§ Order for Second Reading read.
§ 7.36 p.m.
§ The Minister of Health (Mr. Kenneth Robinson)
I beg to move, That the Bill be now read a Second time.
A sentence in the Gracious Speech on the opening of this Session of Parliament indicated that the Government were studying, with the medical profession, ways of improving the family doctor service and would introduce the necessary legislation. The Bill before the House today redeems that pledge of legislation. In itself, it represents only a small part of the outcome of the negotiations that I have been conducting with representatives of the general practitioners.
Perhaps the House will bear with me if I begin by very briefly setting this in its wider context. We are aiming to bring about no less than a radical transformation of general practice as we have known it since the Health Service began in 1948. Since general practice was last debated in this House, in March of last year, officials of the Health Department and I have held upwards of 40 meetings, most of them lasting a whole day, with representatives of the family doctors. We have already published two Reports containing not only the proposals reflected in the Bill, but a number of others including a totally revised system of payment. We hope to publish a third Report before very long, and the profession will then be offered a completely new contract following the completion of the Independent Review Body's current review of the levels of remuneration. Meanwhile, other measures have already been put into effect designed to help the family doctor with the problems he faces and to reduce his load in some degree.
The essence of the proposed new contract is flexibility. Up till now financial reward depended almost entirely on the number of patients on the doctor's list, irrespective of the circumstances of his practice or of anything else. Under the new system account will be taken of many other factors, of the nature of the premises and of the staff employed, of the doctor's age and experience, of the 1373 unattractiveness of an area, of practice in groups, of the need to employ a locum in sickness, of night calls, responsibility for looking after elderly people and so on. Much of this is made possible by the introduction of a basic allowance, expressed as an annual sum and not as so much per person on the list, which will constitute a substantial part of total remuneration.
The new contract, which will also include a re-casting of the doctor's detailed terms of service, represents the first major change in the arrangements for general practice since the National Health Service began. That we have been able to hammer this out has been due in no small measure to the hard work and the fair-mindedness of the profession's team of negotiators, to whom I am glad to pay tribute. Although they have had no firm mandate to commit their colleagues in advance of the outcome of negotiations, their constructive help has been invaluable in working out the new contract. In this connection I would like to pay a no less sincere tribute to my officials who have taken part in these negotiations and for whom this has represented a very considerable additional burden to that which they normally carry, which in itself is by no means light.
Meanwhile, the Government have been able to lake, with the agreement of the profession, certain administrative action to help general practitioners in advance of the new contract. Perhaps the most important step was taken in co-operation with my right hon. Friend the Minister of Pensions and National Insurance, who has made changes in the rules for national insurance certification. These changes should result in a very substantial reduction in the number of insurance certificates doctors have to give, and especially in visits to and by the doctor for the sole purpose of certification. The new rules came into operation at the beginning of this week, and I hope that they will relieve the doctor during this difficult winter without in any way acting to the disadvantage of the patient.
I should like to single out three smaller hut, I think, significant measures. First, the free issue of disposable syringes and needles. This is a matter which has been debated in the House. Even though in principle the doctor is responsible for providing his own equipment, the need for 1374 sterility when giving injections and the doctor's difficulty in securing it in my view fully justified Government assistance Free supplies have been available to family doctors since about the middle of last month.
Secondly, my right hon. Friend and I launched a campaign to seek the cooperation of the public in making the best use of family doctors' time. We have done our utmost to avoid saying anything which might discourage anyone from seeking medical treatment or advice which he needs or genuinely thinks he needs. Our aim has been directed rather at that thoughtless minority—and it is a small minority—who make inconsiderate demands on their family doctor. So long as there is a shortage of doctors, it is essential that we make the most economical use of the available manpower in the interests of patients no less than of the doctors themselves.
Since October, millions of leaflets explaining how to make the best use of doctors' services have been distributed for display in waiting rooms, and more recently a poster on the same theme has been issued. Short television films on the subject have been shown with the co-operation of the B.B.C. and Independent Television companies. Hon. Members may have noticed that letters are now being franked with the slogan "Help save your doctor's time". This is a continuing campaign, but its effect is likely to be most helpful in the winter when the pressure on the doctor is at its heaviest.
The third measure which we have been able to take to help the general practitioner—this is something which bears more directly on the subject matter of the Bill—was the introduction of the scheme to provide Exchequer grants of one-third of the cost of approved projects for improving medical practice premises. This should be a considerable encouragement to doctors to provide a high standard of surgery premises and, in turn, will mean a better service to patients.
That we have been able to do so much without legislation is perhaps a tribute to the far-sightedness of our predecessors who put the original National Health Service Act on the Statute Book. Indeed, the need for one of the provisions in the Bill has arisen only because that Act was later amended. As things stand, there 1375 are two proposals which require legislation, and I now come to the provisions of the Bill.
One of the proposals in the profession's charter was that an independent corporation should be set up with adequate public funds at its disposal to finance the purchase and modernisation of doctors' surgeries and equipment. This was a proposal to which the profession attached great importance, and it was one of the four issues on which it sought prior assurance before negotiation proper on a new contract could even begin.
Most family doctors, like other self-employed professional men, practise from premises which they themselves provide. Nonetheless, I am glad to say that local authorities and, in Scotland, my right hon. Friend the Secretary of State are making surgery premises available for renting on an increasing kale, particularly in health centres.
There has been a welcome and surprisingly rapid growth of interest in health centre provision. Up to October 1964, when there was a change of Government, only 24 health centres had been opened. Nine more have been opened since then or are being built or extended, and active planning is going ahead on another 29, and about 120 further schemes are receiving local consideration. It is to be expected, however, that for some time to come the majority of doctors will prefer to make their own arrangements for accommodation, and I am sure that it would not be right to try to force doctors into publicly-owned premises.
What is important—this has been brought out time and again in my negotiations with the profession—is that working in a group is the best way for the family doctor to overcome the dangers of professional isolation. Such group working not only makes the best use of medical manpower, but makes it easier to support the doctors with services of trained non-medical staff of several kinds. Encouragement to group practice is embodied in the new contract.
But, of course, modern medicine requires modern purpose-built premises, and the problem of financing such premises is becoming increasingly difficult for the doctor. The professions repre- 1376 sentative told me, and I fully accept, that many doctors experience difficulty in obtaining the loans which they need from ordinary commercial sources because of the security required and the limited periods over which the loans have to be repaid. For example, a commercial lender may feel able to advance only a smaller percentage of the value of purpose-built or adapted surgery premises than the doctor needs. The shortness of the period over which the lender requires repayment may involve the doctor in excessive annual liabilities. The doctor joining a partnership and requiring to purchase a share in jointly-owned premises, perhaps from a retiring partner, faces a particular difficulty since he cannot offer the premises as security.
The profession's solution was that the corporation which it had suggested should encourage doctors to practise from good premises by lending money repayable over long periods, perhaps over the whole of the doctor's career, for the purchase or improvement of premises; by acquiring existing purpose-built premises which it would then lease or sell to the doctors as they preferred; by itself building new premises for lease to doctors; and by helping to provide medical and practice equipment.
The Government have been able to go a long way towards meeting this proposal, and the first report of the discussions on the charter records our undertaking to promote legislation to establish a new statutory body with power to make loans to doctors for the purchase, erection and improvement of practice premises and with a reserve power to make loans for the purchase of equipment. Indeed, even before this, in the letter which I sent to the Chairman of the General Medical Services Committee a few days after the charter was submitted to me and from which I read to the House on 17th March last. I had accepted that doctors needed help with the provision of premises.
The Government did not, however, think it necessary that the new body should itself also be empowered to acquire or build premises for leasing to doctors since we felt that it would he inappropriate to duplicate the arrangements which already exist for this to be done by public authorities, which, as I have said, are being increasingly used. 1377 The Bill provides, however, that in suitable cases the new body might acquire a site as distinct from premises which it would then let to the doctor on a long building lease at an appropriate ground rent. Under this kind of arrangement the doctor would be responsible for building the premises, probably with the aid of a loan from the corporation, but he would not have to find the capital cost of the site.
The primary purpose of the Bill is, therefore, to provide for the establishment of the new body, which will be known as the General Practice Finance Corporation. The Corporation will be available to all family doctors in Great Britain who provide general medical services under the National Health Service. The Corporation will raise its funds by borrowing on the market, but the Treasury is being empowered to guarantee both the principal and payment of interest on the money borrowed. From inquiries that I have made, I am satisfied that the Corporation will, in practice, experience no difficulty in finding the money it needs. The profession's leaders understand that it will have to operate on a sound commercial basis. It will be a means not of subsidising doctors but of giving them access to capital which they might not otherwise be able to obtain, and under far more flexible arrangements than could reasonably be expected of the ordinary commercial lender.
Provision of the capital for the building of premises is not, of course, the whole story. The capital must be serviced, and this raises the question of continuing practice expenses. This is outside the scope of the Bill, but to complete the picture I might, perhaps, be allowed to remind the House that the new proposals for remuneration of family doctors provide for payment by the executive council of a notional rent to those who own their premises. This arrangement should assist those who have provided purpose-built accommodation of a high standard whether they have borrowed the capital from the Corporation or not. The Bill will not affect the existing arrangements under which doctors can rent premises from a public authority. These doctors, like others who use rented accommodation, would receive reimbursement of reasonable expenditure on actual rents.
1378 I come now to the second main provision of the Bill, which relates to payment by salary. Another proposal in the doctors' own charter was that family doctors should have the option of different methods of payment, including salary. The Government could not allow an entirely free option to every doctor, but we have agreed that this method of payment should be brought into use for those who desire it wherever the circumstances are suitable. The second report of the discussions contain proposals for this. These proposals cannot be implemented without amendment of the law. Hence the further provision in the Bill which I will explain in detail a little later.
