§ Motion made, and Question proposed, That this House do now adjourn.—[Mr. Oakshott.]
§ 9.50 p.m.
§ Mrs. Eirene White (Flint, East)
I wish to raise a subject which I touched upon on 20th February in a Parliamentary Question addressed to the Parliamentary Secretary to the Ministry of Health, concerning the position of doctors who are reported to the Medical Service Committee and are subjected to censure by their executive committee for some action which is not, I would emphasise, a matter of their work as medical persons and which does not involve the doctor-patient relationship.
I asked the Question because the matter had been brought to my notice through a report in the public Press that two doctors in Flintshire had been censured by the Flintshire Executive Council for carelessness. I do not think there was any question of actual dishonesty, to judge by the report, but only of negligence in making their claims for payment under the mileage scheme. The sums involved amounted between them to more than £7,000. The doctors were partners. In one case the sum involved was £3,831 and in the second case £3,667. There was a third partner who had overclaimed only 1s. 5d., but in the other cases considerable sums were involved.
There were three cases or even more. I was acquainted with the details of at least one other case in similar circumstances in which a claim had been made for mileage payments in excess of what was considered proper. In that case it was nearly £3,000, as far as I could make out. So there have been at least three cases and possibly more.
The reason I am raising this matter is not to go into the details of these cases. I understand that the ones mentioned to the public in December are subject to appeal, so I would wish not to go into detail upon them. The point is that when this report was issued to the public, following the meeting of the Executive Council, the names of the three doctors were withheld, although the other details 958 were given to the Press. On inquiry, I found that this practice was fully in accordance with recommendations made in a circular ETL.248, dated 19th December, 1949, concerning the proper procedure for publicity. It was addressed to the clerks of the executive councils.
This is a most peculiar circular, and in these disciplinary matters it makes no distinction between different types of offence. I should wish to make a clear distinction between offences which concerned the treatment by doctors of patients and offences which concerned doctors in relation to such things as public funds, whether from the Treasury or whether from a pool affecting payment made to other doctors in the area. No such distinction is made in the circular, which simply says that when the report of the Service Committee to the Executive Council has been accepted and a decision has been reachedthe Press should normally be admitted and told of the decision.It goes on:The Minister suggests that it might be convenient if the Council were to publish a summary of the case as presented by the Service Committee, and of their findings.Here is the summary of the case given to the Press in Flintshire. It consists of four pages and goes into considerable detail. I have it by the courtesy of the Chairman of the Executive Committee. I am a little surprised that it is sent to me marked "Confidential," as I am informed in a letter from the clerk that it was in fact handed to the Press. In the succeeding paragraph of this circular, it goes on to say:In due course the Council is notified of the decision. In the Minister's view it is open to the Council at that stage—and in serious cases it would be desirable—to give further publicity. This might be done by way of publishing a summary of the case (if a summary had previously been published a shorter summary should suffice) together with a report of the Minister's decision.Therefore, publicity is positively encouraged. But then in the final paragraph of the circular it is said:At no stage should mention be made of the names of the parties to the proceedings or of other particulars which might lead to their identification.Accordingly, in the report which I have and which is the one which was given to the Press, the doctors concerned are called 959 Dr. A. and Dr. B and their places of residence are concealed as X, Y, Z and I think there was a W as well.
The public is given information not merely as to the formal findings, but if a newspaper editor thinks it is of sufficient interest to the public, very full particulars indeed are given of the charges brought against the doctors concerned and their defence. The result of this procedure, it seems to me, is that the public is in a position in which the greatest possible suspicion and conjecture are bound to be aroused. I appeal to the hon. Lady the Parliamentary Secretary. If she were a member of the public in Flintshire and saw a report in the newspaper that very considerable sums had been involved, she would naturally wonder which doctors could have been so careless as to be in this position.
I know from the experience that I have had in my constituency in these last few months that there has been considerable public feeling in this matter. It has resulted in the public having the general feeling that the medical profession as a whole has been brought into disrepute, and it seems to me to be grossly unfair to the other medical practitioners in the area that they may be subject to some completely unfounded suspicion on the part of the public and yet not be in a position in which they can clear themselves. I might even say that there is a certain Member of this House who has a relative in the medical profession in my constituency and he came to me and said, "I suppose it was not by any chance my cousin?" I had to say that as far as I was aware, there was no suspicion whatsoever attaching to his relative.
