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National Health Service (Consultants)

Volume 884: debated on Thursday 23 January 1975

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7.57 p.m.

I am fortunate to have drawn third place in the Ballot for the Consolidated Fund debate instead of the 23rd or 33rd. It reassures one's faith in parliamentary democracy on a day when it has been somewhat tarnished.

I want to use the opportunity to raise the whole question of the rôle of private consultants and specialists in the National Health Service. The House will appreciate that this is a matter which affects many of my constituents, representing as I do central London, including Harley Street and Wimpole Street. Among my constituents are many thousands of consultants, some of whom work exclusively in the private sector and some exclusively in the public sector. The great majority work in both sectors, and many of them have written to me and seen me over the last few weeks to express their great sense of outrage at the way they are being treated by the Government. I am told that the feeling in the provinces and in hospitals in towns all over the country is even greater than is the feeling in central London.

The doctors and specialists are aggrieved because what started as a reasonable request from them for a renegotiation of the contract under which they work to take account of the fact that they do not get paid for overtime has led to a mapjor dispute in which the very existence of the part-time consultants is at stake. This is the central issue in the negotiations on this contract. The doctors—specialists and consultants—have been driven by Ministers to fight for their independence as professional men.

I begin by asking the Minister about Labour's intentions on this subject. In certain aspects of policy on the health service Labour has come clean. It has made clear its position about pay beds. The Labour Party manifesto made clear, as has the Secretary of State for Social Services, that the object is to phase out pay beds or private beds in the health service. That is a decision which I shall oppose medically and politically, but at least we know where we are.

However, in regard to the rôle of the consultant in the health service—the doctor who works both for the NHS and in private practice—Labour intentions are much vaguer. On occasions the Secretary of State and her Minister of State have said that they have no intention of abolishing the rôle of private practice in the health service. However, that is not the sort of declaration they tend to make on the platform at a Labour Party conference, although they tend to mumble that sort of obligation when meeting representatives of the medical profession.

In 1973 the Labour Party programme said that
"All new medical appointments of a consultant status will be on a full-time basis."
That expresses the real intention of this Socialist Government. They are trying to achieve the object of having consultants working either exclusively for the health service or exclusively for the private sector. In the negotiations they have been trying to achieve that object by stealth.

The situation has been made worse by the way in which it has been handled by the right hon. Lady the Secretary of State for Social Services and her Minister of State who is now present on the Government Front Bench. She seems to have pursued the object of separating the public and private health services with an intensity which I can only describe as a personal vendetta. She has a personal vendetta against private practice in the health service. This can be seen in the way in which the negotiations have been conducted.

When the Labour Government first took office, just under a year ago they set up a working committee, which was referred to as the Owen Committee. I understand from the doctors that they were making reasonable progress through the summer and autumn of last year. I gather that they were close to coming to some sort of arrangement or a compromise which would allow consultants in the health service also to work in private practice. But at some time in November or December the Secretary of State called in the papers and, having read them, obviously realised that the Owen Committee was going a little far. I understand that she published the contract before Christmas on the basis "This is what I want. It has not been agreed in the working party, but you can take it or leave it." If the Minister of State disagrees with that interpretation of events, no doubt he will say so in his reply, but that was the effect of the right hon. Lady's personal intervention, which added a degree of bitterness to the negotiations.

Before we rose for the Christmas Recess the contract was published, and the Government's view was that it was nonnegotiable. During that recess they modified their position to some extent and said that they were prepared to start talking again.

Since the hon. Gentleman is implying that my silence may be taken to be agreement, I should like to say that that is not the case and that I shall put the facts at the end. Has the hon. Gentleman read the initial proposals which were placed in the Library, not in December, but when the document was presented—namely, in October or November? The time scale would appear to be confounded by that factor.

The time scale may be confounded, but the Government's intention is in no doubt whatever. When the Owen Committee was moving towards some compromise, in which the profession was prepared to accept proposals, for political purposes the compromise was not allowed to happen.

Since Christmas the Secretary of State has said that the negotiations can recommence, but only on details and not principles. This is an absurd negotiating posture. Ultimatums are not the language of industrial relations. This raises the question: what are details and what are principles? The details of the contract are very complicated. In some cases the details are so important that they affect the original principles. Therefore, it appears to be quite unacceptable for the right hon. Lady to say that only details, not principles, can be negotiated. The whole profession—doctors and consultants—is concerned with the principle at stake. For the right hon. Lady to say, "This is not negotiable" reminds me of the comment made by Beatrice Webb at the end of her life. She was asked why her marriage with Sidney Webb has been so successful over the years, since it appeared to be a rather unlikely union. She replied, "When we got married, we decided that from that day on Sidney would decide matters of detail and I would decide matters of principle." The point was then put to her that life was not really like that and that one could not compartmentalise married life in that way. She was asked, "How did you decide the dividing line?" She replied, "The difference as to what is a matter of detail and what is a matter of principle is itself a matter of principle." That is what the Secretary of State is saying. Therefore, I urge the right hon. Lady to return to the negotiating table now without preconditions.

I want to mention three important details in the contract. First, consultants in the NHS will have to work set hours, from nine to five. Those times are specically laid down. It may be asked, "If somebody wants to work 40 hours a week as a National Health Service consultant, from nine to five, and then wants to undertake private practice, when is he to do it?" It does not take the Owen Working Party to answer that. Obviously he has to undertake that work either before 9 am or after 5 pm. That is an absurdity. Doctors in the health service run their clinics at a certain time, for the convenience not of themselves but of their patients. Therefore, for the Government to say to a consultant, "You can undertake your private work after 5 o'clock in the afternoon, or on a Saturday morning" is an absurdity.

I am sure that the Minister of State will appreciate this fact, because he has practised as a doctor—is, I understand, still a doctor, and no doubt will practise again as a doctor when he returns to Opposition. He should appreciate that as consultants go ahead in their profession not only are they involved in practising their art, they become involved in the whole paraphernalia of committee work which, in teaching hospitals in London, does not begin until 5 or 6 o'clock in the evening. A prohibition is being put on the activities of those consultants. Therefore, flexibility is essential.

My second point of detail relates to merit awards which are given to consultants, based on experience and skill. The proposal in the contract is that if the consultant wishes to work in the NHS and qualifies for a merit award, and also has a private practice, that merit award is reduced pound for pound by the level of earnings in private practice. That is unfair.

I am not saying that a consultant in the NHS who has a private practice and who has, say, a merit award of £1,000 and spends only 80 per cent. of his time in the NHS, should get the full award, but it is unfair that, compared with a consultant who wants to work 40 hours in the NHS and to do only NHS work, the consultant who wishes to work 40 hours in the NHS but, in addition, to do private work, should have a reduction of his merit award pro rata to his earnings outside. I hope that here at least there will be some give by the Government.

