpretation by the hon. Member for Coatbridge who, in talking about the figures for Scotland, said we had a system whereby women in childbirth received the care of an experienced doctor. It is true that that is our aim, but the figures quoted by my hon. Friend the Member for Monmouth concerned those cases where only midwives attended these women. There were over 27,000 live births, and only 800 women received relief in 1948. But we are discussing the Health Service as a whole and the possibility of improving it. We must make the very best possible use of all our facilities. If we had a fine midwifery service, I think that we should be thankful for it and we should encourage the people in the Service to become more efficient. There is no doubt that under the National Health Service we are facing great difficulty in the shortage of beds in hospitals and the shortage of doctors and nurses. In my opinion it is a mistake to encourage women always to go into hospital for the birth of their children. They ought to be able to feel that they will have the same care and attention in their own homes. Also, I think it is a mistake for them to feel that they can only get proper analgesia service if they go to hospital. We all know that owing to the shortage of beds it is very difficult for women to get into hospitals for the birth of their children unless they are likely to have complications or perhaps it is a first child. That applies in some congested areas: it does not apply all over the country. When we are discussing the National Health Service as a whole, we should try to improve those services which are available, make it perfectly clear what are the duties of the local health authorities and be quite sure that they carry them out."Optional powers are by this Bill made duties, and a direct responsibility is placed upon local authorities to provide services of a quality and standard in keeping with a real national health service. It becomes the duty, and not the option, of the local authority to make arrangements for the care of nursing and expectant mothers and children under the age of five. It becomes their duty, and not their option, to provide a free and full health-visitor service.…"—[OFFICIAL REPORT, 1st May, 1946; Vol. 422, c. 220–1.]
I hope the noble Lady the Member for South Aberdeen (Lady Tweedsmuir) will forgive me if I do not follow her on the question of analgesia, but the House has already discussed it for some considerable time this afternoon. I sat throughout the whole of the Committee stage of the National Health Service Bill, and as far as I can recollect, the subject of analgesia was never raised, and it is rather belated to raise it now.I was rather astonished, when listening to the earlier Debate, to hear the hon. Member for Huntingdon (Mr. Renton) and the hon. Member for North Dorset (Mr. Byers) deploring the fact that the National Health Service Act had been treated as a political issue. I was surprised to hear the hon. Member for Huntingdon deploring that fact. He compared the National Insurance Act with the National Health Service Act and said it was a pity that the House had not treated the latter as it had done the National In- surance Act. The fact is that the Health Service scheme has been political right from the very beginning, and, even before the Bill was introduced the Tory Party and the B.M.A. up and down the country were misrepresenting what was in the minds of hon. Members on this side of the House. When we came to discuss the details, the House will remember the misrepresentation about the relationships between doctors and patients which, it was said, would come about if the Bill was passed. During the Committee stage, the Opposition also opposed us on the question of the direction of doctors and again drew a picture of the terrible things that would happen. They have not happened. They also opposed us on the question of the abolition of the sale of practices, and on dental questions. When we suggested taking over the voluntary hospitals and running them into a co-ordinated hospital system, they opposed us again, and, of course, it has been a political struggle from the very beginning. We deplored it from the beginning, and we are glad now to see that at long last the Opposition are coming to our point of view. As the Debate today has ranged very widely, I make no apology for discussing an important aspect of the National Health Service—the dental aspect. There is nothing in this Bill referring to dentistry, but I wish the Minister had included in it a Clause relating to the priority class in dentistry. We all know, from Questions in the House on the subject, about the lack of treatment for children and expectant mothers. It is an urgent need; it was written into the original Act of 1946 that the Minister should provide a priority service for expectant mothers and young children. The trouble is that, while it is written into the Act, the Minister has no power to implement the Act. The school dentists are employed by the local authorities, and the position today is that the establishment of dentists employed by local authorities in treating the priority class is under 50 per cent. The Minister is not to blame for this. The situation developed almost in a Robertson Hare way. First, when the Minister set up the Whitley machinery to settle differences between the two sides the dentists refused to accept it. Months were wasted in trying to get them to come in, and then, when they came in, the local authorities refused to accept the Whitley machinery, and so the position has gone on until today the whole system is almost breaking down. The only solution is for the Minister to take over the treatment of these priority classes. At present, the Government give a grant of 50 per cent. but this is not enough. As dental incomes have gone up, a vicious circle has started. The local authority dentists want more money to bring them up to the level of the private dentists, and the local authorities fear that if they pay their dentists on that basis, there will be other of their officials who will want the same kind of salary, and so the vicious circle goes on. I am sorry there is no Clause in this Bill enabling the Minister to take over this service and run it on a regional basis. He ought to cut out a lot of red tape and help us to meet the needs of the priority class. I am also very worried because of the way a certain proportion of the private practitioner dentists are treating their patients in the country today. Let us face up to the fact that there has been a considerable amount of ill-informed talk about this. All this talk about dentists making £10,000 a year is not completely true. The position really is that a very small number of dentists are making large incomes, but we must always remember that the gross income of a dentist bears no relation to his net income. Under the old private practice scheme, their expenses were about 52 per cent., while today they may be much higher. All this Press talk about inflated incomes is wrong. There is a small number of dentists, perhaps 10 per cent. of the profession, who are guilty of acting in a most unprofessional manner. The trouble is that the income which a dentist receives privately from a patient does not always find its way to the tax collector, and there is encouragement at present for a certain number of unscrupulous dentists to try to squeeze money out of the public, although the public are entitled to the best possible type of dental service under the Act. We shall have to do something to try to stop it. The trouble with these inflated costs is that the salaries are much too high, although the dentists are working longer hours than before. The demand for dental services has been much higher than anyone ever forecast, and I remember the leaders of the dental profession, and hon. Members in this House, arguing that if we had a free dental service, the people would not rush for it and there would be no shortage of dentists. It has now been proved that the demand has been so great that the shortage of dentists is very serious indeed. All these factors tend to give us these much inflated costs, which are much more than we expected. I would suggest to the Minister one way in which he could cut the costs of the dental service almost immediately, apart from cutting salaries. There is need to cut salaries, it is true, but that will only save a certain proportion of the cost. At present, the number of estimates which dentists are submitting for approval runs into hundreds of thousands each week. We have a dental estimates board which examines these estimates, but every estimate is not examined in detail. Only when there is any doubt and a professional opinion is necessary, it is submitted to the board at Eastbourne. The Government admit that the establishment necessary to supervise this system is 12 professional dentists, as well as regional dental officers who are stationed about the country and inspect the patients where there is any query. At present, because of the inflated salaries of private dentists, where the establishment at Eastbourne is 12, we find it is actually employing only four. There are thus four men to do the work of 12, and the same is the case with the officers in the country. I believe that if the Minister would spend a few thousands in increasing the salaries of these specialists, he would increase the number to the full establishment, and we should have a much better check on the wastage which at present goes on through dentists submitting estimates that are unduly high. There has been a tremendous amount of publicity about dentistry in recent months, and I feel that much of this talk must be discounted. The number of patients wanting dental treatment who did not really require it is very small, and the amount of leeway to be made up by dentists in this country is tremendous. I welcome the attitude of the Opposition tonight, and especially that of the hon. Member for South Hendon (Sir H. Lucas-Tooth). I am glad they realise that they were wrong during the passage of the 1946 Act through this House, and, while I do not praise them for it, I am sorry to see that, now that they realise they were wrong, they are running off ready to jump on the bandwagon.
I shall not follow the hon. Member for East Wolverhampton (Mr. Baird) very far, but I congratulate him on taking up the case of the priority classes of dental treatment, because that is one of the sections of the Service which is still badly in need of development. The only comment I would make is that I very much doubt whether the answer to the needs of those classes is that the Minister should take over responsibility for them. It seems to me that until the question of the remuneration of the private dental practitioner is settled, it is quite hopeless to think of attracting dentists into a salaried service because of the enormous disparity between official salaries and what they can earn as private practitioners.There is one general observation I wish to make. I am one of those who, once the decision to pass the 1946 Act was taken, felt that it should be lifted, if at all possible, out of the realm of party politics. I know that is difficult. We heard earlier today a plea from the hon. Member for North Dorset (Mr. Byers) on behalf of the Liberal Party. I wish we could take his advice, but I hope we shall not follow his example, because no sooner had he made the plea than he proceeded to play "political football," to use his own words. I think we can take it that by this time the Minister of Health knows our public views about himself—I say nothing about our private views—and I am quite certain that we on this side know the views held about us by hon. Members opposite. Let us call it quits and recognise that in this Service there is an enormous task waiting to be done. There are hundreds of people here in London, chronic sick people, waiting in their homes for hospital beds. There are thousands of people suffering from tuberculosis who ought to be in sanatoria, but who cannot get there. Again, there are hundreds of confinements taking place at home when, on social grounds, they ought to take place in hospital There are, I suppose, thousands of nurses who are being housed in quite inadequate early Victorian quarters. To right these things is a task which calls, not for party strife, but for a national effort now that we have the 1946 Act on the Statute Book. At this late stage in the Debate, there are only one or two matters in the Bill to which I wish to draw particular attention. The Minister's main task now, in order to get this great Service settled on the rails, is to carry the professions with him. The Service will not function properly until the professions feel that they are in a position of security, and that, instead of looking over their shoulders wondering what is going to happen next, they can devote themselves wholeheartedly to their professional work. I believe that in this Bill the Minister has gone some way to meet the doubts of the medical practitioners. He may consider that it is of no value, but they consider that it is of value to have a statutory guarantee that a full-time salaried Service shall not be introduced save by Act of Parliament. That may be the beginning of peace in the medical camp. However, I feel that a gesture to the dentists is very badly needed. The difficulty in which that profession finds itself is that the dentists feel themselves faced with a unilateral alteration of terms of service by regulation. One of the things I hope the Minister will be able to tell us is that when the conciliation machinery is set up it is going to be used, and is going to be exhausted before any alteration in terms or conditions of service are made by regulation.
In that case, the leaders of the dental profession must, on their part, be ready to negotiate and to meet us, and not stay away when they are invited to come along and talk.
Here, of course, we are stirring up controversy; it all depends upon one's interpretation of the word "negotiation."
The leaders of the dental profession have been invited on several occasions to meet me or my officials and have refused to come along. They are hardly the people who can complain at the absence of negotiation.
There is no advantage in arguing with the right hon. Gentleman on this point because I do not know the precise terms on which the invitations were made. If they were invitations to negotiate, then I would agree with the Minister that the dentists were open to criticism. If, on the other hand, as has been suggested, they were invitations to come and discuss and comment, but not to negotiate, then it may very well be that the dentists had reason on their side for saying, "We will not come merely to learn what is going to happen. If that is all it is, a letter will do." However, tonight the Minister is in a far better position than I am to put the facts before the House.On the details of the Bill, I want to refer to one Clause in particular, and to one other matter which is not dealt with precisely in the Bill, but which I hope the Minister will look at favourably when we get to the Committee stage. The particular Clause to which I want to draw the attention of the House and the Minister is Clause 12 about which nothing has been said so far, and about which there may well be more than one opinion. Clause 12 imports into the National Health Service a large section of the conciliation machinery which is applied to industrial disputes, and it seems to me to raise two important points of general principle. First of all, the Minister of Labour is brought in under the Conciliation Act, and one of the powers given him under that Act is to seek to settle a dispute. As a matter of constitutional propriety, I am wondering whether in fact it is right or proper for one Minister to purport to arbitrate in a dispute where one of the parties to the dispute is another Minister of the Crown. That is a matter which wants looking into on the Committee stage in order to see that we are not putting either the Minister of Health or the Minister of Labour into a false position in view of the fact that they both share Cabinet responsibility. However, the more important point under this Clause is this. If the Industrial Court is chosen, as it can be under the Industrial Courts Act, 1919, as the means for resolving a dispute between the Minister and any section of employees in the National Health Service, then there is no provision for the enforcement of any award which that court may make, nor so far as I can see, does the Act bind the Crown. The most the other party to a dispute which comes before the Industrial Court can get is a barren judgment of the Court, unless the Minister is prepared, before the case goes to the Court at all, to accept in advance whatever the findings of the Court may be. I hope the Minister will turn his attention to these points and, if possible, will give the House tonight some assurance that in these arbitration proceedings, whatever precise form they may take, he will as a party to them regard himself as bound in advance by the decision of the arbitrator. Otherwise it seems to me that the whole value of Clause 12 is likely to be lost if, in fact, only one party to the arbitration is to be bound by the decision. The last point to which I wish to draw attention concerns the pharmaceutical service, and here I must disclose an interest in that I am the Secretary of the Pharmaceutical Society. Contractors to the pharmaceutical service can be either individual firms, or corporate bodies such as Boots or co-operative societies which practise pharmacy. The actual service itself and the making up of the medicine must, of course, be performed by a pharmacist. It is the desire of the Pharmaceutical Society and of pharmacists in general that the professional man who does the professional work shall share the responsibility for that work with his employer. At the moment the employer alone is liable for mistakes and accepts the responsibility. Under the optical service, where both the individual optician and also corporate bodies may be contractors, the responsibility of employer and employee is joint. The optician provides the service jointly with the limited company, and shares the responsibility. I hope that either in Committee or on the Report stage I shall be able to move an Amendment which will provide for the pharmaceutical service being placed on the same basis as the optical service, so that the individual who does the professional work shares the responsibility with his employer in their relations with the Minister. That is a very important point to establish, so that the professional man may accept the responsibility which goes with the performance of professional service. In conclusion, I wish to return to the plea which I made at the beginning, and express the hope that the Minister will use his utmost endeavours to remove the suspicions which some of the professions still have of his Ministry, and get them wholeheartedly behind this service. If he does that, the service will work. If he is unable to do that, however groundless their fears may be, he will get halfhearted support, and this great service will suffer.