I would most strongly urge the Minister to reconsider this circular. It might even be said that it should be reconsidered to the effect that publicity should be discouraged rather than encouraged. I find it very difficult to see what good purpose is served by publicising details of the case without identifying the parties. I can think of no other instance in which this is done. It seems to be peculiar to the medical profession. As I say, it arouses the maximum public suspicion and gossip. It obviously has little effect on the doctor concerned, because the mere publication of the details without identifying the doctor means that it is 960 neither here nor there. The doctor is reprimanded by the Service Committee or by the Council, but the fact that the details of the case are given in the newspapers does not make any difference to the doctor if his name is not included. It therefore has no deterrent effect upon the doctor and serves no useful purpose in that sense.
§ It being Ten o'clock, the Motion for the Adjournment of the House lapsed, without Question put.
§ Motion made, and Question proposed, That this House do now adjourn.—[Mr. E. Wakefield.]
§ Mr. Robert Crouch (Dorset, North)
Would I be wrong in assuming that at the time the circular was issued the right hon. Member for Ebbw Vale (Mr. Bevan) was the responsible Minister?
§ Mrs. White
I believe that is so, but I am complaining about the circular and I do not care who was the Minister concerned. I am saying that it seems to me to be an ill-conceived circular. There may have been reasons of which I am not aware which led the Minister at that time to send out the circular. He may have hoped later to come to some agreement with the B.M.A. that names could be published in certain cases, but the circular as it stands is all we can discuss and it makes it clear that names should not be published in any circumstances.
The Minister should discuss the matter again with the B.M.A. and should recognise that the present situation is thoroughly unsatisfactory. My own view is that the different types of misdeameanour should be distinguished. It might be much better if the names of the doctors were not published in purely medical cases. I recognise that there is a strong argument here and that in exercising his medical judgment a doctor may be peculiarly vulnerable; for the public may be extremely ill-informed and unreasonable and not in a position to make a sound judgment.
In those cases, therefore, there is much to be said for not giving publicity to the cases at all. It would be better to keep it in the family, so to speak, and for the doctor to be judged by his peers and 961 by the public members of the Council, unless the case involves his removal from the National Health Service register, when the name has to be published for obvious practical reasons, or unless some criminal charge arises, in which case, again, the circular does not apply. In all other purely medical cases where the treatment of patients is concerned it is far better to give no particulars.
The position is different when we consider cases in which doctors are acting as public servants, much in the sense of other public servants and officers of local authorities or of public boards—such as, for example, in making out claims for travelling expenses or mileage expenses. There is some distinction between the two, but the principle is similar in that it is obtaining money for distances said to have been travelled. In cases of that nature I do not see that the doctor should be regarded as sacrosanct.
I have consulted a number of medical colleagues in the House as well as friends outside and one or two of them, although very much in the minority, have said that a doctor's name should not be given to the public for any kind of misdemeanour whatever, because it is essential that the public should have complete, utter and unimpaired confidence in a medical man. I feel that we cannot accept that. If a man is a good doctor, then I am sure that we should be able to give the facts to the public, which has reasonable standards of judgment in these matters, and lei, the public draw any conclusions that it thinks fit. If the man is a good doctor I do not believe he would lose his patients.
I do not see that doctors are in a special position which requires that they should have this anonymity which, as far as I know, is extended to no other body of persons. It may be said that at times doctors are under conditions of great strain and overwork. We agree and have great sympathy with general practitioners who have periods of very heavy work and strain. But so, after all, do others in public life. It may be said that they might lose quite disproportionately in their professional life because of a relatively minor offence.
I repeat that I do not think that on matters of this kind the public is as unreasonable as certain members of the medical profession seem to think. After 962 all, other people in public life have suffered considerably from what might seem a minor offence where sums of very much less than £3,000 or £4,000 have been concerned. We all know of instances in public life in which persons have travelled on the railway with a ticket which was not in order and have been completely ruined as a result. I cannot see that doctors should regard themselves as peculiarly sacrosanct and entitled to special treatment in their non-medical activities which does not extend to other persons.