I now turn to the Clauses of the Bill. Clause 1 of the Bill deals with the setting up of the Corporation and makes clear its status as an independent body. Details of its constitution are included in the Schedule. This provides for the Corporation to consist of up to eight members, including a chairman and deputy-chairman, all of whom will be appointed by the Secretary of State for Scotland and myself acting jointly after consultation with the medical profession. The majority of the members will need to be chosen mainly for their knowledge of financial and business affairs, but I am sure that the Corporation should have first-hand advice from practising doctors. I have told the representatives of the profession that we intend to appoint one or two family doctors to serve on it on a part-time basis. Provision is made for members of the Corporation to be paid salaries or fees as well as expenses from Exchequer funds should this prove necessary. The Corporation will appoint its own staff and meet the costs and other administrative expenses from its own financial resources.
Clause 2 deals with the ways in which the Corporation will be able to help doctors. Its main function will be to make loans to family doctors for the acquisition of sites or premises, the conversion or construction of premises and the alteration, enlargement, repair or improvement of premises. It will also be able to advance money to enable a doctor to repay a loan previously obtained from another source for one of these purposes—where, for example, a doctor wants to spread the repayment over a longer period than the terms of 1379 the original loan permit. The site or premises must be used wholly or in part for the purpose of general practice in the National Health Service but it may include a combined surgery/residence.
Clause 2 also gives the Corporation the necessary power to purchase sites for leasing to doctors. It is envisaged that the Corporation should buy the sites and retain their ownership, thus leaving the practitioner with only the expense of building premises, on the basis of a building lease and paying a suitable ground rent. A practitioner taking such a lease would not be debarred from receiving from the Corporation a loan for the erection of the premises on the site. The Corporation will not have the power of compulsory acquisition.
Clause 3 enables the Corporation to lend money to doctors for the purchase of equipment if provision is made for this by Order made by Statutory Instrument. It is thus a reserve power which would be exercised at some time in the future only if there is evidence that practitioners are generally failing to obtain the assistance they need for the purchase of equipment from existing sources of finance. I have no evidence that this is so at present.
Clause 4 deals with the manner in which the Corporation is to operate. It requires that the Corporation should carry out its functions in accordance with a scheme which it has prepared and had approved by the Secretary of State for Scotland and myself acting jointly and to comply with any directions which we may feel it necessary to issue.
The Corporation will in any event need to draw up working rules for its guidance and the provision, in effect, requires it to ensure that these rules are acceptable as a basis for operating the Government guaranteed money so that it knows from the outset where it stands.
We envisage that, apart from setting out the general framework within which the Corporation will operate, the main point to be covered in the scheme will be the need to confirm that the appropriate Minister is satisfied as to the location and the standard of the premises before a loan is issued. The object of this is to ensure that practice premises are so sited that 1380 they may best serve local needs and to facilitate the co-ordination of general practice with other branches of the Health Service.
We would not expect the Finance Corporation itself to form views on the siting of premises, since this requires local knowledge and is a matter for the Health Service authorities and the profession. It is, therefore, intended, as the profession is aware, that the Corporation should ascertain from Health Ministers that premises are suitably sited and are of a suitable standard before making advances and that Ministers should look for advice to the Health Service authorities concerned. There will be a central committee, on which the profession again will be represented, to advise on policy, including general questions of priority, and on referred cases. Special administrative arrangements will be made for Scotland.
Clauses 5 to 8 deal with the financial arrangements. The Corporation will be under an obligation to conduct its affairs in such a way that over a period it breaks even financially. It will raise its funds by borrowing and will pay the market rate of interest. In fixing its lending rate, it will need to take into account not only the interest which it has to pay on the borrowed capital, but also its administrative overheads and the need to set aside reserves against losses. It would wrong to lead doctors to think that in these circumstances loans from the Corporation are likely to be cheap. The main advantage to them, at least at present, will lie in the availability of the money and in flexibility in the arrangements for repayment. At the same time, the new proposals already mentioned for direct payment of notional rents to doctors will benefit those who provide practice premises of a high standard with the aid of a loan from the Corporation or from any other sources.
Clause 6 empowers the Corporation to borrow by the issue of stock and temporarily by way of overdraft or otherwise. It also specifies the limits within which it may borrow, initially up to£10 million, a figure which can be increased up to£25 million by Order if the House so approves. These limits will exclude borrowings for the purposes of repaying moneys previously borrowed.
1381 Clause 7 deals with the Treasury guarantee and Clause 8 requires the Corporation to keep proper accounts and records and provides for a copy of its annual report, with the accounts included, to be laid before each House of Parliament. Clause 9 deals with superannuation of officers and members of the Corporation. These nine Clauses complete the provisions of the Bill relating to the establishment and functions of the General Practice Finance Corporation.
I now come to Clause 10. The National Health Service Act, 1946, was amended in 1949 to prohibit family doctors being paid, except in special circumstances, wholly or mainly by a fixed salary which had no reference to the number of their patients. The amendment was introduced to fulfil an undertaking given by the Government of the day shortly before the Health Service came into being in 1948 to meet the fears of the medical profession that a full-time salaried State medical service might be imposed upon them. Those fears were as groundless then as they are now.
I have always felt that the plan which was enacted in 1949 was really too comprehensive. There were doctors who felt even then—and I think that there are many more who feel now—that the independent contractor status which was derived from the original National Health Insurance arrangements has certain inherent disadvantages, To the majority of doctors these disadvantages have become more apparent as the need has grown to conserve the doctor's time by relieving him of what I may call the business arrangements of the practice. Though not all doctors who recognise the problem would themselves want to change, for some of them payment by salary in which the onus for those arrangements rests on a public authority offers a more satisfactory alternative.
I was pleased that in their charter the profession expressed the view that since the National Health Service began there had been too little flexibility in the method of paying family doctors and that a proportion of doctors favoured payment by some form of salary. It would not have been possible to allow all doctors to choose to be paid by salary, because that form of payment would not normally be appropriate where the doctor is 1382 providing his own premises, staff and equipment and where he works alongside doctors paid by fees.
The Second Report of the negotiations issued last October set out the Government's proposals to try and organise, in association with the profession's representatives, a number of groups of doctors to be paid by salary, perhaps under differing conditions, with the intention of applying that method of payment to as many as possible of those doctors who desire it.
That would go beyond the special circumstances which the 1949 Amendment exempts from the general prohibition of payment by salary, and Clause 10 is therefore necessary to allow for implementation of the proposal.
First of all, it provides explicitly for payment to be made by salary if arrangements have to be made under Section 43 of the 1946 Act; in other words, if, exceptionally, the normal arrangements for providing services are failing to secure an adequate service in an area and special provision has to be made. That possibility has always been open and would always have constituted "special circumstances" under the 1949 amendment, so that there is no change here. But secondly—and this is the innovation—the Bill allows for a doctor to be paid by salary, with his consent, if he is practising in circumstances prescribed in regulations.
I recognise that there are still misgivings in the minds of many general practitioners on the subject of payment by salary, and the Government would certainly not wish to force it on doctors against their will. In order to make that quite clear, the Clause not only provides for consultation with the profession before regulations are made but also for the consent of the individual doctor concerned to payment by salary.
Family doctors may have no fear that payment by salary will result in any impairment of their clinical freedom. They have only to consider the experience of their hospital colleagues to see how salaried employment and professional liberty can exist side by side. What it can do for general practitioners is to relieve them of the often tiresome and certainly time-consuming business of providing premises, staff and so on, thus 1383 leaving them free to devote their time to the care of their patients.
These, then, are the proposals in the Bill. Of themselves, as I say, they cover only part of the ground, but it is an important part. These new provisions are needed if full benefit is to be obtained from the work that has been done over the past year to devise means whereby family doctors can, under the National Health Service, use their training and their skills for the greatest benefit to their patients and the deepest professional satisfaction to themselves.
§ 8.4 p.m.
§ Mr. Richard Wood (Bridlington)
I hope that the House will forgive me if, before coming to the substance of what the right hon. Gentleman has had to say, I express a view which I think is held not only on this side but also in all parts of the House. I refer to our great sense of loss in the death of Dame Edith Pitt. I heard what was said earlier today in her tribute, but I think that those hon. Members who are now in the House would agree that she has taken part in a number of our debates and always given expression to a well-informed realism. I have the strong feeling that she would probably have liked to take part in this debate, and she is certainly very much missed.
The right hon. Gentleman has taken us over the history of his prolonged discussions with the medical profession. He told us that he had had 40 meetings since our last debate. I calculate that that is an average of about a meeting a week and, as Ministers occasionally take holidays, some weeks must have been fuller than that. We would all like to congratulate him, his officials and the representatives of the British Medical Association for the immense amount of work that they have put in since last March.
It appears from what he has said and what is contained in the two Reports already published—and I presume that the Third Report will appear before very long—that the discussions have ranged very widely from the contract of service which is now being priced by the Review Body to the various proposals designed to enable the family doctor to practise better medicine.
1384 As the right hon. Gentleman made clear, there is a close connection between the contract of service which was discussed and the other proposals, one of which, concerning the loans, is contained in the Bill.
Whilst we were all interested in what the right hon. Gentleman had to say about the contract, all I would say about the matters which are now being decided by the Review Body is that everyone who is in any way concerned with the National Health Service is awaiting its findings with varying degrees of optimism, but with quite invariable interest and expectation.
In view of what the right hon. Gentleman has said in the past about the position of the Review Body, I must take this opportunity to express the hope that when the Review Body reports to the Prime Minister the Government intend to reach their decision without seeking further intermediate advice, and I look forward to an assurance from the right hon. Gentleman that that is the Government's intention.
One of the important matters covered in these protracted discussions was the profession's own suggestion of the Finance Corporation. Up till now there has been a limited system of interest-free loans for group practice. The limit of total finance available has been fairly low, and the right hon. Gentleman, speaking in the debate which took place here in July, 1964, described these loans asquite inadequate for the kind of expansion of group practice that we would like to see.My right hon. Friend the Member for Altrincham and Sale (Mr. Barber) gave the House the information at the end of that debate that about 600 such loans had already been approved.