I regret that I cannot follow the hon. Member for Putney (Mr. Linstead). He has been dealing with matters which are actually in the Bill. I wish to deal with another aspect, the new Clauses on the Order Paper relating to analgesia. I do not wish to discuss these Clauses in detail; I hope we shall do so on the Committee stage. I merely wish to express my great surprise at the manner in which this subject of analgesia was introduced in the House. I am surprised that it should have been introduced from the benches opposite, since hon. Members opposite have never before expressed any interest in expectant mothers. Time and again expectant mothers have had to suffer unemployment and cuts at the labour exchange, but no Member of the Opposition has ever risen to put in a word for them.I claim to have a little experience in this matter, and, while I am always sympathetic to the suggestion of analgesia and even keener on anaesthesia, the only experience of labour pains of some hon. Members opposite was when they heard the results of the 1945 Election. Far more important than analgesia or anaesthesia to the mothers of this country is a mind free from worry and a well-nourished body, towards which our policy of full employment is contributing. Those are the essentials for happy childbirth in our country. I was astonished when I heard hon. Members opposite, particularly the hon. Member for Monmouth (Mr. P. Thorneycroft) and the noble Lady the Member for South Aberdeen (Lady Tweedsmuir), speaking of conditions in Scotland and pretending to throw to the mothers of Scotland something in the nature of a glittering prize, although as long ago as 1937 the mothers in Scotland were delighted with the conditions which arose out of the Maternity Services (Scotland) Act, 1937. Here I must pay a compliment to the right hon. and gallant Member for the Scottish Universities (Lieut.-Colonel Elliot) for his work in connection with the introduction of that Measure. Doctors all over Scotland welcomed that Act. I know of doctors in Lanarkshire, which comprises a large proportion of the Scottish population, who, when that Act came into force, went out with their assistants—very often there were two doctors and a midwife—to expectant mothers. All over Lanarkshire we were grateful for the 1937 Act. The right hon. and gallant Gentleman will now understand that we feel that we are being thrown something very third-rate indeed.
Is the hon. Lady implying what she said in an earlier Debate, that we on these benches are suggesting that the ordinary patient should be fobbed off with midwives? That is a statement which was very much resented by a good service.
I will deal with that point in a minute or two. There is a danger that this political stunt—I cannot regard it as anything else—may become a cheap form of administering the National Health Service Act for the mothers of this country. I ask hon. Members whether that is what they really want—to cheapen the Service. In the 1937 Act, doctors are empowered to take anaesthetists and obstetricians, and that power exists all over Scotland.
I am not questioning what the hon. Lady says about any particular Act, but I should like to know whether she is seriously suggesting that the figures I quoted from the Scottish Office, of 27,000 live births in Scotland attended by a midwife only, and only 800 of them with analgesia, are wrong. Is the hon. Lady really suggesting that Scottish mothers have a doctor at the birth, with an anaesthetist?
I am suggesting that the Bill gives us that power, and that throughout Lanarkshire the system has been operating exceedingly well. I am not questioning the figures which have been thrown at us, but I must say that a great many of the 27,000 births were not first births. Included in the figures are probably second, third, fourth or fifth confinements. My experience of the mother is that she who can have the child naturally, without analgesia, prefers even a towel—a method which has been referred to in so derogatory a fashion in previous Debates in this House.As for the figures and the statements which have been made about compelling local authorities to make this provision, I suggest to hon. Members opposite that they inform the House how many women's associations have demanded analgesia? Were hon. Members opposite approached by any of these organisations in the country? I say that they were not, and that this has not been a burning question in this country at all. From the reports of the British Medical Women's Federation we can see that anaesthesia is a burning question, yet the Minister is being pressed to make it compulsory on local authorities to provide the third-rate analgesic instead of the anaesthetic. It will undoubtedly be found that where the system is not working, the area is that of reactionary county councils which have always returned Tory majorities. When the hon. Member for Monmouth spoke in the House on this subject, his speech was followed by indignant denials from Dumbartonshire, Glasgow, Paisley and Lanarkshire. These counties represent one-half of Scotland's population, so that the figures which the hon. Member gave must allude, therefore, to the backward areas.
I ask the hon. Member not to fidget so much in his seat. I do not want anyone to have to administer analgesia to him while I am speaking.
I apologise if I was fidgeting. Of course, the figures were not mine but those of the Scottish Office. I want the hon. Lady to make one thing plain. She has an Amendment on the Order Paper in which she seeks to make it the duty of the local authority——
The hon. Member may not discuss an Amendment on the Order Paper; after all, that is for the Committee stage. Now we are discussing general principles and, if I may say so, if I had been in the Chair the hon. Member for Monmouth would not, perhaps, have got in as much as he did.
I was not intending to discuss the Amendment for one moment, Mr. Speaker. I was asking the hon. Lady to clarify a point she has made in her speech—whether she regarded the provision of analgesia by all local authorities as a reasonably necessary service or not.
I will deal with my Amendment in the Committee stage and I will then give the hon. Member all the information he wants. I will not commit myself as to whether it should be administered to every woman in childbirth; only an ignoramus would make such a statement. No one who has any knowledge of the medical profession would ever make such a statement. However, let me resume. I am sorry if I am getting under the hon. Member's hair. I must be allowed to go on with my speech. I repeat that the counties of Dumbartonshire and Glasgow, the Burgh of Paisley and the County of Lanarkshire immediately repudiated the statements made in this House and, in fact, to that made by the hon. Lady who represents South Aberdeen, Dr. Harry Rae, the Medical Officer of Health for Aberdeenshire, replied with this comment:
He was asked who started this and he replied——"It is not our intention to deprive the mothers of Aberdeenshire of painless childbirth, and it is very unfortunate that ill-informed Members of Parliament should try to get publicity over analgesia which is really in the experimental stage."
It would be much better to discuss these two Clauses, which I see down, in Committee. I am afraid that this system of allowing Amendments to be put down beforehand, on Second Reading, is really spoiling the whole of Second Reading Debates. We are on the wide principles in Second Reading.
On a point of Order. May I say, Sir, that when you were out of the Chair I was allowed to enter very fully into these matters? After all, the whole Bill is an amending Bill, so almost all the points referred to in it are Committee points. I say that in fairness to the hon. Lady; I think she should be allowed to reply.
I quite admit that. I said that if I had been in the Chair perhaps the hon. Gentleman would not have got away with quite so much.
I do not know whether it is worth while going on. I was replying to points already raised in the Debate.
The hon. Lady the Member for Coatbridge (Mrs. Mann) will forgive me if I do not pursue the topic on which she has been addressing the House.
On a point of Order, Mr. Speaker, I wish to lodge a protest that Members on the opposite side should be allowed to make all their points and we on this side of the House should not be allowed to reply.
The hon. Lady should not say that, because there is no question of unfairness on my part. In fact, I twice rebuked the hon. Member for Monmouth. If the hon. Lady wishes to continue her speech, I am quite prepared to allow her to do so, but she must not make reflections of that kind on the Chair, which I think were quite unjustified.
I felt that perhaps the difficulty was due to a change in the Chair, with you, Sir, following and not having heard what had taken place before, ruling the reply out of Order. I should be the last to cast any aspersion on your conduct in the Chair, Mr. Speaker, and I hope I may be forgiven if I have made any remarks that would offend. I may, perhaps, briefly continue. The Debate in this House has been characterised by medical men in Scotland as being the outpourings of ignorant politicians, and this was said about the hon. Member for Monmouth, that—
The hon. Gentleman can hardly be expected to know that in Scotland we have had a splendid midwifery service, and that we owe a deep and abiding debt of gratitude—when I say "we" I mean the mothers—to the good doctors of Scotland who went in for midwifery work, and who turned out at all hours of the night, and who gave up their half holidays—for babies have a nasty trick of coming at all those awkward hours. We owe a great debt to the doctors of Scotland for the wonderful work they have done for the mothers, and we do not want to see them replaced with analgesia and midwives. Mark you, we must not forget that the midwives have worked always in co-operation with the doctors, and they also have given excellent services. In fact, they are an invaluable team, an indispensable team. I do not think analgesia can be administered without the co-operation and the collaboration of the doctors. According to the Report of the British Women's Medical Federation on Pain in Childbirth, the whole value was the great advance in that the analgesia was administered by trained anaesthetists. We know also from this same report that gas and air is not very satisfactory. The hon. Gentleman read from some letters. Let me quote from memory a letter written to me from a doctor whom I know very well. As a matter of fact, is would be impossible for anyone to know him better. He has conducted, or is conducting, more confinements in Lanarkshire than any other doctor. He prophesies that this analgesic instrument and all connected with it will be in the junk-yard in three or four years. This report practically states the same thing. It says:"he was a representative of an obscure Welsh constituency. It was, perhaps, not to be expected that he would know what happens in the civilised world outside."
It is suggested that there is no such thing as painless childbirth. I will read from the Report:"It is, therefore, probable that if this investigation were repeated in a few years' time the picture, from the point of view of actual analgesics and anaesthetics, would be very different. Under the present investigation, however, much of the information received from the detailed studies is highly suggestive."
I submit that if the mothers had been as anxious as we are led to believe, they would have approached the local authorities long ago, as they approached the local authorities about other things—housing, for example. Local authorities have never been approached by the mothers on this subject, which shows that the mothers have a great deal more good common sense, in leaving matters in the hands of their doctors and in trusting the doctors rather than the politicians of this House."The fact that there is as yet no safe method of analgesia which is completely effective in all stages of labour only serves to stress the need for continuing research into the methods of relief of pain in childbirth."
Let me open my second innings by asking the forgiveness of the hon. Lady—and, I hope, the approval of the House—if I do not pursue the detailed discussion of obstetrics. Quite frankly, I admit to holding the old-fashioned view that discussion of detailed matters of medical science is best left to doctors and other professional men. It is 18 months since the House passed the main Act which we are now seeking to amend, and it is nine or 10 months since the appointed day when it came into operation.
The period of gestation.
If the hon. Member will consult, on the details of this subject, with his next-door neighbour, the hon. Member for North Islington (Dr. Guest) he will no doubt get further details, but I said I would not pursue that particular line and I hope I shall not be drawn into it. In so short a time it would be unwise and unjustifiable, I suggest, to indulge in fulsome glorification or outright condemnation of the scheme, but I suggest that it is the proper time for a little sober reflection. There are one or two reflections which I wish to offer as my contribution to the Debate.The first of these is the question, which we can ask on looking back, whether it was wise to attempt to revolutionise, in such a wholesale and hasty manner, a whole group and variety of services which have gradually evolved through the centuries. I know that the intentions were absolutely honest and the motives sound, but was this the wise way of going about the matter? Only the future can show how it will work out, but it is certain that in the first nine or 10 months there has been an enormous and quite disproportionate amount of human endeavour directed to the creating of administrative machinery and to the safeguarding of individual and professional conditions of service. As a result of this, the amount of time which could have been devoted to an improvement of the actual service of and attendance upon the sick has to that extent been limited. It was inevitable; it was one of the effects of dealing with this matter in such a wholesale and hasty manner. The second general reflection which I want to offer is on the danger—I go further: in matters of this sort, I say the downright wickedness—of building false hopes. Anyone who had any experience in the local authority services or in the voluntary hospital services before this Bill was presented for the First Reading was well aware of the fact that there never has been and there never will be all the money available which those engaged in those services would desire. I suggest that there has never been a local authority that has been able to provide the necessary money at once to introduce all the improvements which it has desired. There never was a voluntary hospital which was not faced with the same problem of balancing priorities. There was always only a certain amount of money available, and the National Health Service, and the Ministry and the Government and Parliament, will always be faced with this question of balancing priorities. I hope that no one will in any circumstances repeat what I say was the wicked action of trying to persuade the people of this country to believe that it would ever be possible to give all the medical services that we would desire, and to give them free. The third general reflection is that I do not think that the country or the House, and most of all the Government, have yet appreciated to the full the immense gratitude which they owe to doctors and nurses, and to many others both lay and professional, and not least to the unpaid and unsung members of local authorities and hospital committees, without whose services, long before the appointed day and since, there could be no Health Service. Alas, some of these people have been denied the opportunity of continuing to give the service which they gave in the past. On those who are still performing this service and on the new recruits there has been placed an extremely heavy strain, and they have been suffering acute anxiety, in the last few months particularly, as to the extent to which they will be able to discharge the services for which they have accepted responsibility. Not the least of these difficulties is, I suppose, the inevitable volume of paper which goes backwards and forwards and round and round. We know that legislation breeds legislation, and that each new piece of legislation breeds like a rabbit, and we have orders, regulations, directions and circulars. Is it not possible to devise some better procedure than the traditional one which we have adopted of having one amending Bill after another, so that we have to refer, when we want to know what we can do and cannot do and what we can get and cannot get, to an enormous reference library? Is it not possible to introduce amending or revising Bills which will also be consolidating Bills? It is bad enough for those who are earning their living by operating these Acts, but it will be extremely difficult to continue to get voluntary service, which I am sure all parties in the House will agree is invaluable, if we make statutes, which these people are expected to administer, so extremely difficult to understand. I want to refer to the minor amendments which are dealt with in the Bill. There are five or six of them, and there are two about which I want to express my pleasure at seeing in the Bill. They are obviously right and desirable. One of these provides the same facilities with regard to private patients, for dentists who are on hospital staffs as are provided for medical men. There is also the amendment which allows hospital boards and management committees to subscribe to certain approved associations. Both of these amendments will, I think, be of real value. Another amendment, the intention of which, I think, is certainly sound and the principle of which, I hope, will be widened, is that which accords to certain medical committees the right to elect their own chairmen. I hope to see that principle extended, and I would ask the Minister to look at the words in the Schedule to make quite certain that the exact words there will carry out what I believe to be his intention. Then we come to other matters in the Bill with which it seems strange that it should be necessary to ask Parliament to deal. There are eight pages to the Schedule, and one of the matters in which apparently the Minister has made a discovery which would appear rather obvious is that neither residential accommodation nor food are articles. Apparently, the Act has to be amended so that residential accommodation can be provided because it has been discovered that the word "article" does not cover it. I should have thought that was an instance where hasty drafting had led to an unnecessary demand on Parliamentary time. I was surprised to learn—I presume that the Minister of Food was consulted on this matter—that food is not an article and has to be separately dealt with. Perhaps at some later stage we may be told what is a sausage—whether it is a food or an article. I see that the Lord Advocate is here, and I suggest that possibly a legal way out of the difficulty might be to regard the contents of a sausage as articles and the casing as residential accommodation; but perhaps he will look up that point. Then there are what appear to be completely minor amendments to which I want the Minister to pay some attention when giving his reply. There are four, five or six cases in which we are being asked to make an amendment in connection with expenses. We are being asked to remove the words
and to replace them with the words"loss of remunerative time"
I want the Minister to explain quite clearly whether this amendment is significant, sinister, or merely silly. I say "merely silly" advisedly because at the same time as we are being asked to introduce this amendment into various Sections of the original Act, there is another Bill, recently introduced by the Ministry of Health in another place, where these words "loss of remunerative time" which we are being asked to remove by this Bill are being put into the Bill which is being passed through another place."any loss of earnings which would otherwise be made."