For these reasons I earnestly suggest that this circular should be re-considered. I think there is much to be said for discontinuing publicity in certain cases, but not in other cases. There, I think, the public is fully entitled to information and the full information could be given with the names of those concerned. If they then proved that they had not been in fact at fault, or if on going to appeal it was decided that their interpretation of the regulations, for example, was correct, well and good. That, of course, should be given equivalent publicity. It is just the same as if a person is charged in any other way—a member of a local authority who may be surcharged—and may on appeal show that he was not in fact at fault to the extent of the claim and so on. In those cases he gets very full publicity, as my right hon. Friend for Lewisham, South (Mr. H. Morrison) pointed out when I asked a Parliamentary Question.
If it is shown that the person was justified in making the claims which are given publicity and his name can be properly cleared, in the same way when a charge against the doctor is not substantial he should be allowed an opportunity of clearing his name. I think the circular makes the worst of all possible worlds as it gives some information, but not all the information, and is very unfair to other doctors in the neighbourhood. It arouses very unfortunate gossip, conjecture and suspicion, which can only be to the detriment of the reputation of the medical profession as a whole.
§ 10.7 p.m.
§ The Parliamentary Secretary to the Ministry of Health (Miss Patricia Hornsby-Smith)
I am grateful to the hon. Lady the Member for Flint, East (Mrs. White) for the manner in which she has raised what is not an easy problem and 963 upon which varied opinions are held. I am glad of the opportunity of explaining in some detail the reasons which lie behind the practise that the names of doctors should not be disclosed when they have been a party to an investigation of a possible breach of contract by an executive council.
I agree with the hon. Lady that the point which should be kept in the forefront is that it is vital that nothing should be done to interfere with the doctor-patient relationship, which it is important to maintain if the doctor is to be able to give his best service to the patient. That cuts both ways. If publicity is to be given to the doctor, we might argue that it must equally be given to the patient against whom a doctor might well wish to complain.
Many people are reticent about personal ills and would think twice about lodging a complaint, which might prove perfectly legitimate, if all the details of those personal ailments were to appear in the local newspaper. We might not get the very frank complaints, not always upheld or justified—but in some cases certainly so—if the whole gamut of the executive council work was to be open to the full blaze of publicity.
The hon. Lady made the point that it was generally desirable in the public interest that the doctor-patient relationship should be maintained. She seeks to isolate and to deal differently with those cases brought before the service committees of executive councils which do not directly arise on a complaint made by patients in relation to treatment and care but are concerned more with the contract between the professional men and the executive council in respect of remuneration, travelling allowances, mileage or something of that nature.
The first difficulty is to separate and isolate that type of case. I can think, for example, of a claim investigated by the executive council on the question of over-prescribing. It affects the monetary position but cannot be dealt with without bringing in the patient. There are many other similar cases, whether it be charging for spectacles or whether it be charging for dental treatment, where it is practically impossible, whilst it affects the monetary payment to the professional man, to isolate the case from the patient. It is true 964 that the great majority of cases which are considered by the executive councils arise from complaints made from patients against doctors in relation to treatment and care. A considerably smaller number of cases arise from circumstances—such as those of the Flintshire case—which are quite divorced from a particular patient's case.
First may I outline the procedure, which is the same for all four professions concerned, whether medical, dental, pharmaceutical, or ophthalmic—and one must remember that these are professional men, under contract with the executive councils, but not in the same position as employees under direction. For the purpose of this debate I shall deal with it as if it concerned the Medical Service Committee only, although exactly the same procedure applies to the others.
The case is first considered by the Medical Service Committee, which may or may not find that the doctor has been in breach of his terms of service. The executive Council to which the report is made must accept as conclusive any findings of fact contained in the report, but may make to the Minister any recommendations as to the action to be taken upon it. A right of appeal lies to the Minister who may, of course, on appeal, reverse the original decision. The doctor found in breach of his terms of service by the Medical Service Committee might, therefore, succeed on appeal in having the decision completely reversed and—if one might so describe it—of having any stain on his reputation wiped away.
The first difficulty in adopting the hon. Lady's suggestion arises from the fact that in practice it is often extremely difficult to distinguish in advance the case which is to be wholly concerned, for example, with the technicalities of remuneration—divorced from any patient responsibility—and the case which may subsequently bring in individual doctor-patient relationships and will almost certainly, in the broader sense, involve the relation of patients generally with the doctor in the course of his duties.
The rule about publishing names, therefore, applies virtually to almost every case. A summary of the case without the names is in the normal course given publicity by the executive council as outlined in the circular which the hon. Lady read. 965 That is done so that the public may be aware that failure to conform with the standards expected by a doctor under the National Health Service does not go unnoticed or undealt with.