With the setting up of the Corporation, I presume that these interest-free loans will come to an end. Therefore, while the new arrangements are going to benefit a very much larger number of applicants, it would seem that there will be a small number of doctors who will no longer be able to get the help which was formerly provided on very favourable terms. Perhaps the right hon. Gentleman will comment on that, as I understand that he is going to wind up.
1385 In that debate, the right hon. Gentleman used words which gave a very different impression of his intentions for the future. He said:A system of loans must be replaced by one of grants. That is what a Labour Government would be prepared to do."—[OFFICIAL REPORT, 27th July, 1964; Vol. 699, cols. 1016–7.]That was no equivocal undertaking. It was no mere promise to consider, or to leave no stone unturned, or to explore every avenue. It was the bold plunge that a Labour Government will substitute grants for loans.
Apart from the limited machinery for grants which has been agreed between the right hon. Gentleman and the profession, the loans are still the mainstay of the system, and we are entitled to a fuller explanation than the right hon. Gentleman gave me in the last debate of why subsequently be changed his mind. In spite of this gap between promise and performance, to which some of my hon. Friends have drawn attention in other fields, the Opposition welcome any steps which make finance more readily and more certainly available to a much larger number of general practitioners.
There are various questions which may be suitably raised during the Committee stage, and I readily appreciate that the Corporation must be given freedom of manœuvre, but for the moment we should be greatly helped if the Minister could tell us one or two things. First, what will be the likely relationship between the interest required by the Corporation and that which is payable on loans though ordinary sources at the present time? Secondly, are rates of interest likely to move upwards or downwards during the period of the loan? Thirdly, will there be any ceiling on individual loans? Fourthly, over what period must they be repaid? Fifthly, we should be interested to know when the General Practice Finance Corporation will begin its work.
Clearly the attractiveness of this new method of providing necessary finance must depend, first, on loans being more certainly available than they would be from normal sources in times of credit restrictions, and, secondly, on loans being available on rather more favourable terms than other sources can offer at times when there is no restriction of credit.
1386 The other matter which the right hon. Gentleman mentioned—but I confess that I am still not clear about it—was that the first Report of his discussions with the B.M.A. made it clear that the Governmentdo not rule out the possibility that the Corporation should itself build and own premises, but wished to study further"—one or two things—before coming to a decision on this".I heard what the Minister said, and it is clear that he has not put these powers in the Bill, but I wonder whether he is still prepared to consider giving this power to the Finance Corporation?
Some of these points seem to me to be of sufficient importance for the right hon. Gentleman to want to give us the Government's views without delay, but in general we believe that this Bill is a constructive contribution towards more efficient general practice, and as such, as the Minister made clear in his speech, it takes its place with other measures which are designed to reduce the load on general practitioners and leave them more free to do the work which they alone can do.
The right hon. Gentleman mentioned some of the measures which will reduce the load on general practitioners. In particular, the alteration of the arrangements for certification, which came into force this week, will most certainly reduce the work load on general practitioners, and to that extent it is to be welcomed, but, as the House knows, some of my hon. Friends have certain anxieties which they hope to express on another occasion.
There is an important sector in which progress could decisively reduce the burden on individual general practitioners. The right hon. Gentleman referred to group practice, and I should like to give him all my support, because I believe that this could make a substantial reduction in the burden, both physical and mental, if I can so express it, which general practitioners have to bear.
The First Report, to which I have already referred, expectedthat purpose-built premises for improved practice, usually in groups, would have first claimon the loans provided by the Finance Corporation. Therefore, it seems clear 1387 from the sense of the Report that the stimulus which the Corporation will give general practice may well be considerable, but from reading the Bill, and from reading the Report, one gets the impression that the stimulus will in fact be incidental. The priorities may be fixed that way, but there is no particular requirement for loans to go to group practice alone. Again, the Minister might like to say a little more about this when he replies. The method of group practice seems to be one of the most fruitful ways of using medical skill, supported by much-needed ancillary help and working closely, both physically and professionally, with other specialists in the health team.
Finally, I should like to refer to the means of remunerating general practitioners, to which the right hon. Gentleman referred, and which are now modified by Clause 10. When we last discussed these matters, last March, we all acknowledged the death of the pool system, and I do not think that many of us shed many tears on its behalf. We noticed at that time the claim of the G.P.s' charter that doctors should be given the choice of a capitation fee, payment by item of service, or some form of salary, and on that occasion I encouraged the right hon. Gentleman to experiment with these different methods of payment.
I am sorry to find that, according to what he said today, and according to what I have read in the Report, he has placed limitations on the experiments which he is prepared to make. It seems to me that we should have learned a great deal if doctors had been allowed to charge a fee for service, which subsequently could be wholly or partly reclaimed, but in fact the right hon. Gentleman has chosen one of the experiments which is a cautious move towards the payment of direct salaries. I believe that the right hon. Gentleman is right to be cautious, and all that he said proves that he is aware of the very cautious nature of this move.
I said during the last debate that…this method of a straight salary raises…the question whether the personal nature of the service could continue if the present relationship between the patient and his or her docor ceased to exist."—[OFFICIAL REPORT, 17th March, 1965; Vol. 708, c. 1322.]1388 As the Minister made clear, the Bill proposes that such an experiment should be possible only with the consent of the practitioner, and in circumstances prescribed by himself or the Secretary of State for Scotland after consultation with the profession.
I wholly support now, as I did last March, the action which the right hon. Gentleman has taken to make this experiment. It is an important departure from the present position, and we are naturally anxious that Parliament should be kept fully informed of the right hon. Gentleman's intentions in this matter, and I therefore ask that any Regulations which he makes under Clause 10(2) should be subject to approval by Parliament. I believe that this is a very modest request, and I hope that he will be able to give an assurance tonight that that is his intention.
Apart from the important questions of that kind, the right hon. Gentleman can be assured of our general support, and of our intention that the Bill should quickly become law so that the Corporation can begin its work as soon as possible.
§ 8.18 p.m.
§ Dr. David Kerr (Wandsworth, Central)
As somebody who has one foot in both camps, I should like to tell my right hon. Friend how much I welcome this latest manifestation of the Government's clear intention to promote the cause of family doctoring. I want to make it clear, and I say this with deep regret, that I have no mandate to speak on behalf of my colleagues. However, I assure the House that in conversations which I have had with many doctors, who are more noted for their fair-mindedness than for their commitments to Socialism, I have found their tributes to our Minister of Health much kinder today than they were a year ago, and I am confident that this progress on both sides will continue.
My right hon. Friend referred to the achievements which, individually taken over the last year, have perhaps not been terribly dramatic. But taken together, and set in the context of the continued advance of Britain, I think that they add up to a remarkable determination to ensure the rescue, the maintenance, and the prosperity of general practice in Britain today. We have to consider the Bill not 1389 only in the context of what has been done for general practitioners alone, but in the context of the Land Commission Bill. That Measure, surely, can contribute as much to the urgent problems of land hunger, as experienced by general practitioners, as can this Bill.
The Minister also implied a recognition of the fact that the Bill has come before the House after he and the profession have broadly agreed its terms. I read it as an acknowledgement by the profession that its historic rôle—that of a group of individual entrepreneurs—is over. At last the profession acknowledges that although it must do it by this back-door, two-step fashion, it cannot survive without the help of the Government or local authorities. The imputations of this should not be lost upon the House.
I speak at the moment as a doctor, and not as a politician. I am sorry to have to change my hat so constantly. The profession is faced with the same difficulties as those which confront the small shopkeeper. The same difficulty arises when the High Street suddenly acquires an enormous land value, which can be met only by the supermarkets. The problem facing both doctors and the Minister is to assist the family doctor out of the era of small shopkeeping into the era of supermarket medicine. I hope that that will not be wrongly interpreted. I am merely emphasising the need for much bigger types of organisation than exist under our present system of family doctors.
The right hon. Member for Bridlington (Mr. Wood) suggested that the salary question should be placed before the House on every occasion. I resist that suggestion, in the hope, however optimistic it may be, that as time passes and pressures grow the number of occasions on which the Minister will want to make orders for the determination of salary payments will increase, so that the time taken in considering these matters, however formally we do it in the House, will grow and grow. Once we have established and accepted this principle it should not be a matter that has to come before the House on every occasion.
The affairs of the Corporation, however, are an entirely different matter. We are setting up a body whose representa- 1390 tion in Parliament will presumably be through the Ministry of Health, and which is required under the terms of the Bill to submit its accounts annually through the Minister and the Secretary of State. This body will dispose of about£10 million a year, and it is quite proper that an annual report of this sort should come to the House. I trust that the Minister or his Parliamentary Secretary will hold himself responsible for answering any points that arise in connection with this matter.
This leads to a very important point. The Minister has left it less than clear precisely what is to be the policy-making rôle of the Corporation. He has referred to the need for continued responsibility and for consultation with local health authorities, but I am troubled—to put it no higher—to think that a body based predominantly on financial considerations, which is small for the tasks which it may be asked to undertake and which disposes of no less than£10 million a year and possibly£25 million a year, will consist of only six members.
I should like to know what sort of infrastructure it will command which will allow it to take into consideration, when determining whether a loan or grant should be made, what advice it will have, and what opportunity it will have to consult local health authorities. Under Section 31 of the 1946 Act local health authorities were given the responsibility of building premises known as health centres to provide for both general practice and general dental practice. It seems to me that it might have been convenient, as a precaution, to include in the Bill the possibility of meeting the same requirement in respect of the dentists instead of leaving them to be dealt with possibly by a future Bill, after future negotiations.
Is it too late to insert in the Bill a reference to the needs of the general dental practice? The dentist is subject to the same squeezes and the same difficulties as those which confront the doctor.