Does not the hon. Gentleman know that when the Lindsay Committee were sitting, they dealt with loss of remunerative time—remunerative time when it was proved that in consequence of loss of time there was a loss of money. This left out such people as lawyers and those who did not actually lose remunerative time but lost time in which money might have been made.
I am grateful to the hon. Gentleman for taking upon himself the rôle of Minister. I do ask the Minister to make this quite clear, because there is at the back of all this a fear that it is imposing some unfair and unreasonable sort of means test. I therefore want the Minister to have an opportunity of telling the House the exact significance of these changes.There are one or two other matters I should like to mention, which I regret to see it has not yet been possible to deal with in this amending Bill. First, I wish to support the view, put forward in more than one part of the House, that the position of both doctors and patients in many rural areas is nothing like as satisfactory under the National Health Service as many of us had hoped it would be. It needs looking into very carefully from the point of view of both potential patients and doctors. It appears that certain hardships may arise from the fact that no compensation is payable to holders of part-time posts. I agree it is arguable that the actual monetary losses which may follow from the loss of a part-time appointment may not be great; but there will be cases in which the loss of status may be of some importance to professional men and women, where the loss of that status may even lead to the loss of future earnings. That is a difficult point, and I ask the Ministry to look into it. From the hospital point of view, and also I think from the regional point of view—and on this I hope to have the support of the hon. Member for South Tottenham (Mr. Messer)—is it possible to do something to speed up the present procedure under which buildings can be purchased or leased? The present procedure is terribly long and involved. Every single request has to go to headquarters at the Ministry; every property then has to be inspected by an official valuer, who has to value not only the land and buildings but every fitting in those buildings. The valuer is naturally guided by the Town and Country Planning Act and other Acts affecting valuations; consequently, nine times out of ten—I do not think that unfair—his valuation is considerably less than the market value, which means that the only way by which those buildings or houses can be obtained is by the use of compulsory purchase powers. The Ministry, quite rightly, is loath to use compulsory powers, but inevitably in nine cases out of ten they are forced to do so. Then the whole process starts again, and weeks and months pass before it is possible to obtain the building. It should be possible to improve this position. There is a small point on war damage. Under the financial restrictions, which I presume have been imposed on the Minister but which he has passed on to individual boards, war damage is, I think, being treated rather unfairly. War damage has to be included with all other items on which capital moneys may be spent. Let me quote an instance. A hospital had put in its original budget certain provision for capital expenditure, which included £100,000 worth of war damage; that was repairing damage from the war, the whole of the money for which would come from the War Damage Commission. That budget has now been cut to a total sum of less than £100,000—I use round figures—to £90,000. Therefore, the board of that hospital must either undertake no capital improvements of any sort but merely repair their war damage, which they cannot do completely, or they must leave a vast amount of war damage unrepaired for another year, and then another year, and so on. It is already four years, and we should like to see—and this applies to every hospital in every blitzed area—that war damage completely repaired fairly soon. I had intended to say something about the many difficulties which are arising in connection with private paying patients, as regards both beds and the recovery of charges. There is no doubt that the intentions in connection with private beds are not working out very satisfactorily at present. That wants looking into. I will leave it at that. Difficulties are also arising in connection with the recovery of charges. Obviously that will always be difficult. No doctor can say in advance exactly what treatment will be required for a patient. For instance, if there has to be radiographical or X-ray treatment, no doctor can say in advance whether it will be necessary for two, 10 or 20 attendances. The hospital authority is required to obtain an undertaking that the private patient will meet all charges. A private patient wants to know what those charges will be, but it is impossible, and always will be, to tell him with accuracy what they will be. I do not know the answer, but the present system is obviously not working. Then there is the payment of emergency fees. The other day I brought to the Minister's attention a tragic case. I am not suggesting that the National Health Service Act was in any way responsible for that tragedy. It was the case of an unfortunate man whose wife gave premature birth to a child which died. Naturally, when it happened he was in a state of agitation, which the House can imagine without my attempting to describe it. He rang up the doctor with whom he was registered but unfortunately was not able to obtain him. In his agitation he rang up the first doctor he could think of, who managed to come along. It is not surprising that in his agitation the man did not say, "I want my wife to be treated as a National Health Service patient." The doctor therefore attended assuming, quite rightly, that he was treating a private patient. Quite properly, the doctor sent in his bill, but the man could not recover payment for that bill from official sources. That may be right or it may be wrong, but the point I particularly want to bring to the attention of the House is this. When I took up this matter with the Minister he was kind enough to write to me a letter in which occurred this phrase:
Those are very admirable sentiments, with which we all agree. But is it in fact possible for a doctor in the Service to guarantee to any particular patient 24 hours' service 365 days in the year? The effect of this letter is that it is up to the individual doctor to assure every registered patient that there will be some doctor available at any time. I agree that that is what we all desire. What I am suggesting is it is impracticable and hardly fair that the whole onus of providing that desirable thing should be placed on the shoulders of the individual doctor."I want to make it clear that doctors in the Service are required as part of their terms of service to make proper arrangements for securing the treatment of their patients when they are unable to give treatment personally."
Would not all this be obviated if we had a whole-time medical service?
I am not going to enter into the medical field. There are medical men here, and they will agree with me that while they will in the future, as they have in the past, make every possible effort to secure a deputy if one is available, they could not possibly give a firm guarantee that at any time in the future a doctor would be available to come in an emergency, and that is the point which I am trying to raise.
How does the hon. Member suggest that his point should be met?
I am not suggesting that it is a point which can be met. What I am suggesting is that it is unfair to pretend that the problem can be dealt with by a general statement. There is an onus placed on the individual medical practitioner, which he is expected to discharge and we know perfectly well that it is an obligation which cannot possibly be discharged. That is my point.There is one final point, on which I want to join issue with the hon. Member for South Tottenham who made a plea for greater powers for regional boards with a certain amount of power removed from the hospital management committees. Lest he accuse me of misrepresenting him, which I have no desire to do, I should like to make it quite clear that he raised this point only in connection with one particular matter, and it may be that he has limited his request to that one particular matter. But I want to take exactly the opposite point of view. As soon as there is legislation there is an immense centripetal phase whereby authority is concentrated on one head in a central office. The Minister has publicly stated that his intention is to delegate responsibility as widely as he possibly can. I applaud him for that, and I urge him to carry it out. I am convinced that this Service cannot possibly work satisfactorily unless there is a widespread delegation and the utmost encouragement and initiative is given to the small units.
Would the hon. Gentleman agree that the regional boards, whose duty it is to supply a specialist service, should be empowered to appoint specialists at the hospital but not to appoint the potential specialists at the hospital?
It is an extremely complicated matter, and I would gladly discuss it with the hon. Gentleman afterwards. I do not think it would be an appropriate matter to go into in detail on Second Reading. I ask the House to accept my gratitude for the extremely patient way they have listened to a rather lengthy disquisition on some detailed matters. Like some other hon. Members, I have never fought for a National Health Service, but I have been trying in a humble way to work for something like it for nearly a quarter of a century.
I do not want to follow the hon. Member for St. George's (Mr. Howard), although like others I am grateful for the great service he has rendered to public health in the medical field, but I think he takes too gloomy a view when he says that we cannot do everything we wish. He underestimates the tremendous amount of work which has actually been done since the initiation of the National Health Service and which is now being done. It is true that we have this amending Bill. I remember that before the beginning of the National Health Act I had an opportunity of discussing the matter with a very high official in the Ministry of Health. We discussed the whole lay-out and came to the conclusion that in view of the complicated situation with regard to medical organisations and disorganisation it would be necessary not only to introduce one Bill, but that, as it subsequently has appeared, a second would probably be necessary. And it was contemplated from the beginning that it would be necessary to introduce amending Bills, not only one but a series, as it became possible to see what were the problems and what was their solution.If one is inclined sometimes to be pessimistic about not being able to do all the marvellous things we can think of, we must remember what is being done. I myself am a doctor and I hope I am a realist. I do not get excited about the marvels which can be done, but I am most frequently amazed at the extraordinary things that are now being done by modern medical research. I do not think they can all be applied at once, but there are two very simple things that have been done since the National Health Service came into operation. By that Act the women and children, who before, unless they were themselves insured persons, had to pay for medical treatment, are now able to get treatment without paying fees at all. That has meant a revolution in the health of women because it will mean that a large number of women's diseases, for which they did not get treated before the Act came into operation because they could not afford the expense, are now being treated. The same applies to the children. The second is the reorganisa- tion of the hospital system itself. Our system of hospital work was disorganised. It worked very well in some places like London, Birmingham, Glasgow and so on, but in other places it worked extremely badly.
In the South-West counties with Bristol as the headquarters for example. When the hospital surveys were made sometime prior to this Act coming into operation, in the South-West area, of which Bristol is the university town, the only hospital which had complete specialised services was the hospital of Bristol. There were no proper specialist services in other hospitals. One of the great advantages of this Act—it has not yet come into operation, because it has not been possible to make the distribution yet—is that there will be a distribution of adequate specialist staffs in all areas of England, Scotland and Wales. It will make a great difference indeed in treatment.
I quite agree that we all hope this will happen, but will the hon. Gentleman agree that it will take a long time to achieve?
I should say that the reorganisation of the hospitals would not take a long time, but a reasonably short time. I am not going to prophesy an exact number of years, but within the lifetime of a Parliament.
It will be years, not weeks or months?