My final point of detail concerns the area where detail and principle come together—the pay differential for full-time service, or the "two-elevenths" as it is called. The right hon. Lady has said that this issue is non-negotiable, but of course it is, because it is at the centre of the negotiations. It is a change in the basic principle of remuneration. Up till now, if a consultant worked both for the NHS and the private sector, he was paid hourly rates on a pro rata basis. The right hon. Lady's proposals would mean, in future, that when a consultant opted for full-time NHS work he would get a premium for that, whereas a consultant who worked the same number of hours but, in addition, had a private practice, would not. This is the instrument by which the right hon. Lady seeks to make part-time consultancy unattractive. I hope that it is far from being nonnegotiable, and is put back into the centre of the discussions.

I turn now to the broad principle involved—whether there should be an element of private medicine in the NHS. That is really what it is all about. I believe that there should be such an element.

The first reason is that doctors—particularly specialists and consultants, who are highly skilled and experienced men and have a great tradition for public devotion—are not greedy. Other professional groups which have skills and arts which can be sold in the international market—airline pilots, for example—have in the past acquired negotiators who have provided them with substantial salaries and attractive working conditions. This is not the case with the doctors, and the Minister knows it. What they cherish above all is their professional independence. I believe that of all the professional groups they cherish independence more than anything else.

They fear that if they became wholly State employees they would be open to direction in a way that they would find objectionable—that they would have to conform more and to succumb to the administrative mentality. I can express this only by comparison with our own status as Members of Parliament. Consultants are being asked, "Do you want to become full-time State employees in the NHS, or not?" If it were proposed to hon. Members that they should become nine-to-five wholly-employed Members of Parliament, I would vote against it. I would do so because it would impoverish this place and be a bad day for our constituents and democracy. Over the years it would choke off a great flow of talent into the House. The doctors feel much the same way.

Does the hon. Gentleman think that the 45 per cent. of consultants who work full time, often because they have no choice because of their locality or specialty, have in any sense sacrificed their clinical independence by doing so?

I would not argue that, just as I would not argue that those among us who are full-time Members of Parliament have sacrificed their independence. But if one makes everyone conform to a pattern in such a profession, one makes it less attractive to the open-minded person. That is surely evident.

Secondly, if the Government pursue their policy they will do grave damage to the NHS. These men and women have rare skills, and already the country is suffering from an export of such talent. If the Government devise a system which will make it more difficult for these people to adjust themselves and to accommodate themselves to what we have been talking about, they are bound to seek jobs overseas. An hour's flight from here will take a specialist or consultant to Holland, Belgium or France, where he can earn, net, in real terms, three times what he is now earning here. In my constituency, a recruiting team from the Queensland medical service has been in the Middlesex Hospital for the last three weeks. In Manitoba, in 1974, more doctors who came from England went on to the register than came from the remaining provinces of Canada. This is an export of talent we can ill afford.

If the Government impose too rigid a scheme, too restrictive and too conformist, they will promote the flow of doctors away from this country. They will also promote something else. They will force doctors to move more into the private sector of medicine exclusively. I have several private hospitals and nursing homes in my constituency, and many consultants who work exclusively for the private sector. But I do not believe that the public health services of Britain should be rigidly divided into public and private sectors, because I think that it would impoverish the services in both. Separatism means duplication, a waste of resources and a lower standard in the NHS. I do not have to argue this case. It was argued much more eloquently by Aneurin Bevan, when he said many years ago, that
"If we do not permit fees in hospitals we will lose many specialists from the public hospitals for they will go to nursing homes."
The Secretary of State and the Minister of State know that to be the case.

Because of Socialist dogma and attitudes, the Government want to impose a degree of conformity upon this profession because they think that conformity is efficient and also because, in my belief, they have a sneaking softness for conformity itself, which they prefer to diversity. But the doctors and many other groups do not want it. They cherish their freedom and independence of action, which this contract would compromise. The opposition to the contract in the profession is overwhelming. In the Middlesex Hospital, a meeting of all grades of hospital staff—not just senior consultants—voted 135 to three against the contract. All the London teaching hospitals have objected to it. Doctors in the Plymouth area have said that they prefer to resign rather than sign the contract.

What the Government as a whole must learn, not only in this matter but in tax matters as well, is that one cannot impose a law upon any community of people who will not accept it. The Conservative Party has learnt that lesson. It is a very hard lesson, but we have learnt it. It should not be for me, a Tory, to lecture a Labour Government on the lesson which they have to learn now. What they have to learn in their area of social policy and tax policy is that Governments can govern only with the grain of human nature and not against it. That is the central issue in this dispute.

It is the Government who are being dogmatic and stubborn. I appeal to the Secretary of State, through the Minister of State, to return to the negotiating table with no preconditions. Let the Government put the interests of the profession and of the patient before their own prejudices.

8.20 p.m.

Like my hon. Friend the Member for Saint Marylebone (Mr. Baker), who spoke so ably, I represent what might be called a hospital city, in that hospitals are the main employers in the city of Lancaster.

For many years the National Health Service has been enjoying the benefit of a great deal of absolutely free overtime worked by consultants in every specialty and throughout the length and breadth of the land. By the terms of their contract, full-time consultants must work 11 sessions during the week. Consultants with nine-elevenths contracts must work nine out of 11 sessions. In other words, full-time consultants are committed to working morning sessions and afternoon sessions five days a week and a morning session on a Saturday, which very few other people do nowadays.

Whether consultants are full-time or part-time, they work virtually precisely the same hours—and very long ones at that. In practice, most consultants work at least double the number of hours for which they are contracted and paid, whether they are full-time or theoretically part-time. In their lunchtime they see patients. Often they are operating or seeing NHS patients well into the night and through the weekends—National Health Service patients as well as their own private patients.

The consultants do this without a penny extra in pay. Who else in this day and age would work such very long hours for no extra pay? The position of the part-time consultant—the one on the nine-elevenths contract—is even worse, because although in theory he is contracted for only nine sessions he works just as hard and just as long as the full-time consultant but receives pay for two sessions fewer than he works. Therefore, he is even more seriously underpaid than his full-time colleague. He does his private work in his very limited off-duty time.

When Aneurin Bevan set up the National Health Service he gave as one of the reasons for keeping private beds in the National Health Service that given by my hon. Friend—and also the very practical reason that if private beds were inside National Health Service hospitals consultants did not waste their time doing a great deal of road travelling. It was the best use of skilled time to have private beds in National Health Service hospitals. Therefore, a consultant doctor was more efficiently and effectively used, to the benefit of the whole service, and this was not done for the benefit of his private patients, but for the service as a whole.

In her aversion to private practice the Secretary of State is wrecking these very sensible arrangements and will oblige consultants to spend more time in transit and less attending to their patients. In the hospitals in Lancaster private patients paid no less than £26,000 in a six-month period last year. This money was used to the benefit of the service. If the Secretary of State has her way, such money will no longer be available to the service but will have to be provided by the hard-pressed taxpayer or the services will be that much worse off.

The Secretary of State has tried alternatively to persuade or to bully consultants to accept full-time contracts and do no private work. She has tried the carrot and the stick but a rather higher proportion of stick.