§ Mr. Reginald Freeson (Willesden, East)
Does my hon. Friend agree that the same point might be made in respect of the ophthalmic practitioners, although not on the same scale?
§ Dr. Kerr
I accept that point. It is worth looking at. This principle could 1391 also be extended to the small chemist. The danger is that the Corporation could turn out to be an instrument for perpetuating the small shopkeeper principle in the Health Service instead of doing away with it. I am not sure what built-in protection we have against that principle. It is subject to Ministerial direction and the acceptance of certain schemes. I hope that, in its traditional fashion, the House will declare itself in favour of the Minister's assisting the profession to move away from this anachronism. In other words, I hope that the work of the General Practice Finance Corporation will be devoted to assisting better standards of organisation as well as making available the land and buildings which are in demand.
Another assurance which I am very anxious to have from my right hon. Friend concerns the rôle of private practice in medicine. The terms of the Bill refer to assistance being given for the acquisition, improvement or extension of premises, which are, in whole or in part, being used for general medical services. Nothing in the Bill would preclude a loan being made available to a doctor 90 per cent. of whose work is private practice and only 10 per cent. or less is concerned with the National Health Service. I am anxious to avoid that situation, and I shall be glad to hear from my right hon. Friend that when the Minister inspects a scheme he will pay heed to this factor.
The relationship between the local health authorities and the General Practice Finance Corporation I have already mentioned, and I should like to enlarge on it. Under the health and welfare document published in 1963 by the previous Government, there was provision for only about 65 health centres by 1974. It is extremely good news to hear from my right hon. Friend of the very rapid advance in planning these important institutions since the present Government have had responsibility. However, is there now to be competition between local health authorities on a rate-financed basis—the only authorities charged with this responsibility?
If they are to have the easy option of saying to general practitioners, who are very difficult to inveigle into health centres anyway, "Look, boys: we can- 1392 not put this on the rates; if you will trot along to the Ministry of Health, you will get a loan from the General Practice Finance Corporation. Everybody will be happy; you will be your own masters and subject to no nasty town hall bureaucracy", this would be a situation about which I have some justification in expressing anxiety.
I hope that the Minister will look very closely at how local health authorities —perhaps even hospitals, although I am not in favour of G.P.s being hospital subordinates—can be given the advantage of comprehensive planning of health facilities for local areas, so that the planning is not competitive, but comprehensive and co-operative. In so far as finance is referred to in the Bill, according to my simple arithmetic,£10 million would pay for roughly 100 centres and£25 million, pari passu, is equivalent to about 250 health centres.
I am not sure what sort of sums we could hope for. Local authorities which are building health centres are content to look to their new estates to establish branch services or similar inferior types of organisational centres for general practitioners. One can compare this with the present system of group practice loans. I should like to endorse what the right hon. Member for Bridlington said about the unhappy lack of encouragement in the Bill for the promotion of group practice. There is nothing in the Bill which in any way corresponds, for instance, to the terms of the Dankwerts Award in 1951, which took conscious, deliberate and very successful steps towards the promotion of group practice.
We seem to have come to a standstill. I would direct the House's attention to the figures in the Minister of Health's Report for the last two years on the structure of general practice in this country. We seem to have advanced very little. If we accept as the basis of group practice a partnership of not fewer than four doctors, we find that, of those practices containing four or more doctors, the total number is about static for 1963–64. If we are really committed to the ideal of group practice—I am not sure that I am: it is difficult to argue this in a short time—it is plain that the principle needs a little more of a push than it will get from the Bill.
1393 Turning now to the salary remuneration principle for general practitioners, I can only say—as did someone who, both personally and as a past Secretary of the Socialist Medical Association, has campaigned for this one acknowledgment of the right way to establish a salaried service—that I welcome it wholeheartedly. It is always curious to me that general practitioners should be so resistant to the principle of salary, when they would not think of paying their own assistants in any other way. This curious paradox —perhaps not the most curious among doctors—is worth noting.
I am not sure that I agree with the repeated assertion which we have heard tonight from the right hon. Member for Bridlington that the pool system is dead. I suppose that the old method of distributing the pool is dead, but until I have seen the terms of the Review Body's recommendations, I do not see the Government being saddled with an open-ended commitment, which seems the only alternative to establishing a general, basic pool for the general practitioner service and its subsequent division, albeit on an entirely new basis.
On this point, I await not so much my right hon. Friend's advice as the Review Body's recommendations. Of course, if he wishes to say something on the subject—though I do not think that he will want to commit himself—I shall listen with interest.
The new salary principle, which I hope that the House will pass enthusiastically tonight, has one shortcoming. It clears the deck for a whole-time salaried service for general practitioners, but it does not actively promote it. My right hon. Friend has spoken feelingly of the inhibitions of family doctors towards a salaried service. I wonder how much progress we shall make towards a salaried service when the Minister allows the principle—as I think he must—of consultation, and when, every time that he wants to introduce a salaried service in a particular locality, he has to consult the doctors.
It is not clear from the Bill whether he will consult the local practitioners through the local medical committees or the national bodies, the British Medical Association, the Medical Practitioners' Union and so on. I repeat, going back to the Corporation for a moment, that I am not sure that six men and a couple of 1394 chairmen are enough to consider the appropriate problems which arise in a locality. In the same way, I am not sure that the national bodies are appropriate bodies to advise or consult the Minister on local problems in establishing a salaried service.
Other problems are bound to arise, notably the determination of salary levels. As things stand, the Review Body would probably be the appropriate body to determine salary levels, but I wonder whether, with the establishment of a salaried service in general practice, the profession should not now be encouraged to take a more constructive look at the Whitley Council machinery which it has abandoned so successfully for so long.
In general, I welcome the Bill as part of the developing plan of the Government for general practice. Although I have, I fear, perhaps overweighted my reservations and anxieties, I wish to make it clear that this is obviously so splendid a part of a new look for Britain's family doctor services that I can only offer my warmest welcome to it and my congratulations to my right hon. Friend.
§ 8.36 p.m.
§ Mr. Alasdair Mackenzie (Ross and Cromarty)
The object of the Bill is to improve the family doctor services. The Minister gave a clear exposition of the provisions of the Measure and the right hon. Gentleman the Member for Bridlington (Mr. Wood) paid tribute to the work of the Minister during the past year. Forty meetings with representatives of the profession is certainly a great achievement, and I; too, pay tribute to the Minister.
It is a privilege to follow the hon. Member for Wandsworth, Central (Dr. David Kerr), who speaks with such authority as a member of the profession. The Liberal Party's attitude in welcoming the Bill depends not so much on the provisions of the Measure as on the use the Minister intends to make of them. The Bill will provide the means whereby capital can be invested in general practice and, as such, it is to be welcomed.
It would appear that the Clauses relating to salary could make it possible to provide inducements to doctors to go to areas which are at present under-doctored. Nobody is more aware of 1395 the problems facing practitioners in the National Health Service than the Minister. The overall shortage of doctors is very serious indeed, and it would seem that unless active measures are taken in the immediate future the situation will deteriorate.
I recently saw statistics—they were published by the Overseas Migration Board—based on the holders of United Kingdom passports. They showed that 900 British doctors emigrated or went to work overseas in 1964. For those responsible for the administration of the Health Service this is indeed a serious matter. This drain on resources must be stopped, particularly when the needs at home are so desperate.
It would also seem that when there is a general shortage of doctors in an area those who remain in the area find the work they must do so much increased that they, too, are inclined to leave for a part of the country where better conditions are obtainable. In certain areas, according to the statistics, the number of patients far exceeds the requirements of the profession as defined by the profession and the Ministry. Meanwhile, other areas have more than adequate provision. Will the provisions of this Bill help to stop this imbalance in the provision of general practitioner services, or help to bring back some of those doctors who have gone overseas? We hope that this will be the result.
Whilst money is very important, it is clear that working conditions matter most. I am led to believe that many of the doctors who go abroad take substantial cuts in salaries in order to have better working conditions.
The Explanatory and Financial Memorandum states:Clause 2 enables the Corporation to make loans to National Health Service doctors for the provision of premises required by them for the purpose of providing family doctor services and for the repayment of existing loans on such premises.This is very good in itself, but whilst it may be helpful in some cases, I believe that in other cases, if the Minister's object is to find more doctors for the under-doctored areas, he will be much more likely to achieve this by providing health centres and improving premises himself rather 1396 than waiting for doctors to make use of a loan service. I know of my own knowledge and from my acquaintance with doctors that many of them are not ready to take on extra commitments at the present time.
Since the object of the Bill is to improve the family doctor service throughout the country, I should like to refer to a problem which affects my constituency, the Highlands of Scotland generally, and perhaps other areas as well, and which, I think, the Bill's provisions could help to solve. When a doctor has to go off work due to illness or to any other reason, it is often very difficult for him to find a locum. This is particularly true of some of the remote areas. While it is then the function of the regional hospital boards to find a locum, it is difficult at times even for the boards to find someone who will go to some of these areas to relieve general practitioners.
This is no reflection on the boards, because the doctors are just not there. If, however, the boards were able to offer a house in a central position, I am convinced that a doctor could be found to act as a locum. In this case, a doctor who was approaching retiring age, or who had retired, would do very well, indeed, and I am sure that he would enjoy the work very well, as it would not be too arduous. As this is a matter for the Scottish Office—
§ The Under-Secretary of State for Scotland (Mrs. Judith Hart)
I am obliged to the hon. Member for giving way. I am sure that he will know of the existence of the Leslie Committee, which is at present looking into the general problems of medical services for the Highlands and Islands. It is examining this kind of question, recognising, as does the hon. Gentleman, the particular problems of attracting doctors to his constituency and elsewhere.
§ Mr. Mackenzie
I am glad to know that this point is being looked at. In the Highlands it is much easier to find a doctor who will go on a permanent basis rather than as a locum. I am grateful to the hon. Lady for her information.