I do not think anyone would accuse me of suggesting weeks or months. I am talking in periods of years, and a great deal has already been done. We have got to do a great many things, and I hope that we are not going to try to bring into this Bill a large number of particular changes which many of us desire to see brought into existence.There is one thing which has been subject to comment already and that is the possibility of extending analgesia to all women in childbirth. It is desirable that women should be relieved of the pain of childbirth, for the sake of their own safety sometimes and their own comfort, but that is by no means the only thing that is valuable about a properly- organised maternity service. Hon. Members on both sides of the House have been inclined to put the question of analgesia in a position which is much too important. They have been inclined to do it in a way which is not the policy of the National Birthday Trust Fund, which has been behind the analgesia proposals which are now before the House. The National Birthday Trust Fund is an admirable body, with perhaps one defect which is that I have been myself connected with it for a number of years as a member of its finance committee advising on expenditure. They have not confined themselves by any means to the question of analgesia. For example, they have carried out research. They are at present inquiring into the use of trilene, and subsidised research by the Royal College of Obstetricians and the Royal College of Gynaecologists. They also have a human milk bureau and carried out research at Queen Charlotte's Hospital and Guys Hospital on other matters. They have carried out an investigation into a variety of matters which conduce to safer motherhood. While we do not necessarily want analgesia for all women we do want safer motherhood for all women. We want to reduce to nil the number of deaths in childbed and the number of cases of injury to mother or child at the time of birth also. It can be done. There was recently reported a series of cases in the "British Medical Journal," in which that result had been accomplished over a period, not by the administration of anaesthetics or analgesics only, but by the setting up of an organisation which meant that, when necessary, every difficult case had a doctor, and a medical and surgical specialist team, to attend to it. That is what one wants to get. Let me return to the question of analgesia in childbirth. As the hon. Member for Monmouth (Mr. P. Thorneycroft) knows, this matter has been discussed among a number of Members on all sides of the House, and there are two slightly conflicting Motions on the Order Paper. The hon. Member, when he was making criticism, suggested that the Amendment put down in the name of the hon. Member for Hornchurch (Mr. Bing) and myself and others was too wide. If the hon. Member will consult the Amendment again I think he will find that if we specified one particular thing, such as analgesia in childbirth, without leaving the door wide open, we might be specifying that one thing and excluding other necessities of safer motherhood which we ought to include. There is a very great danger, and it is desirable that those who are in charge of the two Amendments should think again and see whether some arrangement can be made in the Committee stage. I will not refer again to the matter. I have gone a long way in that direction. It is desirable to mention that there are a few facts about analgesia that ought to be known. I will recapitulate them in a short form. In 1938, the percentage of women who got analgesia in childbirth was only 4 per cent. By 1943, it had risen 1.2 per cent. By 1945, the time of the General Election, it had risen to 3 per cent. By 1946, it was 6.9 per cent., by 1947 it was 13.3 per cent., and in the last six months of 1948 the figure has gone up to 35 per cent. That great increase in analgesia in 1948 has been brought about by administrative methods under the National Health Service. It is one of the advantages that have flowed from the National Health Service. When we hear the suggestion that the Minister would not be willing to put the analgesia service into operation we realise that the suggestion is rather unwarranted. The figures show clearly that the Minister would be willing. The suggestion that no Minister would dare to put the best possible medical service into operation is something which I find very difficult to believe. Why should anyone not wish to put this service into operation? Even a Conservative would want to do so—if one is to be political. I do not suggest that a Conservative Minister of Health would be any less willing to put the service into operation than would anyone else. Why should he be? This is a matter of human service for human suffering, in which all sides of the House can agree. It is untrue to suggest that the Ministry of Health is failing in its duty. I believe—and I will end on this note—that the Amendment put down in the name of my hon. Friend the Member for Hornchurch is drawn so widely that it will include the whole of the safer motherhood service, including analgesia. I see that the hon. Member for Monmouth shakes his head. I can only say in that case that this is a conflict of experts.
I hope the hon. Member will forgive me if I point out that the hon. Member for Coatbridge (Mrs. Mann) put down an Amendment in almost the same terms and that she does not think it includes analgesia at all. It is a conflict between two hon. Members on that side.
I have been consulting the experts and I say that it is a conflict of experts. I am advised by those who are knowledgeable in these matters that the Amendment put down by my hon. Friend the Member for Hornchurch and myself covers the whole of what the hon. Member for Monmouth desires, as well as leaving the door open for other things which are necessary to make the safer motherhood campaign successful.
As the hon. Member is referring to this matter, would he say who he thinks would be the judge of what is reasonably necessary?
I would certainly say the advisers of the Ministry of Health. Those are the advisers upon whom I rely and the House is entitled to rely upon them: I think the House will be quite ready to do so. I hope that we shall come down to the discussions of the detail of this matter. When we get to the Committee stage we can thrash out the details. It cannot be done here. It is much wiser to stick to the wider definition instead of to the narrower. We must otherwise defeat our own object, and make safer motherhood much less likely to be achieved than at present.I hope that it will be possible to come to an agreement. I venture to think that when we have passed this Amending Bill we shall have to look forward, to find what other improvements we can make in the National Health Service. The hon. Member whom I followed almost made me weep, he was so pessimistic about conditions. I hope that he will get over that pessimism, and that in the course of the next few years he will see the very great advantages that are going to take place in the developments of the National Health Service. Immense things are coming along. Great medical discoveries are being made almost daily. I believe that it is only under a National Health Service under national control and with the magnificent organisation that we are gradually developing, that we can apply to a full extent these scientific discoveries to the welfare of humankind.
I hope that the hon. Member for North Islington (Dr. Guest) will forgive me if I do not follow him in all his arguments. I like his optimism and hope he is right in all those optimistic things he has just said. The hon. Member for Coatbridge (Mrs. Mann) made a regrettable and remarkable speech. We can all agree with her, however, when she said the aim was to free people from worry, to see that they were well fed and there was a policy of full employment. The majority in the House do not agree that analgesia should not be available to every woman who wants it. It is our duty to spare as much pain as we possibly can for our womenfolk. I cannot believe that the hon. Lady wishes her own countryfolk and her countyfolk to suffer pain.She also seems to be very easily satisfied. If we look at figures for Lanarkshire, we find that of the 3,375 births that took place during 1947 not one woman received analgesia. I cannot believe that every one of those women declined it when it was offered to them. Again, if we look at the figures in regard to midwives, we find that only one out of four has either a motor car or motor car allowance. It is right and proper that the House should on every possible occasion discuss this subject of analgesia. It is not, as someone has remarked, purely a medical matter that should be thrashed out by doctors. It is an administrative matter, and therefore I hope the new Clause that has been put down by the hon. Lady the Member for Epping (Mrs. Manning) will be accepted by the Minister. I agree with and welcome most of the things in this Bill, but unlike the hon. Member for Batley and Morley (Dr. Broughton), who having welcomed the Bill then disagreed in principle with every Clause, much of what I understand in the Bill I agree with thoroughly. This Bill improves the original Act. It straightens out many of the difficulties and clarifies the considerable doubts that the Act brought about. It carries out the pledges the Minister made, not only during the various stages of the Bill but also to the professions. It shows that the Minister has at last accepted some of the advice that came from this side of the House. The recommendations of the legal committee and Part I of this Bill show that the Minister and the Lord Chancellor were wrong when they resisted the Amendments which my party put down to the Bill. I welcome the fact that the executive councils are at last to be allowed to choose their own chairmen. Many of us remember the very powerful speech made during the Second Reading Debate by the hon. Member for South Tottenham (Mr. Messer), when he spoke about the very undemocratic set-up of the hospital boards, the governing bodies of the teaching hospitals and all these executive councils. Therefore, I think he will welcome, as I do, the first step that, having been nominated by the Minister, they should be allowed to choose their own chairmen. He may have changed his views to a certain extent after filling a very high post, such as that of the chairman of one of the regional boards or chairman of the Central Advisory Committee. We must assume, however, that if this democratic method he recommended at that time had been in operation, he would still have found himself occupying these two important posts.
Is the hon. and gallant Member aware that the Minister did not appoint me as Chairman of the Central Health Services Council, but that that body which has a majority of doctors on it elected me?
I am very glad that the democratic methods the hon. Member preached are carried out on the council of which he is the chairman.I hope that before this Bill passes, Amendments will be made whereby hospital management committees and governing bodies of teaching hospitals, where all the members are nominated by the Minister, will likewise be able to choose their own chairmen. I wish that we could see an Amendment whereby the nominating of members to the regional hospital boards could be done in another way. I agree with those who say that these Health Services should be taken out of the realm of party politics. There are those people who at the present moment, rightly or wrongly, believe there has been some abuse in the appointment of members to these regional hospital boards. For example, we see six Members from the party opposite sitting on the regional hospital boards and not a single Member of the party to which I belong appointed. I make the suggestion that if appointments are made politically it will be detrimental to the hospital services, because when there is a change in the Government there will be a change of personnel, which is something we should regret and hope will not take place. We have recently seen after one year's operation of these regional hospital boards no fewer than 32 members not re-appointed by the Minister—I do not know whether we can call it dismissal. Some were recommended by the regional boards to continue in their present positions. I hope that the Minister will be able to tell us that before making appointments he consults the boards, as laid down in Part I of the Third Schedule of the National Health Service Act. The hon. Member for South Tottenham raised a very important point, to which my hon. Friend the Member for Putney (Mr. Linstead) also referred, and that is the care of the aged sick. The 1946 Act took the care of the aged sick away from the local authorities and put it into the hands of the regional hospital boards. I believe that the regional hospital boards have not carried out these duties in the same way as they were carried out by the local authorities. I want to ask the Minister to tell us why it is that the accommodation available before 5th July for aged and chronic sick is no longer available. Since the year 1601——
What does the hon. and gallant Member mean? There is more accommodation available now than there has ever been, and there is more need for it.
Never has it been so difficult to get the chronic and aged sick into hospital.
The reason is that more people are now wanting to go into hospital, and not that they are being heartlessly refused. I am speaking as a doctor and I know.
I do not wish to suggest that they are being heartlessly refused, but it was obligatory upon local authorities to provide accommodation for these people before 5th July last, whereas that is no longer the case. It is not obligatory on anyone to provide accommodation for these old people. This applies especially in the case of the Midlands. When people get very old and are a little muddled, it is found that the only hospital accommodation is in a mental hospital. I do not say this without having some evidence before me. Taking the figures at one Birmingham mental hospital, we find that from 5th April, 1947, to 10th April, 1948, only 20 people over the age of 65 were admitted, whereas in the period from 5th April, 1948, to 30th April, 1949, we find that no fewer than 93 were admitted. Of that 93, in the last nine months no fewer than 30 have died from pneumonia, heart trouble, pleurisy, etc., from which they probably suffered before they went into hospital.Let us look at another Birmingham mental hospital. We find that in the last nine months 15 people over the age of 80 were admitted, certified, for the first time, under the Lunacy Act. Most of them were in a dying condition before admission, and died shortly afterwards. The explanation of these pitiful facts is that it is difficult to get old people who are chronically ill into other accommodation, such as previously existed. This unhappy and intolerable state of affairs must be altered, and I hope it will be possible to amend the Bill so that an obligation to put, either on the local authorities or on the regional hospital boards to provide accommodation for the aged sick. Before the Bill reaches the Statute Book it ought to be possible to lay down certain priorities of medical service. It appears that it is not possible that all the things which the principal Act promised can possibly be made available for our people. So, we must see that the first priority is adequate hospital service. It should have been foreseen that the brunt of the Health Service would fall on our hospitals. At some of our general hospitals in the North of England outpatients' attendances have increased by 100 per cent. It is, therefore, remarkable that the first drastic cut which the Minister has imposed on our Health Service should have been on the element which has borne the brunt of the whole of our health services. Some of the present unrest and dissatisfaction is caused by people having difficulty in obtaining hospital beds not only for themselves but for old people. I think it is much more important that hospital beds should be made available than that people should be able to obtain two pairs of identical spectacles, or that wigs should be given to foreigners. I believe that people would be willing, if they could be assured of hospital accommodation, to make a small contribution towards its cost. The Minister talked about priority dental service. It appears that that service is not readily available. On the Second Reading of the National Health Service Bill the Minister said:
Can he tell us how much of that priority dental service is available? The figures I have at my disposal show that not half of it is available at present. I hope we shall be able to amend the Bill in such a way as to remove certain injustices which have been caused through the operation of the Act. I hope we shall be able to provide for all patients all the services at public expense, whether they go to a private or a public doctor. It is mean, parsimonious and unjust discrimination against some of our people to withhold these services from them; I do not think it bears contemplation when we think of the unnecessary generosity which is being shown to foreigners. I welcome the Bill, as much of it as I understand, and I hope we shall have other and similar amending Bills which will add to and improve the Health Service. I believe that by amending legislation the Minister can provide the different priorities which are essential in order to build up an adequate and satisfactory health service. If we do not have an adequate hospital service then the whole of our health services might break down, and I do not think it should be said that the Minister or this Parliament destroyed a hospital service and did not put a better one in its place."We have not enough dentists and it will, therefore, be necessary for us in the meantime to give priority treatment to certain classes—expectant and nursing mothers, children, school children in particular and later on we hope adolescents."—[OFFICIAL REPORT, 30th April, 1946; Vol. 422, c. 45.]
I join in the general welcome which has been given to the Bill, which seeks to improve a service which has had nearly a year's run. Of course, there have been snags and difficulties but I am sure that most people will agree that no more popular Measure than the National Health Service Act was ever placed on the Statute Book by any Administration. Generally speaking, we find that practically everyone who has had anything to do with the working of that Act is more or less satisfied.I join with my hon. Friend the Member for South Tottenham and the hon. Member for North Dorset (Mr. Byers), who said that we must regard the Health Service as an expanding service. By that I do not mean to say that I believe it will expand for ever, and I do not quite understand the points made by some hon. Members opposite, who say that we shall never have enough money for the Service. Surely there will be a time when the Service will have reached its peak. With preventive medicine, the best kind of hospitals, the best surgeons and improvements all round the time will come when this great medical service may be expected to reach its peak of expenditure. Probably after that time it may rest there, or even decline, but that time is nowhere near yet. I sympathise with my right hon. Friend because I do not think the blame can rest on his shoulders. He has been asked to make some cuts, and it has been generally agreed today that there is nothing more intolerable than that these cuts should be made in our hospital services. All of us speak with the greatest amount of affection and knowledge of the hospitals in our own areas, and I speak tonight of St. Margaret's Hospital, Epping, where great consternation has been caused. I wish my right hon. Friend could see that hospital. He would find there such a loyal matron and loyal set of doctors and nurses. An improvement out of all proportion to what anybody could have expected has taken place in that hospital under the new service. An hon. Member spoke of the difficulty of buying properties and said that by the time all the difficulties have been surmounted the property is out of the mar- ket. We want to buy property. We want more nurses and we want a place to house them. This magnificent hospital is struggling along with a shortage of staff due mainly to the fact that we have had to let two houses which could have been used for our nurses slip through our fingers. I agree with everyone who has spoken about the desirability not to impose heavy cuts on the hospital services and to remove the sanction on buying properties as quickly as possible. The Lord Advocate said the Bill removes doubts which linger in the minds of certain people. Generally speaking, this Bill does remove doubts which linger in the minds of certain people. The Minister has passed into legislative form the proposals of the Slade Committee. That will certainly have cast out some lingering doubts from the minds of the medical profession. The hon. Member for Batley and Morley (Dr. Broughton) did not seem to approve of it but the Minister has carried out his pledge that the medical service should not be a full-time paid medical service. However, there are other lingering doubts in the minds of some people, not in the minds of doctors, but in the minds of some patients and in the minds of some hon. Members about some matters. I have no intention at any time during the course of this Debate of going into any detail whatsoever about my new Clauses relating to analgesia. That would be out of place at this stage. I do not even want to go into the subject matter raised with such fervour in the Second Reading Debate on another Bill. I do not even want to refer to the trickery which has gone on at the hands of certain people in making long drawn out Committee stages with Private Members' Bills which are ahead of this one. If that had not happened it might not have been necessary for us to put down these new Clauses.