It passes my comprehension why the Secretary of State should be quite happy for consultants to be free to do anything they like in their spare time—gardening, even electioneering if they choose to do it, playing bridge—everything except the very thing that they have been trained to do, love to do, and want to do—their work.

Whether a consultant wishes to exercise his right to undertake private practice is obviously his affair, or it should be, but to try to dictate to doctors what they may or may not do when they are off duty seems to me as an average British person to be an intolerable intrusion into the private lives of these people and a hopeless infringement of human freedom.

I do not want to raise any difficulty or contention, but, speaking as one who is closely associated with the National Health Service, I do not think that that is what the Secretary of State is suggesting. I think that she is suggesting that a full-timer is a full-timer and nothing else and cannot take a fee from any private patient, but that a part-timer has a full-time contract in the National Health Service and can take a private patient elsewhere than in the National Health Service. That is what I understand the situation to be.

It seems to me that the Secretary of State, by giving a very much higher inducement to those in full-time employment, is gradually, by the thin end of the wedge, trying to phase private patients out of the National Health Service altogether.

It is very interesting to remark in this connection that the feeling against this sort of bludgeoning, as the doctors clearly feel it to be, is just as strong amongst consultants who are and who will remain full-time consultants in the National Health Service as it is among consultants who have a private practice. Consultants in my area come out at about 60 to 40 in the two categories. The feeling against the present contract is just as strong amongst those who are full-time as it is amongst those who are not.

An even more absurd aspect of the proposed new contract is the way it deals with distinction awards. Part-time as well as full-time consultants will be eligible for the new awards, but the whole of the consultant's private earnings will be deducted from his payment, so that literally he will be paying himself for his own skill and services. Just imagine trying that sort of thing with a miner or a docker and seeing how it goes down!

What angered the doctors most was the way in which the Secretary of State tried to force them to accept these terms when they had been negotiating for six months with the Minister of State. I gather that the hon. Gentleman had been conducting the negotiations with considerable tact and patience, and the doctors were convinced that they had nearly reached—indeed, they believed that they had reached—a verbal agreement with him on a new contract. They simply wanted it to be in writing and all, they thought, would have been well, when the right hon. Lady suddenly intervened, more or less thrust a contract under their noses and told them that vital parts of it were not negotiable but that she would graciously permit them to discuss what she called "an area of detail".

Just imagine the right hon. Lady in her days of "In Place of Strife" going to Joe Gormley or Hugh Scanlon or Jack Jones and informing them that they could discuss not their main wage claims but only the details! Would she then have described the industrial action which would inevitably have followed within minutes as "industrial backmail"? Of course she would not. Why, then, has she decided to treat the doctors in this highhanded manner?

Moreover, the consultants, in the industrial action upon which they are em- barked, have fully safeguarded the patients. They have made it clear that no patient will suffer, by dealing with emergencies and making themselves available for any treatment required outside their contracted hours, provided they are paid for the work they do. Any lengthening of the National Health Service queues is quite unnecessary, and if it occurs it will be the clear responsibility of the Secretary of State.

The consultants are fighting for a fair choice of contract to cater both for those who wish to work only for the NHS and for those who do not. The Secretary of State should stifle her invective, swallow her pride, which is fast wrecking the health service, and give the consultants and all others who work in the health service a fair deal.

I had not intended to intervene in this debate, and I shall be extremely brief since I have tabled a subject for debate later. However, I am moved to comment by the hon. Lady the Member for Lancaster (Mrs. Kellett-Bowman)—

On a point of order, Mr. Deputy Speaker. I should hate to put the hon. Gentleman in the difficult position of not being able to speak on the subject which he wishes to raise in due time because he had preempted his right to speak by speaking now. Would it be helpful if you were to guide him in this matter?

Yes. I have looked to see whether the hon. Gentleman has a subject down for discussion later. If that is the case, he cannot speak now except by leave of the House.

I am obliged to the hon. Member for Woking (Mr. Onslow). I do not ask for leave.

8.30 p.m.

I did not realise that I should be called so promptly, Mr. Deputy Speaker.

The hon. Member for Derby, North (Mr. Whitehead) said that he would be brief. He was very brief.

I congratulate my hon. Friend the Member for St. Marylebone (Mr. Baker) on his good fortune in obtaining an early place in the Ballot to raise this important subject. I declare an interest in it as a result of my association with BUPA.

I welcome, as I am sure does the whole House, the signs of greater flexibility by the Government which were amplified in the statement of the Secretary of State for Social Services on 13th January. I welcome the discussions which are taking place with, I understand, officials in the Department, and I hope that the Minister of State will be able to tell us more about them and, above all, about the timetables which are envisaged.

However, I hope that the Government realise that a great deal of damage has been done and that the consultants and other doctors strongly resent the way in which they have been dealt with and the Government's take-it-or-leave-it attitude. They feel hurt by the Government's insensitive approach. They are suspicious of the Government's motives. In a profession which is usually noted for its individualism there is a strength and unity which is unusual and which the Government would be foolish to ignore. It is clear from the surveys made by the British Medical Association and BUPA that there is a strength of feeling in the profession which is marked and which runs throughout the profession among consultants, be they part-time or full-time, and among the juniors. I hope that the Minister of State, with his medical background, and in view of the long discussions which he has had with the medical profession, realises how strong and united this feeling is.

The job pressures on the consultants are increasing all the time. The advances of medical science, the greater demands by patients and the poor working conditions in which many doctors operate are obvious examples of this. The work load far exceeds the contractual hours. The average consultant works about 35 hours a week over and above the contract, and he does it for nothing. The contract, must therefore give greater financial recognition to these growing pressures and the work load, quite apart from the adjustment required to deal with the substantial increase in the cost of living.

But there is something much more important than matters of pay, hours and working conditions, what one might call the nuts and bolts of the contract, and that is freedom—freedom to treat patients without political or bureaucratic interference, and freedom for patients to spend their own money on health if they so wish and to go to the doctor of their choice. A consultant's contract which compelled him, either directly or by financial penalties, to go wholly public or wholly private would be wrong in principle and bad in practice. It would undermine the freedom which the consultant and the patient have always had. In practice it would mean less effective use of time and of medical skills, and as a result all patients, both National Health Service and private, would suffer.

I thought that the BMA, in a note produced in January headed "Consultants Care", summarised this deep feeling on the part of the consultants when, in commenting on the contract which was offered before Christmas, it said:
"Such an unacceptable contract could force doctors either to leave the Service altogether or compel many of them, against their professional judgment, into a complete commitment to the NHS. This could in turn lead to a monopoly State service which would restrict the individual's freedom to seek medical care from the doctor of his choice and, in years to come, endanger the clinical independence of doctors which enables them to work solely in the interests of their patients."
That is a very good summary of the issue of principle which the consultants and other doctors feel is involved.

Surely we should be breaking down barriers in the health service and not making new ones. We should be forging links between all aspects of medical care and strengthening the existing ones, not breaking them.