The profession has always considered that it would be grossly damaging to the doctor's professional reputation and to his potential ability to help his patients for his name to be revealed in connection with the investigation of a complaint against him, even if the alleged breach was connected with an administrative matter such as, for example, record keeping, or even if no breach was subsequently found.
The rationale of this attitude towards publication is perhaps reinforced by the fact that where a doctor has been brought before the National Health Service Tribunal—where the case goes if it is referred, on the suggestion that his name should be struck off—and it has been found that his name should be removed from the executive council list, his name is then published. In other words, when a doctor's conduct has been such that it is considered unsuitable that he should treat any National Health Service patients, full publicity is given to the fact in the last extreme, and if he is considered to have transgressed to an extent where he is not any longer regarded as reliable to treat National Health Service patients.
§ Mrs. White
That is rather beside the point. One can hardly help publishing the fact that the doctor is not available to take National Health Service patients.
§ Miss Hornsby-Smith
When it suddenly appears in the newspaper it has certainly a salutary effect.
Where the misdoing is limited in the sense that it does not affect all the patients, or any of them in a medical sense, or where the failure is in one instance to treat satisfactorily, or to comply with some administrative arrangement, the name is not published in view of the possible unjustified disquiet of his patients generally. This line on publication has not become established only since the inception of the National Health Service. It has long been established and dates back to the time before the National Health Service. It was in operation under the National Health Insurance scheme, when panel doctors 966 were treated in the same way. The procedure now laid down under the National Health Service was set out in the circular which the hon. Lady quoted and which was sent out in 1949, and it is based on the view of the professions concerned, but not wholly on their desires and views, but also on the very real legal difficulties about publication of names.
If we can set the doctor aside for a moment, I should like to deal with the legal difficulties to which this gives rise. The procedure has not only the support of the professions, although it was at the direct request of the B.M.A. that the practice was extended to cover the names of respondents before the National Health Service tribunal where names had not to be removed from the list, but is adopted because legal difficulties are involved. We have to remember that the executive councils are not in the same position of being protected from actions for libel as are courts of law. I cannot deal with the case which the hon. Lady has particularly raised because, as she knows, it has gone to appeal, and is to be heard on 6th April. I hope she will forgive me if I confine myself to explaining the general difficulties of this procedure for administrative tribunals and inquiries.
As we understand it, the legal position is that it does not appear that an executive council's proceedings or newspaper reports of its decisions would be protected against a libel action by the privilege which applies at the present time to courts of law and to reports on their decisions. Unless, therefore, the whole proceedings in any case before an executive council were published, it would require the most extreme care, and virtually legal training, to be assured that the summary which was given, including the publication of the names, would be sufficient to protect either the newspaper or the executive council from subsequent action for libel.
§ Mrs. White
I can perfectly appreciate that, if the summary of the kind I have here were published, that difficulty would arise, but I fail to see that it would arise in the same form if only the findings of the council were published, without the summary of the proceedings. It is far more important for the public to know the conclusions than to read the details of the proceedings.
§ Miss Hornsby-Smith
If the proceedings in toto were published there would be less likelihood of libel than in a summary which might unwittingly give a different interpretation of the case. It is the summary, and probably the initial findings, which may on appeal subsequently be reversed, which might give rise to a case of libel. I do not pretend to be a lawyer, but that is the advice I have from legal experts.
The executive councils know of some cases which have come before them, although the actual hearings were private, where the details have been published. That has been because the newspapers have been able to deduce from other sources the names in some cases, or the complainant has disclosed the names to the Press, which, upon their own responsibility, have made use of the information. There has been a case where a doctor has been a witness in the prosecution of a patient, and one where he has himself given the name to the Press.
Where circumstances suggest a breach of the law, the position is entirely different. The matter is then prosecuted by the police or by the Director of Public Prosecutions, and in that case it is fully covered and reported in the usual way. A comparison was drawn between procedure in this matter and publicity given to payments to members of local authorities for expenses incurred or earnings lost in attendance on their civic duties. I believe that a case on that very issue was recently given considerable publicity in South Wales.