For two or three years the Liberal Party has been pressing for immediate measures to help to get the under-doctored areas served, and because we feel that these provisions will help to achieve 1397 this end we give the Measure a cordial welcome.
§ 8.45 p.m.
§ Dr. Shirley Summerskill (Halifax)
I welcome this family doctor's Bill as a milestone in the Measures which successive Labour Governments have taken to establish a family doctor service. We read daily of the crisis in general practice, a crisis among doctors. I hope that tomorrow we shall read in equally large letters about the steps this Government have taken to remedy the situation, I hope that people who have daily intimate contact with their general practitioners will appreciate that the Minister and the Government are doing something about the family doctor's welfare and not allowing this crisis to continue and to become worse.
I welcome not only the record of this Minister and this Government but the proposals which my right hon. Friend put forward for the future and the plans that we shall carry out as we proceed with the welfare of general practitioners. As we all know, and is said so often, the general practitioner is the backbone of the National Health Service. This Bill tackles two vitally important problems in his life. First, it improves his working conditions. By means of loans, the first steps towards more group practice are made. A doctor who has inadequate facilities, whose premises are cramped and small, will not consider taking on extra partners. It is only if he has the finance to expand, to modernise or to create new premises that he will think of increasing the number in the partnership from two to three, four or five.
Once we get the idea into his head of the possibility of group practice, we can go on to the possibility of health, sentres. This is the first step towards the citation of health centres which we want to see. Doctors are conservative animals and we have to start gradually so that they hardly notice it. We shall go on from these loans for private practice to health centres.
The second way in which the Bill is highly significant is that it is the first step towards a full-time salaried service of family doctors, for which members of the Socialist Medical Association have been campaigning for years. They look upon a full-time salaried service as an answer to the problems of the general 1398 practitioner, but here again the average doctor does not feel so strongly. Only a minority are fully convinced that a full-time salaried service is the best method of remuneration. This Bill provides the first step to a salaried service. It is a highly significant Bill in these two ways, towards health centres and a salaried service, both of which are advocated by Labour Party doctors, I admit that they are few, but I think these ideas are now becoming gradually accepted by more and more family doctors, particularly the younger ones.
The loans will provide for expanding, modernising and acquiring new premises. If we can get group practices that will alter the whole mode of life of doctors. Doctors are now realising that they have a right to regular hours, adequate holidays and even to a national locum service and an appointments system. They cannot have that unless they work in groups or health centres. These loans will go towards that.
Last year I was in Uganda, which is supposed to be a developing country. Even there they have appreciated that if they are to set up any form of health service they must have health centres and not isolated doctors in different parts of the bush. A group of M.P.s attended the opening of a health centre right in the middle of Uganda, miles from the nearest town. It was opened with great sincerity by the Minister of Health for Uganda, because it was considered significant. I hope that we shall not find in ten years' time that Uganda has 100 health centres whilst we are still staggering along with the few that we have.
I am glad to see that the Bill still leaves the family doctor with his much prized freedom. He hates to think that he will in any way be dominated or ordered about by local authorities or by the State. The objection of doctors to the National Health Service in the beginning was that they feared that there would be snoopers from Whitehall entering the surgery every few minutes to see what they were up to. This, as they have found, did not happen. To their surprise, they are left very much on their own.
I am glad to see that no strings will be attached to these loans. Doctors will be able to decide what improvements they want, what equipment they need if loans 1399 are given for that, and what facilities they require. They can decide how the money will be spent. Similarly, consultants in hospital who are State consultants are given tremendous freedom of action.
This is a great incentive to the older doctor because, whereas the young doctor is used to modern facilities when he trains as a student and when he does his house jobs in hospitals, the older doctor often tends to get into a rut and will put up with premises he has had for 20 years. I expect older doctors to take advantage of these loans.
This is a vitally important Bill, in that it tackles the doctor shortage. It tackles it at its very roots. When young doctors come out of hospital, they have no money. They are badly paid as housemen. They usually have a family to keep. They look round for a job in a general practice. As we have seen, group practices are few and far between because there are not the modern premises and facilities that young doctors want. They will not go into old premises without facilities. The result is that nearly one-quarter, we estimate, go abroad for better working conditions.
The Bill gives doctors the opportunity to obtain capital, either to set up their own group practices or, if they can find premises, to improve and modernise them. I hope that it will also encourage more people to clamour to take up medicine. Admittedly there are not facilities to train them, but the more that clamour to become doctors perhaps the more medical schools my right hon. Friend will see fit to create in conjunction with my right hon. Friend the Secretary of State for Science and Education. I should like to see at least four new medical schools.
I welcome the fact that these loans will be repayable over the whole of a doctor's career and that a doctor will not be expected to pay them back during a set time. This will be a great incentive for the loans to be used. I should like to see preference of loans given to the industrial North and to under-doctored areas. Quite apart from the fact that I want the medical schools to be in the industrial North, the loans should primarily go to places like my own constituency—Halifax—which is an industrial town with a gradu- 1400 ally declining number of family doctors. Each year the number dwindles. This is in addition to the fact that we have an exceptionally large number of old people in Halifax and in the West Riding in general.
It is the under-doctored areas which face the real crisis today. To take an example of another under-doctored area, some figures have been produced of the crisis in the Rhondda. There are 100,000 people in the Rhondda, and to serve them they have 38 family doctors. Of those 38 doctors, 37 are principals of whom one is 92 years old, another is 77, and 9 are between 60 and 70. This is no reflection on- hon. Members who may be of these ages, but it is rather an advanced age to be in active general practice among 100,000 people. The situation in the Rhondda is an illustration of the fact that doctors in these areas are being grossly overworked, and it is here that we must encourage young people to take up practice. I want these loans to be considered by the general public not as an act of charity but as a sound economic investment in the interests of the community.
The second significant point of the Bill is that it represents the first step towards a salaried service. It will be many years before the average family doctor accepts this as desirable, but a large number of the younger ones are coming to support the idea. Young doctors will no longer emigrate if they believe that their method remuneration can be more favourable.
I am glad to hear my right hon. Friend's proposal for considering, when he thinks further on the question of a salary service, the conditions of employment. It is vital that he should relate the salary to the work load, to the responsibility of the doctor and to the morbidity in his area. Doctors feel now that they have a right to reasonable conditions of work as well as to a reasonable method of remuneration. In this way, too, we shall be able to tackle the shortage of doctors because married women will be able to take up part-time posts where they are urgently needed, on a salaried basis. If we are to create an occupational health service in the years to come, we shall certainly need doctors working part-time in a salaried service. In all the professions, nursing, teaching 1401 and medicine, people must expect that far more part-time posts will require to be filled, particularly among married women.
I should like the salary to vary according to the areas in which doctors serve. At present, medical officers of health are salaried, and, in an over-populated area, with more work to do, a medical officer of health is, naturally, paid more than his counterpart in a less populated area where the work is not so onerous. The same should apply to doctors who are paid by salary, and this, again, would help to attract them to the under-doctored areas.
I welcome the Bill as a Measure which will bring in eventually, in the distant future, group practices, leading to health centres, and a salaried service for family doctors. The right hon. Member for Bridlington (Mr. Wood). saying that we were giving not grants but only loans, made the comment that our promises were not as good as our performance. I do not want to bring a note of acrimony into this pleasant debate—
§ Dr. Summerskill
I can only say that the right hon. Gentleman and his hon. Friends had no performance at all over the past 13 years. At least, we have made an effort to bring in a piece of positive legislation to help the family doctor. I welcome the Bill, and I hope that we shall go on to introduce more legislation, quietly and calmly, bringing in eventually the sort of National Health Service to which the first Labour Government aspired but which has been slightly delayed over the past few years.
§ 9.0 p.m.
§ Mr. Laurence Pavitt (Willesden, West)
This is the first time in my experience in this House that I have had the pleasure of following an hon. Member from my own side of the House. I do not know whether this is indicative of the general agreement on the excellence of the Bill, which means that hon. Members opposite are content for us to carry it through, or of the strength of the Government at this time.
I was interested in the comments of my hon. and qualified Friend the Member 1402 for Halifax (Dr. Summerskill). I may point out that I am the first layman to speak from the back benches on this side of the House. My hon. Friend the Member for Wandsworth, Central (Dr. David Kerr) also speaks as a doctor. My hon. Friend the Member for Halifax forcefully made the point, which I accept, that since the National Health Service began we have been trying to get a more rational, logical and reasonable organisation into the system of family doctoring.
At the same time, we have always been committed to persuasion rather than compulsion in achieving the things we hope to see emerging over the years, such as health centres and a full salaried service. The Bill is a measure of the way in which we can reach the kind of objectives we want through what the Fabians called the inevitability of gradualness.
I welcome the fact that the voice raised among hon. Members opposite comes from Scotland and the Liberal benches in the person of the hon. Member for Ross and Cromarty (Mr. Alasdair Mackenzie) because, in so many health debates, the Liberal voice has been the prerogative of the hon. Member for Orpington (Mr. Lubbock).
I also welcome the comments made about under-doctoring by my hon. Friend the Member for Halifax. As she pointed out, this is not just a question of total numbers. It has a great deal to do with distribution. In many industrial areas of the kind served by my hon. Friend, the average number of patients per doctor is 2,900 to 3,000, while in Bournemouth, for example, the average is under 600. The question is not only about numbers of G.P.s but how we are to get a rational distribution to make sure we get the doctors in the right places. This Bill will help to that end.
The hon. Member for Ross and Cromarty also raised the question of the tremendous problems arising from the shortage of doctors. It is trite to talk about the 1957 Willink Report, which reduced student intake. But the problem faced by my right hon. Friend the Minister of Health is that we cannot produce more doctors in under seven years. Thus, the Bill is one of a number of many things which must be done. It will be some years before we can get out of these difficulties.