Consultants are not only fighting their own battle and the battle of their patients. A wider issue is involved, which I thought was well illustrated in a leading article which appeared in The Times on 11th January. The article was headed "The Anger of the Middle Class". Having dealt with the pressure to which all sections of the community are subject these days, it went on—and this illustrates the wider theme—to say:
"Many people in the middle class feel all the resentment and anxiety of being boxed in. The doctors, who know that they would be earning several times as much in almost any comparable country and find private wards being closed because, on ideological grounds, the cleaners refuse to clean them, are the group who are nearest to action. Mrs. Castle seems to be intent on making the same misjudgment of their mood that Mr. Heath made of the miners. In their sense of social usefulness, their unity and now their indignation, the doctors are the miners of the middle class."
I am not sure whether the consultants would accept that definition. I do not agree with all the analogies there. There is a very real sense of being boxed in which is perhaps most graphically expressed in the present conflict and which is also felt amongst other sections of the community. Therefore, this matter is of greater significance than just the aspect which we are discussing.

In my judgment, the onus is on the Government to undo the damage fast, to restore the confidence of the consultants, to negotiate an agreement with them, and not to try to dictate to an honourable and dedicated profession.

8.40 p.m.

It was not my intention to intervene in this debate—in fact, I hope in a very short space of time to be returning to the deliberations of the Committee sitting upstairs—but it is a welcome relief from the intricacies of the Finance Bill.

I intervene only to draw attention to the considerable amount of mythology which is growing up in the dispute between the consultants and my right hon. Friend the Secretary of State for Social Services. To hear people talk, one would imagine that the whole trouble started when this Government came to office and that it started principally because my right hon. Friend heads the Department of Health and Social Security.

In fact, of course, the trouble started back in 1972 when the consultants were fuming and threatening industrial action. In the event, they did not take industrial action. But they had no redress from the then Government. Eventually they came round to asking for a working party to be set up to discuss their pay and conditions. The then Secretary of State decided to wait until the following administration took office.

That was in February 1974. The next administration took office and immediately got down to the job of looking at the salaries and conditions of the con- sultants. A working party was set up. It worked fairly rapidly, and even more rapidly at the insistence of the consultants when they again threatened to take industrial action.

The mythology to which I refer is that arising from the charge that my right hon. Friend acted in bad faith and completely ignored the consultants. It reached the point where a final decision was to be made by the consultative committee. The meeting was fixed for 12th December. However, just before the meeting, further demands were made by the consultatnts, which could not be met singly by the Secretary of State, who made it clear that this would have to be a Government decision. Accordingly, the meeting was postponed until 20th December.

Then it was said—and here again I refer to the mythology—that my right hon. Friend had acted in bad faith by not turning up at the meeting on 12th December and by ignoring the consultants. This is patently untrue.

It is fair to say that when the Government decision was taken and the report was issued the consultants did not have a great deal of time in which to consider it. It was in their hands only about 24 hours before the meeting on 20th December which finally brought about the break down in the service.

The hon. Gentleman is giving what passes to be an authoritative account, and he is attempting to demolish a number of myths. He has referred to a period of 24 hours. Does he know it was as long as that?

Only recently I met consultants in my district who authenticated this. I agreed that there was not a lot of time, but they had the answer in the meeting on 20th December. Something more than simply pay and conditions is involved: to my suspicious mind there seems to be a political element.

There is a malaise in the health service, and the doctors have complaints, but in this instance the consultants are very much on their own. They are making contradictory claims—for example, about the closed contract. On the one hand they say "We do not want to work 9 to 5, five days a week like other workers." On the other hand they say "After a certain point, we must get overtime." Without prescribed hours, how does one calculate overtime?

There should be some flexibility, of course. A surgeon might work late into the night, and if he has little to do in the morning, why should he come in at 9 o'clock? The accusation is made that it was a take-it-or-leave-it arrangement. That is not true; everything was negotiable—

Well, that is my reading of the matter. The Minister has made it clear that she was prepared to negotiate the arrangements. I am sure that that is the situation now.

I was appalled at that meeting by the complacency of these consultants, these men who had taken the Hippocratic oath, who said that the longer it went on—

I have here the Hansard containing the Minister's statement on 13th January. In column 34 she said that certain principles were not negotiable, only certain areas of detail.

Certain factors were not negotiable, but I am sure flexibility on hours was. I was appalled to hear consultants saying "We are beginning to like this sort of leisurely doctor-patient relationship—never mind the people waiting urgently to see us". That comes ill from such people who had previously condemned others in the health service who had been fighting for a living wage.

8.49 p.m.

As one who represents a constituency in which many doctors and consultants live and which also includes two major hospitals, I think that it is my duty to reflect their attitude to these proposals. The hon. Member for St. Marylebone (Mr. Baker) introduced the debate so ably and comprehensively that I need not detain the House for long.

Three points need re-emphasising, even after the very able contributions to the debate which have been made by Opposition Members. The first point is the intransigence of the Secretary of State concerning these proposals. The hon. Member for Lancaster (Mrs. Kellett- Bowman) has indicated quite accurately the Secretary of State's attitude, and the consultants' joint working party has made the Secretary of State's obstinacy very well known indeed. It is deeply regrettable that an issue of this importance should be in some way jeopardised by the Secretary of State's unforgivable attitude.

The second point is that in this issue we have another example and expression of the present Government's attitude to State control. They are attempting to force men who need individuality, and who need to express themselves in an individualistic way, into some kind of stereotyped mould, which just will not serve the nation as the consultants ought to do.

The third point is that we have an exceedingly serious drain away from the profession. In my constituency there is great concern about appointments which have been made and some which ale due to be made. I do not wish the House to misunderstand what I am about to say. I certainly do not intend to introduce a racialist note into the debate. However, the fact is that because we are losing many of our most able consultants to other countries—and not all to underdeveloped countries; I shall come to that point shortly—we are having to rely on appointing to very important positions men who would not have had such appointments some years ago. The choice, the degree and comprehensiveness of selection, does not obtain as it did some years ago. That reflects on the quality of service and work offered to the whole community.

This is a very serious and important point. It also has a converse side, which is that the countries of origin of many doctors and consultants who are trained in Britain—countries which would benefit immensely from their skill and dedication—are being deprived of their skilled contribution because of the incentive to stay in this country. We owe the underdevelopment countries the right to develop their health services. We do not help them in that respect by making it almost impossible for our best doctors and consultants to remain and to function in this country.

There are many other things I should like to say, but most have been stated already and I shall not reiterate them now. However, I again urge the Secretary of State, through the Minister of State, to think again concerning her intransigence and to meet these men as they seek to acquire a just settlement of the dispute.