No reference can be made to anything which is going on in a Committee upstairs until that Committee has reported.
I do not know whether the two Committees to which I am referring have reported. They have been much reported about the House and in the ears of hon. Members who are interested. I believe that it was the hon. Member for North Dorset (Mr. Byers) who said that this ought not to be made a political matter—I am referring not to analgesia but to the whole of the medical service—but ought to be taken entirely out of the realm of politics. It was a most wounding thing on the part of an hon. Member to accuse me of making this a party matter. If anybody wants this Bill to redound to the honour of the Labour Party, it is I.I have been able to use the National Health Service Act perhaps as I have been able to use no other Act passed by this Government to show how splendidly the people of the country have been treated. I want it to be the best Act it could possibly be. The right hon. Gentleman should therefore not be as cross with me as he has been. I know that he is prond of his Bill. I do not believe he thinks there could be anything wrong with it, but when he is removing lingering doubts from the minds of the medical profession, why cannot he remove lingering doubts from the mind of one who was once his hon. Friend. Lingering doubts are in my mind and it lies in his power to remove them, not for my benefit but for the benefit of the vast body of women. I cannot follow the hon. Lady the Member for Coatbridge (Mrs. Mann) into that obstetric heaven in Scotland of which she painted a picture that was somewhat spoiled by the hon. Gentleman who gave us the figures for her own county. I can say, however, that while she may never have been appealed to by women in Scotland, that is certainly not true as far as England is concerned. Our attention has been most vividly drawn to it by resolutions from women's associations and women's societies of every kind in our own constituencies. That is why we were so anxious to put it beyond a peradventure that every woman who desired to have analgesia in childbirth should have it. Letters from doctors who have interested themselves all their lives in this matter also drew our attention to it and made us anxious to have this placed beyond doubt. I would say one word to the hon. Member for Hornchurch (Mr. Bing) who has interested himself in this matter and has been busy about it. I thought his speech was most illogical. Although I think to some extent it was true, it was one of the things which leaves these lingering doubts in my mind. He had the same county council covering his constituency as I had. It was a good county council, it was getting on with the job, and we believed and hoped that analgesia would be at the disposal of the majority of women in our area. So we did not have to push for our women so much as we had to push for the women in South Wales. I will not mention Scotland, I dare not, somebody would jump on me if I did. The hon. Gentleman pointed out that cuts are already in contemplation, cuts in ambulances, cuts in all sorts of things. Does he not want this put beyond doubt so that this reactionary county council which now rules the lives of the people in his constituency and mine shall not have the chance of going back on the work that was done by the county council before?
If the hon. Lady will allow me to interrupt, there is an argument, I suppose, for taking every function from a county council, but unless one accepts that argument, all one can do is to put political pressure on the county councils to carry out the functions entrusted to them. If the House thinks otherwise, then let us take every function from the county councils and administer everything centrally.
No, I am not desirous of taking every function from the county councils, although I could mention a great many that I should like taken from them if this were the place and the time. I should like to see local government much changed so that county councils did not have as much power as they have. If there were devolution, they would be nearer to the suffering people and would know what was wanted.I appeal to the Minister again. This amending Bill has removed the lingering doubts from the minds of the medical profession, but I have lingering doubts and there are others who have them. The Minister seems to have none himself. We shall have a chance of discussing the proposed new Clauses, including that of the hon. Member for Hornchurch, fully on the Committee stage. That is why I have not attempted at any time to be out of Order in discussing them tonight. I hope that some time during that stage of the Bill the Minister and I will become again the good friends we once were, that he will not look so blackly as at me as he now does, that he will believe that I have done this in the hope that the Bill shall be the Bill that is nearest to our heart's desire. I hope, when it comes out of Committee, that it will be something of that kind.
I shall not follow the hon. Lady the Member for Epping (Mrs. Manning) on the topic to which she devoted the main part of her speech. She concluded with an appeal to the right hon. Gentleman, with what success I do not know, and in the course of my speech I am also going to make an appeal to the right hon. Gentleman—again I do not know with what result. As I listened to the whole of this Debate, I was struck, as I know were other hon. Members, by the number of practical contributions which were made on different aspects of the great topics with which the principal Act and this Bill deal. Indeed, as I listened to the hon. Member for South Tottenham (Mr. Messer), to my hon. and gallant Friend the Member for Pudsey and Otley (Colonel Stoddart-Scott) and to the hon. Member for Huntingdon (Mr. Renton), I was reminded of those many days we spent in discussing the principal Act when it was a Bill in Committee some three years ago.During that Committee stage I paid my tribute to the right hon. Gentleman for being a very doughty fighter on some of the matters on which there was real controversy in that Committee, and on those matters of controversy I do not propose to say anything tonight. On one that was mentioned by my hon. Friend the Member for South Hendon (Sir H. Lucas-Tooth), who opened for the Opposition, I took a different view from his. I did not think it was wise to deprive doctors of their goodwill, but that matter has been settled and I propose to say nothing about it. What I wish the right hon. Gentleman to do, if he will—I will remind him of some things in the past—is to try to differentiate between those matters on which there was acute controversy, and on which—in his view no doubt rightly—he insisted on his view prevailing, and those matters on which there was a real desire on all sides to improve the Measure, even from the Minister's point of view, and on which, I think quite wrongly, he failed to listen to our contentions. The hon. Member for South Tottenham and others have spoken from their expert knowledge of the hospital service and other branches of this great Service. I have, I believe, only two qualifications for speaking in this Debate. The first is that since, with one exception, I number more medical men among my constituents than any other hon. Member, I have throughout these controversies known something of what was passing in their minds.
What a rotten constituency.
The other qualification is that I happen to be a lawyer, and as a lawyer I made an honest and, I hope the House will agree, an honourable attempt to help the Minister and to advise him on a matter on which, in the sequel, I have been proved correct and he has been proved wrong. I take no particular credit for that, but the appeal I would make to the Minister is to assume that lawyers have some uses and can sometimes advise him well. Almost the whole of the first part of the Bill, and certainly the first seven pages or so dealing with partnership, are rendered necessary by specific defects which His Majesty's Opposition pointed out to the right hon. Gentleman on the Committee stage. It has been said by many hon. Members, among others, I think, by the hon. Member for Northern Dorset (Mr. Byers), that after a great new Act like the principal Act, some amending legislation will, no doubt, be necessary. That is true, but there are certain exceptional facts to be noticed about this particular amending legislation.First, its necessity had to be acknowledged before the principal Act came into force and, secondly, this matter is being put right by Part 1 of this Bill after it has caused, I would assure the right hon. Gentleman, a great deal of quite unnecessary suffering and work to a great number of medical men and their advisers. I hope that anyone who is interested in this topic will refer to the proceedings of the 15th day in Committee upstairs. I wonder whether the right hon. Gentleman would allow me to quote a short passage on the provisions which were looked into by the Legal Committee on Medical Partnerships and which give rise to the principal part of Part 1 of the present Bill. This is what I said:
A little later in the same speech I said:"I hope the Minister will do everything he can to render this subsection less obscure than it is at present. I should like to sympathise with the right hon. Gentleman. I have the greatest admiration for his forensic powers, whether he is arguing from the point of view of the law, of politics, or theology, but I think before we finish with this particular Clause he will require the assistance of one of the Law Officers of the Crown. One of the things about which the Minister and the Government must make up their minds is what they wish to happen to partnerships. My suspicion is that in drafting subsection (1) the draftsman had not got partnerships in mind at all. I cannot conceive of draftsmen, with that in mind, not specifically making clear what it is intended should happen to partnerships."
Then the right hon. Gentleman said:"I believe it is quite impossible to make this Clause satisfactory without dealing quite specifically with partnerships, saying what it is intended shall happen to them."
Because I felt quite convinced that the right hon. Gentleman there was wrong, and quite honestly wishing to make the legislation better than it would otherwise be, before the Committee concluded that day I said:"I see nothing obscure in the Clause at present."
that is to say, from the Opposition—"If the Minister does not accept any of these things from us"—
Today the right hon. Gentleman has had the assistance of the right hon. and learned Gentleman the Lord Advocate. In Committee on these very technical matters he did not have the assistance of any Law Officer. I hope that that was not by his express wish because he could not tolerate Law Officers. I do not wish to put an embarrassing question to him, but I urge him to take the lesson of what has here occurred and to realise that lawyers who speak from the Opposition benches and call attention to defects in these Measures are really attempting to get those defects put right. If he is in doubt about that, let him fully consult the Law Officers. I believe that in an intervention earlier today the right hon. Gentleman said that he had subsequently consulted the Law Officers. If that is his contention, needless to say, I accept his word, and I can only commiserate with him on the bad advice which he must have received, because we have not only these first seven pages of the present Bill but we have the Report of the Legal Committee on Medical Partnerships, Cmd. 7565. The principal part of that document occupies 16 pages and it has various appendices. Reference to a few of those paragraphs makes it absolutely clear that this clarifying and amending legislation is essential, that it cannot possibly be avoided. I welcome the Bill. I am glad that the right hon. Gentleman is providing this necessary clarification and amendment of the law. At the same time, I ask hon. Members, in whatever part of the House they may sit, to use their imagination and to consider what is well known to those of us who have many doctors among our constituents—how much suffering has been caused to medical men by these years of uncertainty about what their position was. All that suffering was completely and absolutely unnecessary. The expenditure of time which their legal advisers had to employ in trying to explain the position, and in actually explaining how hopelessly obscure it was, might have been avoided. I wish to end by saying what has been said by so many hon. Members in all parts of the House: whatever are the differences on various aspects of this matter, everyone wishes to do the best possible for the health services of the country. I have no doubt that amendment of the principal Act will, as has been pointed out, be necessary from time to time, but I make an urgent plea that we should stop this habit of passing great Bills and making them Acts with known and obvious defects which we could have put right before they were ever put on the Statute Book. This method of procedure is bad. I fully accept what has been said from the Government, Opposition and Liberal benches that in any event some amending legislation would have been necessary, but I appeal to the right hon. Gentleman to get rid of his great distaste for lawyers, if indeed he has such a distaste; I think sometimes that he exaggerates it. I hope that in any future legislation which he may have to conduct through this House or in Committee upstairs he will follow the precedent he has set today by having a right hon. and learned Gentleman next to him, and that he will not try to pass Clauses which he is assured by all the lawyers present in the Committee are legally obscure, by saying that he thinks that there is nothing obscure in them and insisting that they should go on the Statute Book as they stand. Having said that, I welcome the Bill—[Interruption]—I do not think that anything I have said conflicts with my welcoming the Bill. I have made my criticism of the facts that make necessary the greater part of Part I of the Bill. While the Bill will no doubt need careful attention in Committee, it is a useful Bill and one which we should put on the Statute Book."I appeal to him to consult the Law Officers between now and the next sitting. If either of the Law Officers had been present I know he would have seen the point we have been making."—[OFFICIAL REPORT, Standing Committee C, 20th June, 1946; c. 1656–8, 1684.]