1403 I ask the House not to accept too readily the figure of 900 doctors per year emigrating. I went into the figures quoted by Dr. Seale and the arguments when they were first made. The right hon. Member for Wolverhampton, South-West (Mr. Powell), when he was Minister of Health, did some extremely useful mathematics at that time which demolished a number of figures that were being quoted. I accept that there is a problem and that more doctors leave the country than we should like, but we should not exaggerate the extent of the problem.
I share the welcome given in general to the Bill. We must recognise that, a year ago, we faced a bad atmosphere in the medical profession. There was the threat of withdrawal. To the tributes already paid to him, I would add my own to my right hon. Friend. In spite of the great difficulties that he faced, he has produced a new atmosphere between the Government and the doctors. This Bill, and the general support of it, is indicative of the success of the 40 meetings mentioned by the right hon. Member for Bridlington (Mr. Wood). My right hon. Friend has made a slow, patient and very tolerant approach and that has led to the possibility of geting as far as the present proposals and beyond.
The referendum among the doctors which gave the background to the Bill showed that 17,602 were prepared to accept the new arangements subject to pricing and that only 2,660 were against. Less than 12 months ago, these figures were reversed, when 17,000 wanted to opt out of the National Health Service. It will be a comfort to my right hon. Friend to recall, however, that referenda among doctors do not necessarily reflect their practice. In 1948, in a referendum, 24,000 said that they would not join the National Health Service but, only a few months later, when it began, 21,000 joined.
The main provision of the Bill is twofold. I believe that this is part of a larger and grand design that has been going on ever since October, 1964, to move away from a curative to a preventive National Health Service. To do that we have to seek fresh methods of organisation. By doing what I hope will be fundamental and seeking to help the general practitioner in the vital part he will have to play if we are to move 1404 towards preventive medicine and to give him the kind of conditions and tools and surroundings which will enable him to do the job, the Bill will be an important step in that direction.
The Bill provides an opportunity to do something about premises. There have already been two attempts to give doctors the right kind of premises from which to practise. Section 21 of the Health Act was obviously the right answer if only doctors would have accepted it, for there would then have been established local authority health centres custom built for the job. That did not materialise for a number of reasons not least because of the doctors' suspicions.
Group practice loans were another effort to persuade doctors to use cooperative rather than individualistic methods. That has had some little success, although the accent must be on "little". In 1963, the last year for which I have figures, only 95 loans amounting to a total of£608,000 were taken up in this interest-free arrangement. I hope that the group practice loans will continue to operate on the establishment of the Finance Corporation. The money involved was set aside from the doctor's own money—it was part of the global pool—and I hope that not only will the loans continue, but that other incentives will be offered towards providing a more rational approach to domiciliary medicine.
The Group Practice Finance Corporation only facilitates the money arrangements and it would be interesting to know whether my right hon. Friend will try to get interest rates lower than would be the case on the openmarket. As I understand the Bill, if he did, that would mean that in the immediate future the Corporation could no longer be self-supporting and financially viable. I hope that the provision calling for financial stability over a period of time will mean that it is possible for the Corporation to be heavily in deficit over an interim period, provided that it can catch up with its deficits in the long run.
I hope that the Bill will provide the power to help doctors not only with finance, but to have the right kind of premises. In the Ministry there is a very fine hospital building unit, as there is in the Ministry of Education for the schools, 1405 in order to provide rationalised building by getting standard patterns and know-how for the required functional building. For general practice there has recently been established a voluntary centre set up with the aid of the College of General Practitioners and with some help from the B.M.A. and the M.P.U. But it is running very much on a shoe-string and a great deal more architectural advice and service is needed.
For instance, if there is to be an appointment system, as one would hope in new premises, the best architectural advice is required so that the receptionists and health visitors and other ancillary services can be sited where they will be best suited to the general practitioner. I hope that the Finance Corporation will have a department of promotion, or an evangelical approach to improved methods, able to give doctors the knowledge needed for co-operative medicine, a subject on which at the moment they have to get advice from many different sources.
I hope that when my right hon. Friend replies to the debate he will say what happens in connection with the Clause allowing for the alteration of existing premises, and for the rationalisation of existing groups of doctors. Will there be some compensation for redundant premises? What happens to the doctor or group of doctors operating from a house, for which they have had to pay excessively because it is a doctor's house on the corner? If it was bought before the Act came into effect, or even if it was bought afterwards, there could be a hidden goodwill in the price. If some of these old premises are to be made redundant, it may be difficult to persuade doctors to come into groups to practise, or to operate under this scheme if they find that they have a very heavy financial loss as a result of having to convert their houses, which are their business premises and homes, into purely residential accommodation.
I was interested in the Minister's comments on Clause 3 on the subject of equipment. I should like to know what kind of powers the Corporation will have in order to prevent overlapping of the provision of equipment as a result of the general practitioners having loans and the National Health Service providing facilities for G.P.s through its other sec- 1406 tors. The Minister gave the example of the need for sterile syringes. At the moment a number of hospitals are making available such syringes to G.P.s. Will there be some form of overlapping here so that we find ourselves paying for a sterile syringe service in the local hospital which can be used by the G.P.sthe last such scheme I looked at was going to cost about£20,000—while the G.P.s are running another duplicate service?
In the same way when there is a possibility of new diagnostic aids for the doctors, will they be encouraged to do their own X-rays or will arrangements be made through the local hospital, and access provided, thus avoiding having expensive equipment as part of the loan? The point of co-ordination will have to be thoroughly looked at during the Committee stage. There are many decisions that the Corporation will have to make concerning the local health authority and the local hospital. My hon. Friend the Member for Willesden, East (Mr. Free-son) raised the question on Monday of the power of the local health authority to initiate health centres and to pay G.P.s to provide services from such centres. This means that one would have different responsibilities between the local executive council and the health council. In many cases it would be advisable, where a local authority is going ahead with a wide scale of local health coverage, for the local health authority to have power to move into this area and help with the payment of doctors' salaries, through arrangements with the local health committee and local executive committee.
The more we reach the stage where we can achieve a rationalisation in family doctoring, the more the divorce between the three wings of the service becomes apparent. I hope that the decision to give loans will be seen against the other decisions mentioned by the Minister, including the arrangements for rent and rates to be reimbursed to doctors under new expenses arrangements. This opens a new sphere. If the public and the State are to pay the total amount of rent and rates then we have a right to know that we are getting value for money. It could be that the Corporation could ensure that, because it will enable the right kind of premises. If all that we do is given carte blanche, so that whatever 1407 rents and rates are paid they will be reimbursed, we shall inherit, as we have in many undertakings, a whole host of decrepit property, which is run down, and for which we have to pay very high prices, and which would be far more useful if it could be turned to some other purpose. We need the custom-built centres.
I hope that the financial considerations will not prove to be too onerous. In my view,£10 million a year is inadequate over the long term. I presume that we will see how this goes in the first period. I am delighted that nobody has sought to find money from that place which has been, for the last 12 months, the sole repository of money as far as the Chancellor of the Exchequer is concerned. I refer to the£38 million which has been paid in abolishing the prescription charges. In the discussions which have gone on about reorganising the Health Service it is surprising how often that money for prescription charges has been spent to give the doctors money, to build hospitals, to pay nurses and to satisfy so many other needs. Even the right hon. Member for Birmingham, Handsworth (Sir E. Boyle) has built training colleges with it. It has been argued that if we taxed the sick, with this 2s. we should be able to pay for everything that the nation wants—roads, railways, the lot.
I hope that the Minister will ensure that, from wherever else he gets the finance for the Bill, we do not return to the time when a person with a coronary thrombosis is taxed regularly for 100 pills a week. I hope that we shall never return to the stage when the more sick people are the more they are taxed. The Bill should lead away from the past attempt to make health some kind of commodity which one buys and sells in the market place and restore it to the kind of social service which was undoubtedly behind the inception of the Act.
I welcome Clause 10. I have pressed for this in the House during the last six years and have continued to press that doctors should have this option in deciding their remuneration. I can never understand the difference about a cheque which is received once a month computed in one way and a cheque which is regarded as a salary. If they get a cheque once a month, however it is com- 1408 puted, they are being paid a salary by the community. It is amazing how many general practitioners would be only too pleased to be consultants with an A merit award, but the consultant gets a salary. Nobody says that for that reason he has less status than a general practitioner.
The capitation basis gives a very rough and ready measurement of a doctor's service to the community. May I give the House a very short example? A doctor working in Swansea with 1,000 patients will do as many items of service as a doctor working in Surrey with 3,000 patients. They would do precisely the same amount of work if one averaged out the items of service between Swansea and Surrey. But the doctor in Surrey will get three times the amount of remuneration of the doctor in Swansea. Although this is only a first step towards a salaried service, if we are to achieve greater justice between doctor and doctor it is a step in the right direction.
The Bill will receive a good deal of support not only from my hon. Friends who are doctors but from a number of general practitioners in the country. Unless they support the other measures which the Minister is trying to get through on behalf of the family doctor service, however, it will be difficult for the family doctors as we know them to survive. Domiciliary medicine can be organised in other ways. It is possible to have polyclinics. It is possible to find other ways to deal with people when they are sick in their homes. But the family doctor service is the best way to do it if only it can be organised in a proper and rational manner.
As I said at the outset, I believe that this valuable Bill is the first step to a large number of very important Measures which we shall need in the next few years to get away from merely curing illness to preventing it from starting. The only way in which that can be done is to give the family doctor a smaller number of patients so that he can give them adequate time before they are ill.
§ 9.20 p.m.
§ Mr. Michael Foot (Ebbw Vale)
This has been an extremely quiet debate, as many hon. Members have remarked, and it is certainly not my intention to disturb the quietness, even if I could. It is, 1409 however, proper for one who has the honour of being the Member for Ebbw Vale to note that there is a slight ironic nip in the air.