I have been assured by the consultants to whom I have spoken that they are deeply embarrassed by the present dispute. I think that they would be the first to admit that they are very poor negotiators. They are not used to this kind of argy-bargy or cut-and-thrust. During their negotiations they feel themselves to be at the mercy of a very expert, very ruthless and certainly a very vitriolic Secretary of State. I have their assurance that these men, who certainly exercise a tremendous degree of dedication to society, would not in any circumstances be prepared to let society down over an issue like pay beds. Although it is a related issue it is one on which those of whom I have spoken would not be prepared to strike. Where principles are concerned, however, particularly those enumerated by my hon. Friend the Member for St. Marylebone (Mr. Baker) it is quite a different matter. It is our hope and prayer that we would not force the hand of these well-intentioned and very able citizens.

8.56 p.m.

I add my congratulations to those which other speakers have already tendered to my hon. Friend the Member for St. Marylebone (Mr. Baker) on his good fortune in the Ballot and the good use he has made of it. We have had a valuable debate. I hope the Minister's contribution will make it yet more valuable. We are dealing with a highly topical and most important matter, and the House could not possibly be accused of having wasted its time in spending an hour or so on it this evening.

There was a remarkable degree of unanimity in the contributions which were made, with the exception of that by the hon. Member for Ilford, South (Mr. Shaw) whom I am sorry to see has now left us. He will have to read in Hansard what I would have been prepared to say to his face, which is that the only effect of his intervention this evening has been to cast grave doubts on the value of his contributions to the Finance Bill Committee. With that exception, everyone who has taken part in the debate has fixed the attention of the House on the real issues, and I hope briefly to add a little more to what has been said about them.

As I understand it, the situation now is that talks about talks are restarting tomorrow, if they have not actually restarted today. I hope that the two parties will find a way of getting serious negotiations going again, because this dispute has done no good for the health service, and in certain respects it has already done damage, which will be difficult ever to repair. For instance, there has been—this is unfortunate—an upsurge of ill-feeling between the doctors and some of the ancillary staffs in the way in which some of the latter have reacted, by breaching their own contracts in reaction to the consultants' decision to work to contract. This is bound to leave an unfortunate legacy.

The pressure created by the action has also served to highlight some of the deficiencies which have for long existed in the health service. I believe that the public have begun to understand how far the service has relied on unpaid overtime from its staff. Not only the doctors but nurses and others have been working long hours without adequate remuneration, and anyone who has been concerned with these matters in the past must accept a share of the responsibility. It would be well to remember the recent statement by the Secretary of State in which she made plain that there is little likelihood of finding a considerable increase in resources to put right some of the deficiencies which we see so clearly. It therefore behoves us to be even more careful about how we tackle the present stresses and strains on the health service. I hope that the Minister will give us evidence of his awareness of that fact.

In many ways the consultants can be said to have acted in a responsible and restrained way, even though they have been driven to this difficult pass. If the Minister does not think that it is responsible for them to have elected to give priority to emergency cases, to ensure that the emergency cases receive highest priority and treatment, perhaps he will say so. If he thinks that working strictly to contract is irresponsible, when the consultants have been instructed to work as required under contract and for the hours upon which their remuneration is based, let him say so. But if he believes that the action which the consultants have taken is irresponsible and unrestrained, then the chances of the two sides getting together must be smaller than ever.

I hope that the Minister will be restrained and responsible in his approach to this difficult matter. The talks about talks are I think, based on the presumption, on the consultants' side that if there is evidence of a real change in the situation—if the atmosphere is different, and if the most objectionable proposals are withdrawn, there is every likelihood that their members would be prepared to resume their normal schedules of work. That must surely be the objective to which the Minister is first and foremost dedicated.

I hope that in the Minister's approach to the talks he is ready to say to the consultants either that their reactions are mistaken, and patiently to persuade them, or to understand their objections and to show flexibility and a willingness to go as far as need be, consistent with what the Minister thinks to be the essential principles at stake, to meet them.

It may help the Minister and the House if I identify some of the proposals in the paper of 20th December which the consultants seem to find most objectionable. The first, in order of appearance in the paper, was the insistence that the Department's agreement was available only on the basis that the new contract was taken as a whole. It is that statement which is the basis of the accusation, in the leaflet headed "Consultants Care", that it was a "take it or leave it" situation. It may be that there was a certain carelessness or rigidity in the phrasing If so, I hope that the Minister will say so. Other proposals in the paper have aroused strong objection on the side of the BMA and the HCSA. For example, though this may seem a trivial matter, the new standard contract required that a doctor should be in hospital from 9 a.m. to 5 p.m., including meal times. He was not even allowed to go home for lunch. It would seem an unnecessary provocation if that were rigidly insisted upon.

There was concern about the effect of the proposals on the differential and about the way in which they would favour the man who opted for option B. There was a stipulation that a consultant who agreed to take a full-time contract would have to undertake to work extra sessions as an indefinite commitment. He would be tying himself to compulsory overtime on a continuing basis. If the Minister thinks that that is justifiable, the House will be interested to have his explanation.

There are other features upon which I could spend time but I do not want to delay the House unduly. I shall merely refer to three points which are worthy of mention. First, it was stipulated that the consultants who elected to retain their existing contracts would in so doing retain their existing merit awards. As the proposal appears to be drafted there would be no opportunity for them to move to a higher grade of award. In other words, election to remain on the old contract would carry with it the freezing of award levels.

Second, the provisions on the career supplement relating to earnings from private practice would have had the effect that the doctors most successful in private practice, and, by presumption, the most successful and able in their speciality, would forfeit the career supplement even though the contribution which their skills make to the NHS must be among the most valuable of any.

Third, for some curious and unexplained reason, the limited session contract for disabled doctors or married women unable to work full time carried with it a stipulation that no private practice would be allowed to anyone taking a contract of that kind.

In running through the provisions the House may have detected—certainly, in the exchanges which have taken place in the past it has been evident—that this Government, seem to have a phobia about private practice. I very much hope that the Minister, even if he thinks that that is an unrealistic attitude on the part of the consultants and even if he is persuaded that they are entirely wrong in the belief, will take some pains to explain precisely why those who believe that he and his right hon. Friend have a phobia about private practice are, in fact, mistaken.

We must accept that on the face of it there is a fairly wide gap between the Minister and the doctors. The solidarity of the doctors, as my hon. Friend the Member for Somerset, North (Mr. Dean) has pointed out, is one remarkable feature of this unhappy situation. But how does it look to the Minister? I hope that he will not mind if, in an attempt to analyse the situation, I refer to a letter which he recently sent to my hon. Friend the Member for Wallasey (Mrs. Chalker). My hon. Friend has kindly let me see a copy of the letter. If the Minister has no objection I shall quote one or two passages. If he objects I shall not do so, as I accept that I have given him no warning.