These allowances are in a different position from payments towards expenses incurred or earnings lost through what is in principle unpaid voluntary work. The payments which the hon. Lady has in mind are out of the mileage fund which is part of the remuneration of doctors. I should like to make a point regarding the hon. Lady's desire to see certain cases published which do not affect the doctor-patient relationship. Her argument could cut both ways and defeat the object which she has in mind.
If we are not going to publish cases where there has been medical negligence which might have resulted in a reprimand or a fine but we are going to publish a doctor's name in a case of some technical negligence such as failure to fill a form correctly, we are going to undermine 968 public confidence in a doctor whose medical practice is perhaps beyond reproach whilst accepting the need for secrecy in a case where a doctor may have been reprimanded on some medical service. We may well safeguard a doctor in a matter of medical negligence and give publicity and perhaps undermine public confidence in a doctor in a matter of pure technical negligence.
I should like to say a few words on the facts of the present case without expressing any opinion, as it has gone to appeal. There has been a certain amount of misconception and perhaps I might say something to clear up the basis of the case. It should be made clear in the first place that the difficulties have arisen with regard to the claims of certain doctors on the mileage fund for the area of the Denbighshire and Flintshire Executive Council. They do not relate to "travelling expenses" in the ordinary sense of repayment of the expense of journeys by car, bus or train.
The purpose of mileage payments is to recompense rural practitioners on a basis which will take reasonable account of both time and money incurred in travelling to their patients over and above that incurred by urban practitioners for the same number of patients. A sum of £2 million annually is made available for these payments for the whole of Great Britain and this is part of the total sum voted annually by Parliament to provide remuneration for general practitioners in the National Health Service. Under the arrangements made for the distribution of this sum, any excess payments affect the proportions available to doctors in all rural areas. They do not constitute a loss to the Exchequer. Therefore, whatever claims may or may not have been made or may or may not be substantiated on appeal, it is not a case of drawing money from the Exchequer or of putting in additional expense claims.
The hon. Lady quoted the sum of money involved generally in this case. I do not wish to go into the details because the matter has gone to appeal. To deal with the principle, I can say that mileage units are based as a general rule on the distance from the residence of the doctor to the patient's home. In this area, as an additional local rule where a partnership is concerned, the calculation is from 969 the residence of the nearest partner. The point at issue is the definition and selection of residence. On that issue I can make no comment, but it is fair to point out that it is not a case of an inflated expense allowance but a question of definition which has gone to appeal.
§ Mrs. White
The hon. Lady will agree that, although this is not making additional claims on the Treasury, it means that other doctors obtain less if certain doctors obtain more?
§ Mr. G. B. H. Currie (Down, North)
Would my hon. Friend agree that doctors find it confusing if, when a new partner is introduced into a partnership, all the calculations of the mileage allowance must be made again, because mileage is calculated from the residence—in other words, from the bed instead of from the surgery? The result is that if a new partner is introduced into an existing partnership of two or three doctors all the mileage allowances may be changed without the doctors appreciating that fact.
§ Miss Hornsby-Smith
The instructions are issued by the local executive council and there is a certain elasticity in relation to local rules. In the case the hon. Lady has in mind, the calculation is based on the residence of the nearest doctor. I appreciate that difficulty may arise if a new partner becomes the nearest doctor and is perhaps miles nearer than the one whose residence was previously used as a basis of computation.
§ 10.26 p.m.
§ Mr. A. Blenkinsop (Newcastle-upon-Tyne, East)
It has been useful to have this short debate, because it has reminded many of us of some of the problems involved in this difficult matter, and it is just as well that we are reminded of the position of the patient as well as of the doctor. As there is undoubtedly some anxiety that there should be the maximum amount of publicity that is fair for the sake of other doctors, then we ought to consider with the British Medical Association whether it is satisfied that the interests of the other members of the medical profession are fully covered by the present position.
My hon. Friend has raised the fair point that a good deal of suspicion may attach unfairly to a number of practitioners. The answer is for them to take action with the British Medical Council to ensure within their profession that any breaches of medical conduct, or of the contracts with the Ministry, do not occur. This rests largely on the profession, so it might be of value if it was brought home to the British Medical Association.
§ Miss Hornsby-Smith
Perhaps I may add that this procedure will come under consideration by the Committee on Administrative Tribunals and Inquiries. We shall, of course, consider this set of administrative committees in the light of what may emerge from the report of that Committee.
§ Question put and agreed to.
§ Adjourned accordingly at twenty-nine minutes past Ten o'clock.