First, if we consider the Minister himself, it is a very different situation, as has already been noticed, from that which was described in the newspapers some months ago. We do not yet know how the newspapers will report this debate tomorrow, but it would be an instructive exercise, both for the doctors, for the newspapers and for the country at large, if alongside reporting the quietness of this debate they were to print several of the headlines that were published at that time. It would be very helpful for the doctors, among others, because they would be able to judge whether the charges made against my right hon. Friend were correct. He was in some quarters portrayed as an enemy of the medical profession, as one who was out to deal with them in the most monstrous fashion. But there is not one doctor or representative of the doctors who says that today, certainly none in this House, and the doctors have always had a few representatives here. Therefore, on those grounds, it is proper that we should underline this contrast between the atmosphere that was stirred up a few months ago and the reality of today.
That is not the only contrast which we should note. The Minister referred in his speech to the far-sightedness of some of those who were engaged in the controversies when the National Health Service was introduced. With his usual superlative tact he did not make any special awards as to who among them were far-sighted. My right hon. Friend is an extremely skilled negotiator. Indeed, his negotiating skill has a certain therapeutic quality about it, if that is the right word. He manages to reduce neuroses that seem to grow in the minds of those with whom he has to deal.
Not only were the doctors or their organisations a year ago working themselves into an extraordinary state, for which I do not know the medical name, but they did the same thing 20 years ago. It was exactly 20 years ago, in February, 1946, that the late Aneurin Bevan presented his first outline of a National Health Service to the doctors' organisations. Several other arguments were used, but it is worth recalling that 1410 the major argument over the next two years prior to the introduction of the Service concerned exactly the matter which is dealt with in Clause 10 of the Bill.
When Aneurin Bevan made his proposals to the doctors, it was immediately said by their representatives that one of the reasons why they opposed the Bill and why they proposed not to work it was that it was a conspiracy to enforce a complete salaried system upon the doctors. That was their interpretation of the original Bill. Anybody can confirm what I say by reading the first reactions of the British Medical Association and some of the other doctors' organisations, who at that time denounced the whole of the Bill which eventually became law precisely on the ground to which we are now referring.
What happened over those years of controversy was that Aneurin Bevan made it clear that it was never his intention to introduce the State salaried system that the doctors were saying he intended to introduce, but that what he wanted and intended to do was to give the doctors the greatest possible flexibility of choice. "Flexibility" is the word that was used by the Minister today. It is now perfectly accepted by the doctors. In 1946, however, "flexibility" was regarded by the doctors as a word that was almost unmentionable. The doctors then made the most scandalous charges against him because of the flexible apparatus that he was proposing to introduce for the payment of doctors, and what the doctors have secured under their charter is what Aneurin Bevan originally offered them and which they rejected, if I may say so, with a certain degree of discourtesy.
It is useful for us to remember these things. I do not know whether the hon. Member for York (Mr. Longbottom) was here on that occasion. If he had been, he would have voted three times against the proposition which is now passing through the House perfectly acceptably.
The Amendment Act of 1949 was the last concession made to the doctors because they said that they would not agree to serve under the National Health Service if it were not provided by law that the benefits for the doctors which had been included in the Bill were withdrawn. Aneurin Bevan was perfectly prepared 1411 to agree to that. It was said that it was a great concession that he had made, but, as he had been prepared to agree with what the doctors wanted on that head all along, it was not a concession. However, he made it look like a concession, and it may be that that is why the doctors came in.
The doctors should look back to that when they next engage in negotiations and remember that it is wiser to listen to the Minister of Health of a Labour Government or to the Ministry of Health itself, which was subject to many attacks from the medical profession. Damaging things were said about the Ministry. Among other things, it was said that it wished to injure the medical profession. What is being sought by the medical profession today as a concession is seomething that the Ministry was in favour of 20 years ago, along with the Minister.
I was interested in what my right hon. Friend said about health centres, and I am glad to see the progress which has been made, as Aneurin Bevan would be. Health centres were a principal part of the Act, a special section being provided for them.
Many of the things which are now regarded as original were envisaged by him in that original Act. It was only the physical circumstances at the time which in his view prevented the much speedier progress towards health centres 20 years ago which might have solved many of the further problems which the doctors have been debating during the past three years. It may be that the doctors should pay some respect to the politicians on that score—not all politicians, but some of them.
Another major purpose of the National Health Service Act was to ensure a better distribution of doctors, which was something that had never been attempted in previous years. No plan had been devised over the previous 30 or 40 years for trying to influence where doctors should serve.
I am not saying that the Act has achieved everything that we should desire in that respect, because it has not. The figures given by one of my hon. Friends about the Rhondda are very significant, and they apply in my own constituency and in other parts of the 1412 country which have severe difficulties on that account. These were foreseen by the Act which the Labour Government introduced in 1946. It was a very far-seeing Act.
Nothing that we are discussing today was not foreseen in the Act which was introduced then. We are catching up with some of the original proposals which were put to the medical profession in 1946. Some of the things that they regarded with horror then they now acclaim as being acceptable contributions to their welfare. These are important facts for us to remember.
It is perfectly true that there is one proposition that Aneurin Bevan put to the doctors which has not been carried further. After they had had all these controversies, when they had been settled and the doctors came into the Service, he was asked what was his future longterm prospect for the doctors. His reply was that he wanted to see a high incidence of unemployment. [HON. MEMBERS: "Hear, hear."] We have not moved fast enough yet, but I believe that we are taking steps in that direction. My hon. Friend the Member for Willesden, West (Mr. Pavitt) talked of the preventive side of the Act and of it being a further step. One of the objectives of the Act was to substitute preventive medicine for curative medicine as much as it could be done, and even now it has not gone as far as we would like.
Another thing which he foresaw was that the structure which was originally devised, partly for the purpose of encouraging the confidence of doctors, was not to be a permanent one. Indeed, he made proposals very soon afterwards for overhauling the structure to make it more democratic. This, too, was foreseen, and I hope that this is one of the matters with which the Minister will proceed after his great success in getting this Measure through so successfully and with such universal approval. I hope that he will proceed to examine the structure so that we can make it much more democratic.
I think that when the doctors look back on this history they should recognise that they owe a debt to the National Health Service. We have had many tributes paid to the Minister, and quite rightly. I think that he deserves them 1413 all for the way in which he has assisted doctors. They have deserved assistance in the many hardships with which they have had to deal, but they owe a debt to the National Health Service.
Doctors must play fair with the Service. Not all are doing so, and some who ate not are bringing the whole Service into disrepute. It is very difficult to put one's finger on the practices which are bringing the Service into disrepute, but we all know about them. We know that some doctors give preference to people who can pay. This must be stamped out, and the whole medical profession, for its own good name, should be eager to stamp it out. It is very difficult to supply the Minister with evidence of it, but we know that it occurs. Fair-minded doctors who look at the history of the past twenty years and look at how successive Governments, in particular the Labour Government of 1945 and the present Government, have dealt with them, must realise that the medical professional has no grievance against the Labour Party. I think they must acknowledge that on both occasions the Government and the Department have done their best to understand the problems of doctors and to provide them with the equipment and apparatus for discharging their professional skills. Every doctor in the country should recognise what he owes in this respect.
There is perhaps one other more general moral which might be appreciated by the country and by the Government. It is that what Ebbw Vale says today will be unanimously welcomed by the nation twenty years hence, and probably the greatest problem of the nation and of the Government is to try to reduce this time lag.
§ 9.33 p.m.
§ Mr. William Shepherd (Cheadle)
It is very enjoyable to be able to follow the hon. Member for Ebbw Vale (Mr. M. Foot) and agree with something that he has said. I approve of what he said about Aneurin Bevan, and I approve, too, his approbation of the National Health Service.
During the last year or so the Service has been under considerable fire from unworthy elements in our own country, aided by even more materially minded elements from across the water and other 1414 parts of the world. I think that when one is able to stand back for a longer period than twenty years and look at this system, one will still find that it is one which will stand the tests of time, and one which, in the long run, other nations will follow.
The hon. Member for Willesden, East (Mr. Pavitt) made a lot of claims for the Bill which I do not find in it. The suggestion that it is going to open up a vast era of preventive medicine is a view which I cannot find anywhere in it, and I hope that in the course of the years we shall devote much more of our time and resources to preventive medicine, and for that matter to industrial medicine, because I feel that these are two spheres in which we can spend the nation's money to advantage.
The hon. Member for Willesden, East was also rather naïve when he referred to prescription charges. I have never been very keen on prescription charges, but I shall not go into the reasons for that. It is the least effective way of spending the nation's money to pour cascades of medicine down people's throats, and it is perhaps even less effective to put them into medicine cupboards.
The dissatisfaction that I felt with the hon. Member was more because of his complacency about the method of financing the National Health Service. We have been hopelessly unimaginative and unprogressive about this. In 1946 we instituted a method, and we have not sought subsequently to consider an alternative. The additional amount which the Bill will bring to bear upon the public purse should be dealt with in some other manner, although for the sake of brevity I will not now deal with that question.
My main purpose in rising was to congratulate the Minister on the changes which he has brought to the scene. Last year I said some rather harsh things about doctors because I felt very angry with many of them. I thought that for professional men their behaviour was intolerable, and I still feel that there is a tendency among people who are paid by the State to think that if they kick up enough row they can extort from the State the most inordinate demands. I do not like to see professional men behaving in this way.
1415 But I can find some excuses for the doctors. I hope that hon. Members will consider the mechanics by which doctors arrive at their decisions, and their methods of consultation with each other. We are apt to think that the methods of the House are out of date, but I suggest that hon. Members should study the mechanics of the doctors. They will realise that they are so hopelessly Heath-Robinson that it is not surprising that doctors often get into the sort of difficulty they got into last year.
I hope that doctors will examine their consultative machinery and try to produce a system which will more accurately reflect their opinion, for it is almost impossible for the existing machinery to do so. Further, it is almost impossible for the doctors' leaders to be effective in their leadership.