I am grateful to have the Minister's agreement. In his letter he says that he believes

"that there are many, many misunderstandings about the present consultants' contract that can only be developed in further negotiations. We have never tried to insist on everyone becoming whole-time and if you study the proposals I think you will agree that it represents a broadly fair package of measures'.
In the next paragraph the Minister sets out the points of dispute as he sees them. The paragraph begins:
"The points of dispute are that the BMA want the Government to give up the long standing 18 per cent. differential that has existed between the whole-timer and the maximum part-timer. This we are not prepared to do."
The Minister then lists his reasons. It may be that he will go through them tonight, so I shall not take time to read them to the House. He ends the paragraph by saying that
"Apart from that 18 per cent. differential, the only way that we would be changing the position of the balance between whole and part-timers would be in the suggestion that the career structure supplements, which were put forward to replace the present distinction award system, would be subject to an offset arrangement whereby you would take account of private practice earnings. This, though controversial, has some positive merit; but the Government has been careful to say that this is not a principle on which it is not prepared to negotiate. We are certainly prepared to discuss the method of payment."
That seems to be a step forward and, if I may say so, without in any sense being patronising towards the Minister, a step in the right direction. But if the paragraph to which I have referred summarises all the areas in which he sees himself as being in dispute with the consultants, I must tell the hon. Gentleman that, from what I know of the consultants' side, he does not seem to have hoisted in sufficiently the extent to which they see his actions and the statements of his right hon. Friend as presenting an almost vindictive attitude towards private practice. This appears consistently in the proposals that I have mentioned.

It is encouraging to note that in this letter the Minister says
"Admittedly the meeting on our proposed contract could and should have indicated that there was a little more flexibility than might appear."
It is good to have the admission that that is so, because it shows that there is some willingness on the hon. Gentleman's part to say that this is not a "take it or leave it" situation. He seems to be saying that the Government are prepared to sit round the table and talk about this. It seems to imply that one and a half hours was not sufficient time during which to examine the document.

I am not trying to lead the hon. Gentleman into criticisms, implicit or otherwise, of his right hon. Friend. I am hoping to give him some suggestions as to how he can make the most of the opportunity, which we all want to see developed to the best advantage. At the top of the next page of this letter he comes to the nub of the matter because, with devastating frankness the hon. Gentleman says:
"The medical profession is traditionally almost impossible to negotiate with."
The hon. Gentleman should know. I do not know why this is so—whether it is because those in the profession are desperately bad negotiators, which I guess he did not mean, or because they are quite tough negotiators. If that is the case I can tell him that the BMA would be glad to have that testimonial, since it would do much to reconcile some of those in its ranks who feel that it has not been sufficiently tough. The hon. Gentleman may think that the profession is not skilled in this business of negotiation—that it is not a professional negotiator. If that is what he means, perhaps it is fair enough.

I do not believe that doctors need to be trained—so far—in the art of negotiation before they are let loose, if that is the correct phrase, upon the public. But if the Minister recognises that the profession is almost impossible to negotiate with, it is most inept that his right hon. Friend should have been so insensitive as to provoke and exacerbate the situation by her attitude towards pay beds in particular and private medicine in general.

After all, this is a contract which has its roots in 1948. It is based on the presumption that people want to work a five-and-a-half day week. The 11-session contract presupposes Saturday morning work. I do not believe that that is generally known. If it is, I do not believe that it is generally supported in current social conditions. On this, at least, if people understood the position, they would have great sympathy with the doctors and all those who have to work for them on a Saturday morning, under a contract long since out of date. That makes it all the more unfortunate that the hon. Gentleman and his right hon. Friend should say that if the doctors do not like the new contract they can always go back to the existing one. That is adding insult to injury.

I realise that it is difficult to be brief when dealing with this subject, but there is one further argument that I want to put in some detail. Why does it matter to the general public that the case of the doctors should receive the most sympathetic consideration possible? Naturally it matters to the doctors. We have their testimony, and we can see by their actions and hear by their words that they care deeply. But why does it matter so much to us—the general public? There are some important reasons which go beyond that connected with our immediate reaction, which conjures up the possibility of emigration. That is an obvious danger. My hon. Friend the Member for St. Marylebone (Mr. Baker) mentioned the existence of overseas recruiting teams. Perhaps the most instinctive reaction of anyone who considers the situation is that we shall be left with no doctors. But if we were left with doctors who had no independence, what would be the consequences?

First, we should lose the check which private practice provides on the performance of the National Health Service. I do not know whether the Minister, when he was in practice in the NHS, was ever asked by a patient for a second opinion. I suspect that a doctor in the NHS who is asked by a patient to obtain a second opinion is unlikely to be wholly sympathetic, on the grounds that if he had thought a second opinion necessary he would already have arranged for it, so the patient does not have freedom of choice in that situation, and if there is no private practice the patient cannot go outside to seek a second opinion on his or her own initiative.

I speak here on a personal point. If private practice is stifled, the spur to progress which it provides will be lost to the NHS, and a great many people will suffer thereby. One of these days, when I get the time, I shall need to go to a doctor and ask him to be kind enough to give me a new hip joint. The fact that I am able to do that inside or outside the NHS stems from the fact that one brilliant surgeon, working in the private sector as well as in the NHS, drawing upon private patients in larger number than could ever have been referred to him within his own hospital area, was able to develop a technique which has been applied more widely and brought relief to large numbers of people who would otherwise have ended their days sitting in a wheelchair.

That kind of spur to medical advance would not survive without the ability of people constantly to demand better medicine and to urge doctors to raise their standards and their sights, because they would be at the mercy of medical bureaucrats and tied down by the financial limitations of the hospital administrators.

Finally, and perhaps most important, we need to recognise that the hospital service sets out to cure but not to care. In certain situations the NHS, in effect, says to a patient, "We can do no more for you". I have had personal knowledge of this in recent months. Given that that is so, and given that the resources to alter that position are not there, it is essential that private practice and private medicine should be available to take over where the NHS leaves off. People who want to provide for themselves from their own resources, or to provide for others by means of charity from their own resources, will then know that the medical skills of the consultants who are essential in this area will be there, and they will be confident of getting the kind of care and attention to which they are entitled.

It may be difficult for Labour Party conferences to understand that. It may be difficult for Socialists to accept that there are, inevitably, inadequacies in the NHS, and that when they occur it is right for people themselves to seek to meet the need and for the doctors to be there to help them to do so.

I hope that the Minister will not misunderstand me when I say that the doctors feel themselves to be left out of the social contract and to be part of an important element in our society which is not being given its due.

The negotiations, to which the Minister is, I hope, honestly committed and in which I hope he will work towards success, turn as much on his understanding of that point as on the fact that he needs consent if he is to have a National Health Service worthy of the name. He needs the consent of the consultants. I hope that no personal dogma or political prejudice will stop him seeking that consent. I do not doubt that the consultants are prepared to respond as far as they can.

9.20 p.m.

This has been an interesting debate. I do not wish to go too much into the philosophy and principles of private practice because we shall probably wish to spend most of our time in this debate concentrating on the consultants.

In response to the remarks made by the hon. Member for Woking (Mr. Onslow), I should like to say that my political philosophy, and, indeed, the policy of my party, aims at widening the area of consent and, indeed, extending it. Indeed, one of the papers which were put to the working party about the philosophy in a democratic State over private practice said that it should be clearly demonstrated that the adverse effects to society of failing to restrict individual freedom are such as to outweigh decisively the disadvantages of restrictions, and that there is a predisposition in favour of individual freedom. That document was presented to the working party before the General Election and subsequently published.