Like other hon. Members, I welcome this Bill as the first instalment of the improvements which have already been mentioned as being necessary in the principal Act. I hope that the second instalment will come along at a fairly early date. If it is not found possible to include in this Bill any of the amendments which we shall propose from these benches, I hope that they will be included in the next Bill. My hon. Friend the Member for Monmouth (Mr. P. Thorneycroft) made a very moving appeal to the Minister and made, I think, a very generous offer. Other hon. Members have discussed the subject of analgesia and I do not propose to go into it at any length. I merely want to say that at the appropriate time in Committee I hope the Minister will give the proposals put forward to him very careful consideration.There is one matter about which I have had a good deal of correspondence from my constituents and which I raised with the Minister at Question time earlier this year. It is in regard to private patients who are unable to obtain drugs and appliances at the expense of the State. When this Service was introduced the Minister stated very definitely that people would be free to have the service in whole or in part. Members of the public who wished to pay for the services of a doctor, and therefore do not use that part of the service, feel a great grievance that at the same time they are debarred from having the free appliances or drugs available to other patients who take advantage of the whole Service. It seems quite wrong that just because a person elects to be a private patient of a doctor he should be debarred from the benefits which the Minister has stated very definitely would be available to him. When I put this point to the Minister he replied that it was not possible for these drugs and appliances to be given to any person who was a private patient, because the doctor would not be subject to State discipline as he was not in the State service. I pointed out that in one particular case, as in many others, the doctor, while having private patients, was in the State service, and therefore was subject to the discipline of the State. The Minister then replied that while that might be so, the doctor was not subject to State discipline in respect of his private patients. We all know that if a doctor in the State service in treating a State patient prescribes appliances or drugs which are not acceptable to the State, those appliances and drugs are not allowed to be given free. I cannot see why the same set of rules and the same administrative requirements should not be applied to a person who is a private fee-paying patient of a doctor. Why cannot the same drugs and appliances be supplied free to any person who pays fees to a doctor as they are to any State patient? There is a real feeling of grievance amongst many people. They consider that they have been misled. It is a pity that in connection with a great State service of this kind, which we all wish to see run in the best way possible, people should feel they have been led up the garden path. My constituents also write to me and say that they read in the papers that this Service is very costly, yet they see that foreigners who make no contribution can receive the Service free of charge. They pay for the drugs and appliances by way of taxes, yet they are denied them. But foreigners who come to this country can get the free State Service. But people feel that that is wrong. I suggest that the Minister ought to remove this grievance. He ought to make it possible for people to receive drugs when they pay fees for private treatment from doctors. Also, he ought not to give the Service free to foreigners who come to this country. Those are two points to which I hope attention will be paid, if necessary by amendment of this Amending Bill. There is one further point concerning the proportion of paying beds to general beds. The effect of high charges at present imposed on some private beds is to deprive part of the population of amenities which were available to them before the introduction of the State Service. I suggest that there should be a substantial reduction in charges for private accommodation and that such charges should be on a uniform basis throughout the same region. Alternatively, I suggest that whatever expense there would have been to the State ought to be allowed for in any charges made for private paying beds. Similarly, some consideration ought to be given to the patients who have paid for the State Service. The hon. Member for Putney (Mr. Linstead) rightly welcomed this Bill because it was a further stage in our efforts to improve the position as it relates to doctors, and to remedy some of their grievances. I welcome it for the same reason. Anything that can be done in that direction undoubtedly will be of benefit to the service; but it is a fact that the doctors as a whole still have grievances. In my constituency where there are some 600 of the best and most well-known doctors in the country there was a meeting last week and the decision of the doctors was that the National Health Service during its first year
The reasons they gave were:"has fallen far below the standards the public were led to expect."
These statements were made at this meeting of doctors. It was said:"The Minister and Ministry of Health have shown little or no desire to co-operate with the medical profession; have met the profession's suggestions with indifference and procrastination; and have been guilty of a breach of faith."
The doctors said:"Waiting lists at the hospitals are getting longer, and beds are being closed down. Patients are not getting efficient treatment because doctors who have not been given the clerical assistance they were promised are overworked. They have difficulty even in getting essential X-ray examinations done. It is time we stated plainly that it is not the fault of the doctors.'
If any other action can be taken, either in this House or outside, by the Minister or anybody else, to try to stop that state of affairs, it cannot be other than to the public advantage. I hope that the Minister will be able to say something tonight to try to alter that attitude which, whether we like it or not, undoubtedly exists in the minds of the great majority of doctors. Everything possible should be done to help the doctors in their most difficult task of putting this State Service over in the way in which, to whatever party we belong, we want it to be put over. I for one would welcome anything that the Minister can say tonight to help to remedy the position."Instead of getting better, everything is getting worse."
We have had a most interesting discussion, and the Bill introduced by the Lord Advocate is perhaps a smaller peg than one would have expected upon which to hang so many topics, but the Lord Advocate did not make any divagations from the strict path. We welcome his incursion into this wider field, and I am sure the whole House will agree with me that he showed a singular lucidity and clarity of expression for which the whole House is grateful. We on this side are specially grateful, because it is admittedly our Bill, and we were very pleased when our Advocate introduced it. We feel that we have retained a very good counsel indeed and that he made a very good case for the Measure. His admirable example was not, I regret to say, followed by every speaker.In fact, the discussion on this Bill ran down three channels, occasionally converging and occasionally diverging—what was in the Bill, what was not in the Bill, and what, by skilful Parliamentary usage, had been got on to the Order Paper with the possibility of it getting into the Bill at a later stage. The combination of these three strands has led to perhaps a rather longer robe being woven than I had anticipated, but I do not complain about that at all, because the fact is that the Bill itself is in some respects a Measure which only lawyers can explain, and, it may be, only lawyers can understand. I am not quite sure whether they themselves fully understand it or not, but at any rate I would not challenge—nor would anyone on this side of the House or the other—the legal exposition which was given. I am willing to take it from a Law Officer that the Slade Committee's Report has been faithfully incorporated into the Clauses of this Bill, and I will not attempt to go into that or go further into the history of the matter, which was so admirably sketched by my hon. Friend the Member for South Hendon (Sir H. Lucas-Tooth). The House, however, in its usual way, is interested in going a good deal wider, and I would refer, in passing, to the parallel discussions which went on concerning the vexed question of analgesia, on which I noticed some hon. Members, including some of my hon. Friends, making very skilful use of Parliamentary opportunity to seek discussion of that which is nearest their hearts. I do not think it can be said that that was in any way made a party issue, as the hon. Lady the Member for Coatbridge (Mrs. Mann) seemed to indicate, because we have just listened to a most eloquent address by the hon. Lady the Member for Epping (Mrs. Manning) who pleaded with some passion that the Minister should not turn from her the light of his countenance. I would indeed say Amantium irœ amoris integratio est—"The wrath of lovers is the rebirth of love." We hope it will be so in this case. Undoubtedly, the subject of analgesia is one in which the House has recently taken a great interest, but the Minister may think that there are other subjects equally desirable for consideration, and, indeed, or even closer consideration, such as the great subject of research and the necessity of research in cancer, tuberculosis and other great diseases. The discussion went very wide, and the hon. Member for South Tottenham (Mr. Messer) even brought in the question of housing. I certainly would not wish to pursue that, except to say that I fully agree with him that the present housing shortage is one of the reasons for the great strain on the hospitals. If the hospital authorities could get adequate accommodation for many of the cases, it would ease the strain on the beds and enable them to admit certain cases which they would greatly desire to have under care rather than outside. The first breach in the harmonious conduct of the Debate was caused, I think, by the hon. Member for Northern Dorset (Mr. Byers), whose attitude may be summed up in the words, "Play the game, you cads." I think that one who handed it out as vigorously as he did has no cause to complain if he gets it back. To make the demand that it should be carried out in an atmosphere of good will, and to proceed to wreck that atmosphere of good will in every way he possibly could, was not the way to bring about the object which, he said, he had in view; all the more so since the National Health Service policy was set on foot by the war-time National Coalition Government, with its great Conservative majority, over which the right hon. Member for Woodford (Mr. Churchill) presided. It may be said, "That is all talk; nothing was done." I am certainly in a position to speak upon that because I had the honour of taking the second great step in the National Health Service. The first step was taken by a former leader of the hon. Member for Dorset, Mr. Lloyd George, but I may claim to have taken at least a step of some considerable importance in the setting up of the Emergency Medical Service which was in existence when the National Health Service came into being, and without the preliminary work of which it would not have been possible to set afoot the National Health Service. I had to form an organisation covering all the doctors of the country and integrating all the hospital beds of the country.
Although the Conservative Party had been in office for 20 years, it was not until there was a war that something was done in order to get beds for the National Health Service.
The hon. Gentleman's well-meant efforts to introduce an atmosphere of good will is a singular insight into what the atmosphere of good will must be at Liberal Party meetings. When the hon. Lady the Member for Coatbridge went out of her way to thank me for a step towards the improvement in the National Health Service; actually dealing with one of the points we were discussing, namely, the service for maternity benefit, I think that it is quite far-fetched for him to suggest that nothing was done by the Conservative Party between the wars. Does he think that the 1929 Act of Mr. Chamberlain, and the change-over of the Poor Law hospitals to——
The hon. Gentleman says that the 1929 Act was carried out under pressure. As Disraeli said when a man said, "Mr. Smith, I believe?"—"If you believe that you will believe anything." I have myself shared many of the difficulties which the Minister of Health has had. On the more particular task which we were discussing just now in some detail—the task of providing hospitalisation—I can certainly speak with a great deal of sympathy, because I myself had the task of providing a very large number of hospital beds. The right hon. Gentleman has said that there are more hospital beds now than there were before the war. That is quite true, but it is not, I think, the very large increase which seemed to be suggested by the hon. Member for North Islington (Dr. Guest). It is, I think, something of the order of between five and ten per cent. Even so, the present number of hospital beds in this country is of the order of 454,000. The Emergency Medical Service ran the number up to well over half a million, and we had all those beds completely staffed; so that, although there has been an improvement from before the war, there has been a considerable recession from the war-time beds which were provided and staffed.
For obvious reasons.
It is quite true that many of the advantages which appear in war disappear in peace. But so do some of the disadvantages. I think the right hon. Gentleman will not deny—in fact I am sure he will agree—that as long as there are 50,000 hospital beds in existence but not staffed, nobody can say that we have solved the problem, or even taken all the steps we can towards solving the problem, of producing an adequate Health Service.Let me deal with the assertion that on this side of the House there is no support for a National Health Service, or even for this National Health Service, because we voted against the original Act when it was introduced. Surely the right hon. Gentleman, as a skilled Parliamentarian of long standing, will not bring forward that argument. The Labour Party voted against the Housing Act of 1936, not because they objected to housing but because they objected to the approach which was being made. They voted against the Education Act of 1936, not because they objected to housing, but because they objected to the particular treatment which we were bringing forward. They voted against the Widows', Orphans' and Old Age Contributory Pensions Act of 1925. It is most interesting historically that the right hon. Gentleman who moved the rejection of that Act was the right hon. John Wheatley, the uncle of our present Lord Advocate. But he did not object to widows' pensions or old age pensions; he objected to the particular avenue of approach we were making. More recently the Labour Party voted against the Milk Act of 1935. I had the honour of introducing that, and I well remember a difficult struggle. We were there dealing with milk for school children. The Labour Party voted against that Act, not because they objected to the provision of milk for school children but because they objected to the particular provision which was being made. All those things have since been accepted by all parties. Indeed, the Labour Party proposed the rejection of the Widows', Orphans' and Old Age Contributory Pensions Act because it introduced the contributory principle into a Health Insurance system; but that principle has since been built upon with great vehemence and keenness by right hon. and hon. Gentlemen opposite, and now forms a cardinal feature of their social policy. The thing which the House would really wish to know tonight is a little more of the future. There has been considerable uneasiness and distress amongst the medical profession. The Minister of Health is a heavyweight boxer of the most formidable character. He might be called a bruiser. Anyone getting into a rough-and-tumble with the right hon. Gentleman is bruised both mentally and physically, and there is a deep Freudian bruise in the mind of the medical profession about those negotiations which were conducted, to quote their former chief of staff, more as a military operation than as a kind of negotiation. The right hon. Gentleman is doing his best to dispel that; and today the Lord Advocate said that it is the desire of us all to make matters run smoothly. This Bill is, I think, an earnest of that. I do not take the view that there is any breach of faith in this Bill. I take the view that this Bill carries out the promise of the Minister. There may well be further steps to be taken, but these will be a matter for future discussion. If the Minister had tried to put in all the amendments which appeared desirable up to date, then he and I, I regret to say, would have to continue the intimate series of meetings which we have been carrying on now for so long, and which neither of us would wish to have prolonged more than is absolutely necessary. I say that in the professional and not in the personal sense. The next point is the position as to the services, and more particularly the hospital services. The hon. Member for Batley and Morley (Dr. Broughton) who has early succeeded in acquiring particular political tricks, including one of using part of a quotation which suits him and leaving out the rest, quoted from a "British Medical Journal" leader to the effect that they had refused to accept the assurance of the Minister; but the hon. Member left out the explanation in the second half of the sentence, which was that although the Minister might not remain, he could not bind his successor. That shows that the hon. Member is going on very fast in his apprenticeship. He might perhaps have quoted from another leader in the "British Medical Journal" of 14th May, 1949, dealing with the subject of what will be the actual reduction in beds due to the recent circular of the Minister. I do not take the view that there will certainly be a reduction. The Minister has sent out a circular to regional boards in regard to the Treasury cut of 5 per cent. It works out with varying severity on various hospitals, but it certainly has left a lively apprehension in the hearts of many of the hospital authorities, and this was a point which was referred to by the hon. Lady the Member for Epping. This leader said:
That is not to be dispelled by the statement which the leader says was made by a Ministry of Health official, that in 1948–49 the hospitals received £172,796,000, and for 1949–50 they would be receiving £177,531,000. The House will be much more interested in the possible closure of beds. The leader went on to say"The cut in the budget of St. Bartholomew's Hospital is as much as £300,000 … Oxford, for example, suffers a cut of £170,000 on an estimated expenditure for maintenance of £960,000; Bristol a cut of £120,000 out of an estimate of £970,000; Birmingham a cut of £87,708 out of an estimate of £1,308,329."