If we go on to question the problem of why the controversy over private medicine exists, we are bound to say that the experience in the National Health Service is that the general public have begun to recognise that no system of health care will ever be able to provide wholly adequate resources. Some degree of rationing is now seen to be inevitable and this realisation, instead of damping down the controversy over private medicine has tended to emphasise it. People realise that there will always be unsatisfied demand, so they question whether rationing of scarce skills can be justified other than on the basis of need.

If society decides, as it did in 1946, that its national pattern of health care should be organised on the basis of need, inevitably it will question the justification of a health care system organised on the basis of ability to pay. There is inevitably additional controversy if an alternative minority health care system based on ability to pay not only exists but operates within, and is tied to, the public system, organised on the basis of need. That is why the Government have come to a policy of separation. That is why there is a controversy on which there is more than one view, and I ask the House to recognise that this is a controversy which now exists within the health service. Any Government would face the prospect of dealing with it.

There are two other points I wish to make at the outset. I believe that it is possible to have a second opinion within the National Health Service. Many full-timers encourage second opinions. It may have to be decided whether a second, third or fourth opinion is required, and, in my experience, many patients are referred to other centres of excellence for a second opinion.

I was not casting doubt on the willingness of doctors spontaneously to refer for second opinions. I was seeking to ask what would happen if the patient sought a second opinion and the sort of response he would be likely to get.

My experience is that most general practitioners, if asked for a second opinion, are only too happy for that to be done and agree that degree of choice is an important part of the health service.

In my reply, I am taking what I am sure is the basic view of the House—a wish to see a settlement of the dispute. It is sad for me, as a doctor, to see a situation where, since 2nd January, a section of the medical profession has been taking industrial action. But I must say to the hon. Member for Woking that I hope that it is not the considered view of the Opposition that the consultants have acted with responsibility and restraint. I take a different view, quoted from The Times of 3rd January. It said of the industrial action:
"As an exercise in industrial pressure, the campaign has a fair chance of success if a large number of doctors are prepared to persist in it. But it does not deserve to succeed, not at least if its targets are those proclaimed by the leaders of the British Medical Association and the Hospital Consultants and Specialists Association."
It went on:
"… the proposals are in truth not out of reach of what most doctors would accept. With a softening of the (broadly desirable) service supplement proposals, a modification of the rule about taking meals on the hospital premises, and with less passion in the air, the plan might appear in a very different light."
At least we have the right to expect that the Opposition would not seemingly almost support industrial action which can, and has in some cases, damaged patient care.

It is in an attempt to try to resolve the dispute that we must approach the situation. Hon. Members have mentioned private practice as being an element in it. I quote again The Times. In a leader on the grievances of the consultants, it said:
"It is possible to hold, without inconsistency, that the proposals are within reach of reconcilement with the interests of the profession and the health service, while also believing that the present relationship between private and public medicine is broadly beneficial to both sides."
It is against the background of such quotations that we should look at the issue more dispassionately than has been done so far in the debate. It is striking that, throughout the dispute, with the objective case which needs to be argued and on which the medical profession has taken precipitate industrial action, it has not been able to persuade many people outside the profession of the total validity of its claim and of the need to take industrial action. I have quoted from The Times. I could have quoted also from The Guardian, from the Observer, from the Financial Times and from the Economist. Of course, opposing views have been expressed—the Daily Telegraph and the Daily Mail would be two examples. [HON. MEMBERS: "The Sun."] Many of the Sun's comments have tried to personalise the issue. I say, therefore, both to doctors and to hon. Members, that if they consider the difficulties with which my right hon. Friend has been faced since she took office last March they will realise that they owe a great debt to her for what she has done for the National Health Service.

Ever since we took office last year, we have faced unprecedented problems of industrial relations. We faced difficulties with the nurses, the ancillary workers, the technicians, the works engineers and the hospital pharmacists. My right hon. Friend inherited a whole legacy of problems, mainly of pay. Many of these have now been resolved, I am thankful to say, and many are in process of being resolved. I believe that the dispute with the consultants is equally capable of resolution. Unfortunately, it is a very complex issue, but I do not want to go too much into the background and the legacy we had.

Completely absent, so far, from the comments of the Opposition is any indication of whether they support the differential pay which has been given to the whole-timers ever since 1948. In their comments, the right hon. and learned Member for Surrey, East (Sir G. Howe) and the hon. Member for Woking have concentrated on the career structure supplements. It would be helpful to know, in this dispute, whether they support the Government in their belief that it is right to maintain the two-elevenths differential, which has broadly stayed in existence since 1948. Do the Opposition agree that the doctors, by putting this factor as one of the major planks in their negotiations, have been wrong to try to change the differential? If the doctors would at least concede that—it is hard to see a single major concession by the profession's negotiators to date—the chances would be greatly increased of finding a resolution to the problem. There is a peculiar and particular reason why this should be done. This dispute has gone on for some time. In July 1972 the BMA submitted to the then Government its proposals for a new contract. In its proposals the association made clear that all consultants should be permitted to engage in private practice consistent with their contractual obligations—that is, they wanted the differential and the ban on whole-timers engaging in private practice to be removed.

Discussions proceeded between the profession and the Department from July 1972 until October 1973. They made little headway. No conclusions were reached. In October 1973 the profession indicated that the contract claim details I mentioned should be laid on one side and that it wished to submit a claim which took full advantage of the then existing Pay Code.

In January 1974 the profession asked the then Secretary of State for the establishment of a working party to consider consultants' contracts. The profession was told that the request would be dealt with by the incoming Government.

In early March my right hon. Friend the Secretary of State announced in a speech on the Address in reply to the Gracious Speech that she had agreed to meet the request of the profession to set up a joint working party, which was to be chaired by myself.

The request for a major change came from the profession. We have constantly reiterated that it is not the Government who are seeking to impose a new contract on the profession. Quite the contrary, it is the profession that came to the Government. It is the profession that asked for a closed contract. I believe that some of the requests for a closed contract were made without full recognition of what this sort of contract involves.

I am anxious to know whether the hon. Gentleman will tell me that he supports the two-elevenths differential.

I was hoping that the hon. Gentleman would give me an opportunity to reply on that point. It is clear that there must be a distinction between those who work full-time and those who work part-time.

What seems to me to be most extraordinary—it is understandable that the consultants should find it extraordinary, because it is a new element injected into the situation since they first came forward and asked for a review of the contract—is this obsession with separation. That is a deliberate act of policy to which the. Minister of State has committed himself tonight. If only he would show some signs of being prepared to accept reality and would moderate his dogmatic views, it might be possible for a workable solution to be found to the differences which there must be between a full-timer and a part-timer.

The hon. Gentleman has intervened to say precisely nothing, so the House is no closer to knowing whether he and his right hon. and learned Friend support the existence of the differential, which they supported all the time they were in Government between 1948 and 1974. The question is whether they support it now. It would help the resolution of this dispute if they were to make their views quite clear on this issue. To introduce the question of separation of private practice into what is a discussion about the contract seems to me to have evaded the issue.

The hon. Gentleman spoke for long enough but did not introduce much light into the discussion.

The question I was dealing with was the question of what are the implications of a closed contract. This is a serious issue. Broadly speaking, the professions have adopted the attitude that there are no fixed hours for their professions. They work long hours. They get higher pay than most people on fixed closed contracts perhaps. That is part of professional status.

With that has gone considerable freedom to choose their hours. The Times had this to say—
"The first is the humiliating proposal that men of distinction should have in effect to clock in and out of hospital. This requirement arises, however, almost inevitably from the professions' own insistence on a 'closed' contract with extra pay for work outside the sessional hours."
Whatever we say or do about the hours of nine to five, the proposals had actually said that "normally from nine till five"—but I am perfectly willing to concede that there should be greater flexibility about this; it was never meant to be a rigid implication—was to be one aspect of the closed contract. [Interruption.] No, it was not. Everyone knows that there are some times, quite properly, when it is of considerable advantage to have sessions out of closed hours. Paediatricians and venerealogists work very different hours. We must try to give a broad outline. Basically, if one goes for additional sessions—for payment out of hours, for emergency payments—some degree of definition becomes absolutely inevitable and implicit in the request for a closed contract. Many of those in the profession had not recognised the inevitability of that—in effect—restriction in order to gain the other advantages which they wanted of a more work-load sensitive contract.

The question of the definition of the session needs further discussion. It was our intention not to specify where a consultant has lunch but simply to get across the point, which should not be too controversial, that under a contract of the type which the profession negotiated there must be a clearer definition than there is at present if the system for paying extra remuneration is to be fair.

I shall not deal with the question of the differential. A number of comments have been made about the proposed career structure supplements. These have been warmly welcomed by many people who find the existing distinction award system in need of change. The profession has many views about this system. Our proposals are an attempt to spread the money for the distinction award system more evenly through the country and to be a bit more sensitive to some of the specialties which perhaps do not have any private practice. This is an important element, when we consider why the Spens Committee first introduced the whole concept of distinction awards. But our proposals are in many ways a novel concept, and that is why discussion of all the details and methods of application will be needed. They have not been discussed as fully as they should have been.

The principle of the service supplement is that it should provide financial recognition for special efforts to maintain or develop National Health Service services, particularly in situations which are specially burdensome or difficult. As the Secretary of State said in her statement in the House, it should be possible to negotiate criteria and methods of payment for these supplements which are both right for the health service and fair to consultants.

The question of payment for on-call has been raised. This is extremely difficult. When it was first discussed in the joint working party, we argued and hoped that payment for emergency visits on a fee basis, which is a new provision, would recognise, to some extent, the unsocial hours responsibility of consultants without payment for on-call as such. We anticipated that the visit fee might be priced accordingly.

We are prepared to consider any proposals made for the remuneration of on-call as such, but it is fair to say that there are difficulties of definition in a system which ensures that the cost of such remuneration is not out of proportion to the cost of consultants' remuneration generally. The hon. Member for St. Marylebone (Mr. Baker), who has considerable interest and concern in this matter, knows from his experience with the Civil Service how repercussive on-call arrangements might well be. We cannot look at any contract, which will be for the future—many people will decide to stay on their existing contract—without taking into account the implications for many other people in other jobs.

It is difficult to argue whether these are points of detail or of principle, but it would be wrong to mislead the House by saying that there are not considerable practical difficulties about payment for on-call.

Other points were raised concerning the extra session and the overload situation. I sometimes wonder whether hon. Members understand the peculiar way under which the whole-time and maximum parttime contracts have come about. The evidence suggests that the hours worked by maximum part-timers are similar to those worked by whole-timers. In any event that is expected, since under the terms of the agreement reached between the then Minister of Health and the profession, candidates are not allowed to specify in advance of appointment whether they would prefer to be whole-timers or maximum part-timers. Under the terms of the agreement, where an employing authority decides that the needs of the hospital service demand a whole-time appointment, the competition should be thrown open to all applicants who are prepared to give substantially the whole of their time to the post, whether they prefer a whole-time or a maximum part-time contract. In such a case the successful candidate should not be asked to state his preference until after he had been selected for appointment.

The commitment between a whole-timer and a maximum part-timer is important to the employing authority—I am sure the profession would wish to keep this in any new contract—if the decision whether to go whole-time or maximum part-time is not made until after the appointment has been decided.

I have dealt with some of the detailed proposals. There is room for considerable negotiation on many of those aspects. However, I wish to draw attention to the extent to which the Government have already compromised their proposals. If we compare the proposals put to the working party in October, which were then published, because of the heated reaction of the profession and the proposals published late in December it is clear that the Government considerably modified their proposals to try to understand the profession's viewpoint. In the October proposals the career structure supplements were not going across the board and were confined to whole-timers. When the case was put that there were many part-timers with small private practice earnings who would feel this to be very discriminatory, there then arose the suggestion of the offset which has caused a great deal of criticism, although there is some positive merit in the system and in retaining the money within the Health Service. This was an attempt to meet genuine objections made by the profession.

The working party worked for the last few weeks almost under the constant threat of sanctions from a profession which had started to ask its people to sign on with employment agencies, which seemed to want a confrontation, and which pushed the Government into producing proposals in a rapid space of time.

I say to the profession that now is the time to think carefully before continuing with industrial action. It should come back to the negotiating table, remove the sanctions and enable us to agree to a pricing of the existing contract for implementation as soon after 1st April as is humanly possible, which is what the general practitioners and the junior hospital doctors want. We can hopefully negotiate a new contract which will meet many of their demands and make the modifications and changes necessary to the proposals put to them on 20th December.

The Government have exceptionally agreed to price the proposed new contract before the agreement is made, which I think allows the profession to see both the new and the old contracts. The Government is not imposing a contract.

The hon. Gentleman said that there is considerably more give and take in the Government's attitude than there was in December. This is not a debating point. He has asked the medical profession to return to the negotiating table. He has indicated some of the areas of important details where there can be further discussions. Will the hon. Gentleman undertake, on behalf of the Government, to return to the negotiating table and meet the request I made earlier, namely, that the Government should be prepared to negotiate on the underlying principles of this contract? It is not just a matter of details. There are important principles in this contract, of which the Minister is aware.

The Government made clear their view about the existing differential between the whole-timers and the part-timers. That is a principle to which they attach considerable importance.

The other aspects where principle and detail merge need to be discussed in negotiations. My plea to the profession is to take off the call for industrial action and to negotiate in an atmosphere which is conducive to settlement. We are discussing neither pay nor an existing contract. This is a strange industrial dispute, not about pay or an existing contract—because there is an existing contract—but about a future contract. The negotiators would serve the interests of their members now if they called off sanctions and negotiated a new contract to be priced by the review body before the profession needs to make a final decision whether to accept it.