The hon. Member for Batley and Morley might have considered bringing these facts before the Minister instead of the facts which he brought in for the purpose of acerbating the Minister's winding-up speech, which he will find later is a work of supererogation. It is true that the work of the medical service is expensive, and we all agree that the expense must be very carefully watched, and, indeed, pruned where necessary. My hon. and learned Friend the Member for Wirral (Mr. Selwyn Lloyd) recently gave an example of a hospital whose clerical bill before 5th July was £350, and it had gone up to £1,200. The clerical expenditure at Skegness Hospital has gone up by a multiple of three. These are examples of expenses which can and should be reduced. I do not deny, and no one denies, that the expenditure upon these services has not yet reached its peak. The Minister will no doubt ask in his winding-up speech what is our attitude on these things. Where do we stand? I will tell him. The word of the nation has been passed, and the health services must be implemented. We recognise, and indeed we have constantly called attention to, the fact that the cost of these services has not yet reached its peak. The money to complete them will have to be found. We do not propose to cut the health services. Vigorous action will have to be taken to bring that about. The Chancellor of the Exchequer has indicated one possibility. No such steps are mentioned in the Bill. It would be quite wrong, and it certainly would not be fitting, to consider steps of the order suggested by the Chancellor of the Exchequer. Undoubtedly, prune and trim as we will, the cost of the services is on the rise and is still rising. It is vitally necessary that the health services should be rounded off, for them to be as the nation desire them to be. That is the position of hon. and right hon. Gentlemen on this side of the House. [Interruption.] I am speaking on behalf of my party, with a sense of responsibility. I say that that is the attitude of right hon. Gentlemen on this side, and I ask the hon. Member for Northern Dorset to believe that."The Manchester Regional Hospital Board, for instance, has decided that if the cuts in capital and maintenance estimates are put into effect, there will be 2,019 fewer hospital beds available for the already long waiting-list of patients. St. Bartholomew's had planned to reopen 330 beds, but the heavy cut in its budget now makes it necessary to keep this block closed."
I am extremely grateful to the right hon. and gallant Gentleman for what he has said. Perhaps that could be conveyed to Conservative candidates throughout the country.
The emollient effect of the hon. Member for Northern Dorset continues. I must return again to my subject. The Minister has to rise, and emollients at this stage are perhaps out of place. I say that the Bill before us certainly implements the promises which were made by the Minister during the passage of the Bill, promises which we believed were necessary. If they had not been implemented it would have given rise to a grave breach of faith. The general task before us now, as before the whole House and the whole country, is that of finishing the building, which has now been begun and is by no means completed.I think this is not the last of the amending Bills which we shall have before us. It is a very noble aim that the nation has set before it. I think it will not be possible to lift the matter above party politics, as it is called. This matter is on the smithy of party politics, on the anvil of which great policies are beaten out. I do not make any apology, nor do I ask for any quarter in that matter. It is in the cut and thrust of debate, in the hammer and clang of the House, that these matters are finally decided. The air of peace which hangs over matters which are above party politics is very often the peace of death. This Health Service is a live decision, taken after live discussion. Let the discussion go on, and in that way will a policy emerge and the future of our nation finally be worked out.
I am afraid that such a very wide field has been covered in the course of the discussion that half-an-hour is hardly sufficient to enable me to answer every point which has been made. I do not propose to spend very much time on the Bill because no one else has spent much time on it. I want to disagree with the hon. and learned Member for the Combined English Universities (Mr. H. Strauss) about the genesis of the Bill. He says that the Bill is a complete vindication of the attitude which was taken up by him and some of his colleagues on the Committee stage of the Bill in 1946. On the contrary, the very microscopic examination which has occurred since then shows how wrong they were in what they said. The statements which were made at that time were to the effect that the Clauses relating to partnerships and compensation and to the abolition of the sale and purchase of practices would have the effect of dissolving partnerships and making them impossible and that therefore it was necessary to amend the Bill.Most of the doubt which arose at that time and most of the anxieties which the doctors have been suffering were a direct consequence of the unbridled propaganda of some leaders of the medical profession at that time. They were creating suspicion and doubt where none in fact existed. What they were really arguing against was not the partnership Clause in the Bill but that relating to the sale and purchase of practices. I do not want to recriminate too much but it was really a part of their propaganda at the time to cloud the whole matter and to suggest that something dreadful would happen. Nothing dreadful has happened. All that has occurred is that a large number of doctors believed what some of their leaders said and have been suffering unnecessary anxiety in the meantime.
I am obliged to the right hon. Gentleman for giving way. Is he aware that the doctors took legal advice and they were given advice that the section was obscure in the way that paragraphs 8 and 9 of the White Paper inter alia say they were right in thinking it was obscure?
I was coming to that point. The fact of the matter is that the lawyers disagreed about it.
The lawyers always do disagree.
Will the hon. and learned Gentleman give an assurance that the lawyers will not disagree about these Clauses? Of course he will not. No one can. No one can say that the Clauses which we have been compelled to put into this Bill as a consequence of the examination are less obscure than the Clauses in the 1946 Act were. I challenge any lay Member to compare these revised Clauses with those we had in the original Act, and before they compare them I advise them to put cold towels on their heads.What we are dealing with here is not the obscurity of a piece of legislation but the complexity of the subject. It is extremely difficult, as was realised by the very competent Committee under Mr. Justice Slade which inquired into this. So complex are the circumstances and so varied are the partnership agreements that the committee suggested a most original and novel procedure, that we should have arbitration powers of such a wide nature that the Act of Parliament itself could be altered by the arbitration. That proves the opposite to what the hon. and learned Gentleman was saying. What he was trying to prove was that we were incompetent to frame clear Clauses. What examination has proved is that the subject itself is so complex and so largely unknown that original powers have to be given even to alter the Act of Parliament by arbitration.
Why not put it in the original Bill?
With all respect, we did a most original thing here. Because the propaganda had confused the minds of the doctors we did not even wait for the courts to interpret the Act of Parliament. Yet the courts might have decided that the Act of Parliament was clear and have interpreted it in our sense. Although there are between 17,000 and 18,000 G.Ps. in the country, this Bill affects only 50. [An HON. MEMBER "Subsection 7."] Fifty partnerships.
I think also their assistants.
I daresay. That was not a matter of obscurity. I am speaking here about the scope of the Bill. In fact most of the fears that were expressed at that time have proved entirely groundless, and what we are doing at present is clearing away the doubts that need never have occurred at all at that time were it not—I do not complain about it—that the Act had been launched in a polemical atmosphere.
Surely the right hon. Gentleman is referring only to Part I when he says only 50 people?
The right hon. Gentleman said the Bill.
Yes, because that is the matter I am discussing at the present time. We ought not to be reproached on the ground that an amending Bill proves that we made a mistake. If making a change, if making an improvement—[Interruption.]—Hon. Members are not supposed to take note of what happens outside the Chamber. If making an improvement upon what was done before, is to be regarded as an admission of having been wrong before, then we have the explanation of why the Tory Party has stood still for 100 years. As has been said over and over again, we are perfectly prepared to introduce amending legislation whenever it can be shown to be necessary and, as has been said also, it will probably be necessary before the National Health Service scheme has properly "bedded in" to have a good many small amending Bills.
The Minister says that Part I will affect only a few people. Has he any statistics to show how many partnerships were dissolved before the appointed day on account of the complete obscurity of Section 35 of the principal Act?
No, I cannot tell that, but if there were partnerships dissolved, it was not in consequence of the obscurity of the section but of the propaganda to which I have referred because, as has been shown, it has not been necessary since the appointed day to dissolve partnerships. If, therefore they were dissolved before, the guilt rests on the leaders of the profession and not on me. I want to leave that point because sufficient has been said about it.Now may I make a reference to one matter which cropped up in the course of the Debate and, Mr. Speaker, may I be permitted to make a reference to the Standing Orders of the House? During the war a change was made as a result of which it became possible to put Amendments to a Bill on the Order Paper before the Second Reading had been taken. I cannot and ought not to criticise the Rules of the House, but I think that perhaps they ought to be reconsidered because what has happened this evening is complete evidence of the confusion that can arise if we start with the Committee stage of the Bill, before we have had the Second Reading. I am not complaining that hon. Members have done it. They are perfectly entitled to use the Rules of the House in the way they wish, but I suggest to hon. Members in all parts of the House that we are likely to get into a confused condition if we are to have Committee discussions before we have had the Second Reading. The proposed new Clauses upon analgesia, to which reference has been made, are a case in point. I shall not say, and I ought not to be asked to say, how I shall deal with those Clauses in Committee. I must leave that until the Committee stage has been reached. Certainly, if I may say so with all respect, I cannot permit the existence of those proposed new Clauses, in the course of a Second Reading, to be part of a bargain to be made about a Private Member's Bill. I certainly cannot agree at this stage to admit certain Clauses into the Bill in Committee, in return for which a Private Member's Bill, that may never reach the Statute Book, will be withdrawn. That, indeed, is a peculiar bargain to strike, and I do not propose to do it. We shall discuss the merits of those Clauses when we reach them. What I want to make clear—and this is in answer to my hon. Friend the Member for Epping (Mrs. Manning), who made a very charming and conciliatory speech—is that what vexes me about the whole of this propaganda is that the country is being given the impression that if only these new Clauses were in operation, more women would be relieved of pain in childbirth. That is what I resent, because it is not the truth. Not one additional woman in the country would be relieved of pain in childbirth if the Bill were on the Statute Book. What we are faced with in connection with the development of that service, is not statutory limitation, but physical limitation, a limitation placed upon us by the lack of sufficient trained midwives and general facilities. It is like saying that it is the absence of statutory power which is responsible for the fact that there are 50,000 people on the hospitals' waiting lists. It is not statutory power that we need in order to provide beds for those patients; it is nurses and general facilities. Those waiting lists could be wiped out immediately——
Of course, we acknowledge the physical difficulties, but no physical difficulties could justify the position—and area after area could be quoted—where not one woman has the opportunity of this relief.
That is not really the case. In fact, as hon. Members in all parts of the House know, very remarkable progress has been made over the last year or so in the provision of analgesia or anaesthesia. Indeed, in England and Wales, between 60 and 70 per cent. of all confinements have now analgesia or anaesthesia. I do not want to be unduly controversial over this—I am in a comparatively benign mood tonight—but I suggest that it does not lie in the mouths of hon. Gentlemen opposite to speak about analgesia at all, because their record is as black as it can be. In fact, almost all the progress that has been made in the provision of analgesia has been made since 1945.The reason why I have been a little concerned about this matter is this. I personally am not really concerned about my own reactions about it, but I think that in this matter of health administration hon. Members ought to be extremely careful in what they say because they can give unnecessary pain. It is not possible for a Minister of Health, no matter to what party he belongs, to say that any particular class of patient is going to have priority over any other class of patient in the Health Service. It is a wicked thing to say to people who are suffering from cancer that the House of Commons regards the provision of this or that relief to some other class of patient as taking priority over the treatment of cancer. We must not have that sort of psychology in the Health Service. I beg hon. Members to realise that. It is a part of the psychology of sickness that every sick person must feel that he or she is receiving as much attention as any other person. Therefore it is a monstrous intrusion, a violation and mutilation of that psychology that it should be said that a certain group of patients are to have priority over any other group of patients.
I do not know why the hon. Member is shaking his head over that, because it is precisely the issue involved.
I do not want to be controversial, but exactly the same priority is given to make it the duty of the dental surgeon to look after the welfare of young children.
And that is a classical illustration of the foolishness of using such words and I regret that because, as a consequence of the movements between private dentists and public dentists, there is danger of the priority dental service breaking down. In other words, once more we are not in statutory difficulties, but in physical difficulties, and no legerdemain or alteration of words on the Statute Book is going to alter physical facts. I am really sincere about this. Let us press on, let us go on training midwives as quickly as we can. Let us go on providing this relief on the greatest possible scale and, before many years have passed, every woman in this country will be able to have analgesia or anaesthesia if she wants it. Let us for heaven's sake be a little more proud of what we have accomplished and not be forever "girning" about what we are not doing.I want to say a word or two about the question of expenditure put to me by the right hon. and gallant Gentleman. Hon. Members opposite must make up their minds about what they are going to do. In speech after speech hon. Members opposite have been asking for increased expenditure this evening. Hon. Members want all the items put up and the totals to be down. It is no use to come to the House of Commons, as they have come, making nice quiet speeches and then saying, "We want to take the Health Service out of party politics." The right hon. and gallant Gentleman, in fairness to him, did not say so, but look at the posters in the country. Let me make this quite clear, subject to the Ruling of the Chair: this amending Bill is very wide and the Opposition can put down Amendments if they wish suggesting what should be taken out of the Health Service. I would welcome their suggestions. It has been asked by one hon. Member, "Why on earth should we cut the hospital service and issue free spectacles?" By what conceivable alchemy can I transmute a citizen without a pair of spectacles into a trained nurse looking after a patient? If it be the fact—and it is a fact—that the limitation on the provision of hospital accommodation is the lack of trained nurses, I cannot get trained nurses by letting half the country go blind. Hon. Members must make up their minds. I cannot reduce any of these services, or make a charge for any of these services without an amendment of the law. I cannot do it administratively—[Interruption.] What is that? Do not mumble, let us have it. If the Opposition wish to economise at the expense of the provision of one of the free services, let them have the courage to put down an Amendment to the Bill. But do not let them go "girning" around the country saying that the Health Service is extravagantly administered and ought to cost much less money, and yet demand that the service be given. The Leader of the Opposition does not hesitate to talk about extravagant administration. He made a speech in the North the other day and talked of the gross extravagance of the Health Service and the incompetence of the Minister of Health. I notice he never says it here now, but goes there to say it. Does the House know what the percentage is? The administrative expenses of the National Health Service Act work out at 2.3 per cent. of the total cost. I challenge any private industry in the country to reveal their figures and compare them with that. Ask the private insurance companies what their administrative expenses are. Anything from 9½ to 40 per cent. Let me be quite clear: in these administrative expenses are included the Health Division of the Ministry of Health, which by the way is smaller than it was before, with all these added responsibilities. The price-fixing machinery for the pharmaceutical services, the Estimates Board for the dental service, all the executive councils, all the regional boards, all the management committees of hospitals, including all the secretarial expenses people have been speaking about—they are all in this 2.3 per cent. total. It is perfectly correct that here and there unnecessary appointments will be made. The percentage I have given is no reason why we should not scrutinise the administrative expenditure as narrowly as possible but it does mean that there are no great savings to be obtained on the administrative side. It means, therefore, that hon. Members mislead the country if they suggest that they can secure any great savings on the National Health Scheme by cutting out administrative extravagance; they are just not there to be obtained. Before I sit down I must say a word in reply to the right hon. and gallant Gentleman about the cuts. I apologise for not answering many of the points raised, but I have not the time. What we are witnessing is a financial exercise. It must be realised that the regional hospital boards and management committees had been in office for only six weeks before they were asked to make their estimates. Everybody is taking this plant up to see how it is growing; the thing is not having a chance to settle down. The Opposition Press are introducing a note of hysteria all the time; they will not let the thing have a chance. We know very well—I am not saying this about all hon. Members—that among very large groups in the country who are opposed to us there is a vindictive animosity against the Health Service, and they seek every opportunity of sneering. When these estimates are sent in, the management committees estimate what they want, and those estimates are added up by the regional hospital boards and are sent in; they say, "This is what we would like to have," but we do not accept them without examination. We say, "Take these estimates back and have a look at them again." They must realise that they must justify their estimates or there will be no financial control at all. We are at the moment witnessing an attempt by the central administration progressively to exercise financial discipline over the whole Service, while, at the same time, leaving the utmost amount of independent action at the periphery, and we shall succeed. I have told regional hospital boards and management committees that in making economies where they can be made they must not make them at the expense of the patients. That means that they must not close beds. It also means that where it is necessary and advisable to open new beds those new beds must be opened. But hon. Members will realise that management committees and regional boards, when asked to make a cut, will say, "Oh, this means that we have to close beds." I say, "Oh, no. It does not mean that you have to close beds. If you cannot save all the money without closing beds you cannot save it; but look at your expenditure more narrowly, scrutinise it more carefully; make economies where they can be made," because there is nothing worse for any administration than to feel that they can have all the money for which they ask. We get slack administration all round if we do that. It is only ten months since the Service started, and it will have to run for three, four or five years before we shall really know what the repetitive annual expenditure is going to be. But in the meantime, if we are concerned about the Service, we must have patience. Reductions have been made in the remuneration of chemists—or slight reductions will be made—in the remuneration of opticians and in the remuneration of dentists. Where it was shown to be necessary those economies have been made. But there is one prerequisite in the study of human behaviour, and that is people must first of all be allowed to behave. It was not possible to see how doctors were going to react; it was not possible to see how dentists were going to react, until they were allowed to react. It is a simple thing, but it happens to be true. As they have only been acting for ten months it is a bit premature to reach any conclusion about their ultimate behaviour. I will make hon. Members opposite a gift of this information. To the extent that abuses exist in the Health Service; to the extent that it has been difficult to prevent them from arising; to the extent that there are faults they arise directly from those parts of the Health Service that have to be articulated through private enterprise. Opticians, dentists, chemists—but not much the chemists. Hon. Members should think when they are speaking about these things that it is awfully difficult to make the motives of private enterprise subserve a great social purpose. That is the difficulty which we are experiencing. But I am hoping to raise the ethical standards of the professions. I am hoping to put the nimbus of public service upon private enterprise brows. Before very long, as the years go by, I believe everybody will take a pride in this Service. It is alleviating pain, it is giving relief, and, at the same time, it is serving as an inspiration to the other nations of the earth.
Question put, and agreed to.
Bill read a Second time and committed to a Standing Committee.
National Health Service (Amendment) Money
Considered in Committee under Standing Order No. 84.—( King's Recommendation signified.)
[Mr. BOWLES in the Chair]
"That, for the purposes of any Act of the present Session to amend the National Health Service Act, 1946, and the National Health Service (Scotland) Act, 1947, and otherwise to amend the law in relation to services provided under the said Acts, it is expedient to authorise—
(a) the payment out of moneys provided by Parliament— (i) of compensation, in certain cases, to members of medical partnerships, being compensation additional to the compensation payable under section thirty-six of the National Health Service Act, 1946, and section thirty-seven of the National Health Service (Scotland) Act, 1947; (ii) of remuneration and allowances to the members of any arbitration committee appointed under the said Act of the present Session and of the expenses of any such committee; and (iii) of any increase attributable to the passing of the said Act of the present Session in any grants or sums payable under any other enactment out of moneys provided by Parliament; (b) the payment into the Exchequer of any sums received by the Minister of Health or Secretary of State under the said Act of the present Session."—[Mr. Glenvil Hall.]
Resolution to be reported Tomorrow.
Landlord And Tenant (Rent Control) Bill
Lords Amendments considered.
Lords Amendment: In line 4, leave out from "1939" to "to" in line 7 and insert:
"further to restrict the requiring of premiums in connection with tenancies to which those Acts apply; to make further provision for the purposes of those Acts where the tenant shares part of his accommodation with his landlord or other persons or sublets part of his dwelling-house furnished."
I beg to move, "That this House doth agree with the Lords in the said Amendment."This Amendment is necessitated by the introduction of what are now Clauses 2 and 9 of the Bill.
Question put, and agreed to.
Clause 1—(Variation Of Standard Rents Fixed By Reference To New Lettings)
Lords Amendment: In page 2, line 17, at end, insert:
"Provided always that in the case of a dwelling-house the first letting of which occurred between the first day of September nineteen hundred and thirty-nine and the fourteenth day of August nineteen hundred and forty-five in consequence of the landlord serving in any of His Majesty's forces or otherwise being required to reside elsewhere than in the dwelling-house by reason of circumstances arising out of the war, the rent so determined as aforesaid shall, as from the date of the determination thereof, be the standard rent of the dwelling-house whether the same shall be greater or less than what would be the standard rent apart from this section."
I beg to move, "That this House doth disagree with the Lords in the said Amendment."It has been made clear to this House on several occasions that this Bill is designed to achieve the limited objective of defending tenants against gross abuses by landlords. It is certainly not the vehicle for a general review of the Rent Restrictions Acts. In our view it is not possible to deal in isolation with a few cases where hardship may arise to a landlord without such a general review. Indeed, the proposed Amendment makes clear this weakness, for it would be almost impossible of interpretation within any narrow limits. Who could be certain, for example, whether or not the exigencies of war had necessitated removal in a certain case? I think also that it is clear that the hardship caused to individual landlords who had to leave their houses either to serve in the Forces or to go to other parts of the country during the war years has been much exaggerated. In fact, in the great majority of cases these landlords have now returned to the occupation of their houses. It would be wrong to attempt to take action on what is a comparatively small issue rather than to wait for a general review of the Rent Restrictions Acts which must take place at a more convenient date.
Would it not be better not to refer to these people as landlords having to leave their houses but as owners who were forced by the war to leave their houses? I think that would be better than saying that they are landlords.
I hope that my right hon. and hon. Friends will not be satisfied with what the Parliamentary Secretary has just told us. All that he has said is that for administrative reasons it is not convenient to the Government to make a particular exclusion as indicated in the Amendment. He said the cases were few and, although there might be some injustice, the hardship was limited. The hon. Gentleman has cloaked himself under the excuse that this is not an easy thing to do. Where cases of justice and injustice are concerned, I think I speak for all my hon. Friends when I say that we do not hesitate, even though it might mean some administrative inconvenience, to further the just cause.I would point out to the hon. Gentleman that if the original intention of the Minister of Health when he presented this Bill had been carried out and if the right hon. Gentleman had not been led astray by a Communist Amendment which he accepted, the present Amendment which we support would not have been necessary. It is only as a result of that Communist Amendment that this is necessary, because these cases of hardship will arise. The House should give serious attention to the type of person to whom we are referring. We refer primarily to ex-Service men who had to give up their houses when called up or when they volunteered, and particularly, to members of the Armed Forces who lived in the towns. We should not forget that it was the policy of the Government of the day to try to get people out of the big towns if they were not essential to maintaining the life of those towns. What happened was that the men were called up or volunteered, and their wives and children were encouraged to evacuate from the centres of great cities like London. We naturally expected—and I am sure the Minister will agree—that the demand for houses in the centres of these great cities, which were all the time either under the threat of bombing or were actually being bombed, would be very small indeed. The majority of those affected were members of the Armed Forces, but there were others as well. There were key people who were asked by the Government to take up essential war work in other parts of the country, or who were sent abroad for that purpose. In addition, there were a large number of civil servants who were evacuated from London to places like Colwyn Bay at the request of the Government, and who had to make arrangements to dispose of their property because they had to work elsewhere. I feel that this is a reasonable case, because the rents which these people were able to obtain during this time were rents which today are very much below what could be termed reasonable rents. What the Minister has done by accepting the Communist Amendment and making his Bill effective as from 1st September, 1939, is to impose upon the type of person to whom I have referred the obligation of receiving a rent which was obtained in a period, not of scarcity of houses, but of superfluity of houses, and that is really beyond argument. The Parliamentary Secretary made the point that this case should be dealt with when a general revision of the Rent Restrictions Acts is considered and is before Parliament. We agree with the hon. Gentleman that that should have been done, but his Government have been in power for almost four years already and it has not been done. Have we any reason to think that, if they are returned to power, they have any intention of dealing with this matter? We should be most interested to hear what they have to say—but it is probably an entirely theoretical question.
Is this the only theorising in the Conservative programme that we are to be vouchsafed?
A very interesting interruption, but an irrelevant one.I hope that, in view of the points which I have put to him, which are reasonable and just, the Minister will think again. I hope that hon. Members on all sides realise that it is the job of this House to do justice, not to carry out things merely for reasons of administrative convenience.
I feel that another place has sent forward an Amendment to this Bill which deserves the attention of hon. Members on both sides of the House. The Minister was quite right when he said that the prime reason for the introduction of this Bill, in which I have given him all support, was the extortionate rentals due to the housing scarcity. Whereas all Members of this House are in favour of removing that abuse, I fail to see why we should not be interested in other abuses as well. To my own knowledge—and I should be pleased to give the right hon. Gentleman any further information at any time he may wish to have it—there was quite a large number of lettings in London during the blitz, not, as a supporter of this Amendment has said, at 50 per cent., but very often at only one-third of the value of a reasonable rent. The owners had to leave London and choose between letting their houses or closing them. In the latter case they ran the risk if the houses were damaged, of having anything inside them of value pillaged. There were large numbers of lettings at a comparatively nominal rent which had no relationship whatever to a low reasonable rent. I have always stood up for what I call a low reasonable rent.I think that the right hon. Gentleman has admitted, and certainly his representatives in another place have admitted, that there is hardship under this particular provision. Is it quite fair when the Government have the chance to rectify an abuse, that they should say, "If we cannot rectify all abuses, we will not rectify this particular abuse"? I do not think that is a good argument. The members of the tribunal will be well chosen and men with considerable knowledge of letting values, and I fail to see why they cannot deal with a very reasonable Amendment such as this one.
I think that hon. Members will agree that there is much to be said for making provision for those who were compelled to leave their homes, whether through war service or otherwise, during the war. If that were the only point at issue in this Amendment, I think that the Minister would have been pleased to accept it; but it is, unfortunately, not the only point. I think that so long as the Rent Acts are not dealt with as a whole, which, as hon. Members will know, many of us have been trying to bring about for a considerable time, it would be invidious to make a distinction in this particular respect, because by avoiding a hardship in one direction we should probably create hardships in other directions.I would like, first, to deal with some of the arguments adduced by the hon. Member for Woodbridge (Mr. Hare). It is drawing a red herring across the track to suggest that because the original Amendment to the Bill was proposed by a Communist—and my hon. Friends will know that my sympathies do not lie in that particular direction—that has created a position which justifies the introduction of this particular Amendment in another place. If I may say so with respect, that argument does not hold water, because the original Amendment was introduced for the reduction of rents. It did not introduce any question of increasing rent, and did not deal with the position of a man who had left his premises in consequence of the war. All it did was to extend the provisions of this Bill to enable a person who had let a house in the period from 1939 up to now to have the rent revised and reduced, not increased. This unfortunate bee in the bonnet which is put forward as an argument by those who support the Amendment which we are now considering ought to be forgotten at once, because it has nothing to do with the case. 10.15 p.m. Secondly, the Rent Restrictions Acts do not include houses let at rentals below two-thirds of the rateable value of the house. I have, I hope, made myself clear on that point on many occasions, because I think that unfortunately the provisions of this Bill can be avoided by certain subterfuges which can be used in that direction. But for the purpose of this Amendment it must be made clear that if the rent was so low that it was below two-thirds of the rateable value of the house, this Amendment is not necessary, because the rent can be increased in any case.
Where the house has been let in a hurry at a nominal rent below two-thirds of the rateable value, to what can it be increased?