I am glad that the right hon. Gentleman has succeeded in creating a more rational atmosphere. At one time I feared that he was being a little too generous and accommodating, but I realise that there are various methods of achieving a given end and that the most direct method is not always the most effective. I congratulate the Minister—and I also congratulate the doctors on having got over an almost neurotic period and on now realising that any major disturbance in the concept of the National Health Service is not a practical reality, and that their job is to co-operate with others engaged in medicine to produce the best kind of service.
I hope that we are now soundly launched upon a new era in which doctors will direct their attention not to their own grievances, or to the shortcomings of the National Health Service, or to the dfficulties created by a tiny minority of their patients, but to an all-out effort to improve the standards of medicine. Those standards are not sufficiently high. The report of the College of General Practitioners shows that the authoritative body of doctors themselves agree that there is a great distance to travel before we reach a sufficiently high standard.
I hope that general practitioners—especially the young ones—will realise that it is their duty to work for the best possible end in improving the existing service, because no substantial alteration 1416 in this concept is possible or likely in the near or relatively distant future.
I have some criticism of the salaried service. I said to doctors while they were in this difficult frame of mind, "What this so-and-so "—naming the Minister— "is really after is to get you into a salaried service and you are not sensible or alert enough to realise it." I do not want to see doctors in salaried service, because it will impose on them certain elements of supervision which are not compatible with the job of a general medical practitioner.
I should like to see this principle applied even more strongly to hospital service. I would like to get rid of multiple consultations and make many changes there. It is not desirable to extend the field of salaried service for the general practitioner. I appreciate that there are circumstances in which salaried service becomes inescapable, but I hope that the Minister will restrict his application of such a service to the minimum.
On the whole, I do not think that the best type of doctor, who wants to give his best and do the greatest amount of work, will opt for a salaried service. I do not say that very worth-while doctors will not seek a salaried service, but, on the whole, the man who is most likely to render the most service to medicine will not be attracted to a salaried service. Therefore, I hope that the right hon. Gentleman will limit to the greatest possible degree the application of a salaried service.
I welcome the Bill, and I hope that doctors will take the consequences, not only for tidier and easier minds, but for tidier and easier surgeries in which to work. I emphasise above all that medicine is not simply a matter of a nice clean, tidy, efficient surgery, or even of having an efficient secretary. Medicine is something entirely removed from that. Although I do not deny the merits of these physical aims, the intangibles in medicine still remain the most important thing.
§ 9.44 p.m.
§ Mr. Charles Longbottom (York)
It is always a great pleasure for the House to listen to the hon. Member for Ebbw Vale (Mr. Michael Foot) and it was right of him to remind us of the enormous part 1417 played in the Health Service by his distinguished predecessor as Member for Ebbw Vale. Those of us who have had the pleasure of reading the hon. Member's writings about his predecessor appreciate fully everything he has said today about the way in which the Health Service came into being.
It is a great pleasure to see that the hon. Member approves of at least one small thing which this Government are doing. He has had to suffer much over the past 16 months. Often, we have seen him glowering in a corner or jumping to his feet in agonised appraisal of some items of Government policy which have happened since October, 1964. This is only a small progress, but it is a very good thing and we are delighted to see that at least this one Measure of this Government attracts his approval.
The Minister referred to one or two items which I should like to mention before coming to the Bill. He mentioned the question of free supplies of disposable needles for doctors. I took up with him in private correspondence on behalf of a constituent the question of why this should not be similarly applied to dentists and I was not completely convinced by his answer. I wonder whether he could have another look at this, as there are good grounds for believing that the requirements of sterilisation and hygiene, which is the reason for the doctors' need, are equally as important for dentists. For that matter, in his consideration of the Bill would the Minister consider the needs of dentists generally in this connection because in some areas the problem of their practices, surgeries and waiting rooms must be as great as it is for doctors?
It is appreciated on both sides that the sharing of professional knowledge, group practice, is right and that the ability to hire ancillary staff is bound to lead to better medicine. However, I share the feelings of the hon. Member for Wandsworth, Central (Dr. David Kerr), particularly in view of the statistics he quoted for the number of group practices in existence today compared with two years ago. I, too, wonder whether we are doing enough to encourage group practice.
The Bill is one of a number of moves the Minister is taking to help the relationship between the general practitioner and his patient. It is, therefore, extremely 1418 valuable. Doctors should have all the modern means to hand and the Minister rightly said that the profession attaches great importance to this. It is equally important for the patient to feel that he can go into a well-aired doctors' surgery and that, particularly if he must wait for quite a long time on what might be called a nervous occasion, he can sit in a reasonably congenial waiting room. Since the Bill will be of help to both doctors and patients, it is to be welcomed by all hon. Members.
I will deal with a number of questions which have been raised but which the Minister has not yet had an opportunity to answer. I hope that he will answer them all when he replies. When the question of interest-free loans was discussed it was pointed out how small in number they were. Indeed, the hon. Member for Willesden, West (Mr. Pavitt) quoted the figure of only 95 loans amounting to£608,000.
§ Mr. Longbottom
That makes my argument even stronger. Considering the speeches which the Minister made about two years ago when he was on this side of the House, and considering the special cases for which these loans were made and how they will be affected by the operation of the Measure, has the right hon. Gentleman any comment to make about the future status of the loans which have been made? I imagine that they will continue to be based on the contractual obligations originally entered into. Would the right hon. Gentleman confirm this?
We appreciate that the Minister is setting up a Corporation to provide more attractive terms than those available in the open market. Will this apply in terms of years, remembering that the banks are notoriously "short" in the number of years over which they lend money? I was rather mystified by the Minister's remark about loans possibly applying for the period during which a doctor is in practice. Does he anticipate that a doctor going into practice at, say, 25 and retiring at, say, 65 will be able to repay the loan over the whole of that period? Or, if a doctor retires earlier, will he, when he sells his practice, be able to transfer his loan to his successor? This is an important provision and, perhaps, one of the 1419 drawbacks to anything that could be done privately in this sphere.
The Minister was right in what he said about the rate of interest. As the Corporation will not be able to make either a profit or a loss, taking many years into account, there must obviously be a rational rate of interest, but does the right hon. Gentleman envisage a permanent or fluctuating rate of interest on loans from their inception? If the Corporation has to borrow in the open market it will presumably have to pay, perhaps, 1½per cent. above the current Bank Rate.
We are in a period of high Bank Rate now and the Corporation may have to borrow at 7 per cent. or 7½per cent., but we hope that when this Government eventually come round to bringing a better side to our economic affairs—or, certainly, when the next Government come in and do so—the present high rate of interest will be much reduced. In that case, the Corporation might in two or three years' time, or longer, be able to borrow at a substantially reduced rate. Are the people who borrow from the Corporation to be subject permanently to the rate of interest operating when they borrow, or will the rate fluctuate, as it would with a building society? I presume that the latter will be the case if the Corporation has to borrow at different rates.
I hope also that the activities of the Corporation will not be affected by any credit squeeze that might be imposed in future. It may be difficult for it to borrow in the open market, and I hope that there will not be a clamp down on its borrowing money there.
The hon. Member for Wandsworth, Central and the hon. Member for Halifax (Dr. Summerskill) have both referred to the fact that in the centre of urban areas the cost of buying premises is extremely high. I therefore hope that the Minister will not set some rigid ceiling on the amount of loans. Group practices in high-cost areas where land and buildings are extremely expensive will have to borrow substantial sums in order to take full benefit of the scheme—
§ Dr. David Kerr
Will not the hon. Gentleman agree that this point is covered by the other proposals of my right hon. 1420 Friend, which will deal with these high-cost rents on a pro rata basis?
§ Mr. Longbottom
I am not entirely clear or satisfied that they will. I am sure that those hon. Members who have knowledge of the high cost of offices or other premises in any of our large urban areas will recognise that group practices that are necessary there will need to borrow very much larger sums of money than would be needed in an ordinary small community or town, and at the moment I am much more keen on asking that there should be no rigid ceiling over and above that sum.
I am glad that the Minister made it very clear that two things will happen before Clause 10 operates; first of all, that there will be consultation with the medical profession as a whole and, secondly, that no salaried service or conditions will come about without the consent of the practitioner concerned. Those two points are an adequate safeguard to the profession—a safeguard that, having listened to the speeches of the hon. Member for Halifax and the hon. Member for Ebbw Vale, I can well see the profession wanting.
I appreciate that the Minister has not yet had time to do so, but will he say, in answer to the question posed by my hon. Friend the Member for Bridlington (Mr. Wood) whether Clause 10, and particularly subsection (2) of Clause 10, will be subject to the approval of the House, not in every case in which this would be used, but in the general overall circumstances in which this salaried service would happen? This is such a departure from previous practice in this field that it is right—I hope that the Minister will be able to give us the assurance—that it should be subject to the approval of this House. Subject to the answers to the questions we have posed from this side of the House, this Bill has our approval and we commend it to the House.
§ 9.55 p.m.
§ Mr. Derek Page (King's Lynn)
I am grateful for the opportunity to speak in this debate and I will not impose on the House for more than a few moments. I add my congratulations to my right hon. Friend for a very worthy Bill and for the dignified way in which he has comported himself over the last 12 months. He is greatly to be congratulated.
1421 One matter which has been raised by certain practitioners in my constituency was touched upon by my hon. Friend the Member for Willesden, West (Mr. Pavitt). It concerns the disturbance which doctors are likely to encounter when entering group practice or health centres. This is liable to be a very severe stumbling block in the implementation of the ideas my right hon. Friend has in mind. I refer to the health centre report of the Medical Practitioners' Union which mentioned that the figures for the capital cost of health centres were difficult to assess due to the varied methods of presentation of accounts and that they all failed to take account of the cost of premises vacated by general practitioners and the subsequent lost value.
When general practitioners, particularly the more senior ones, are faced with the possibility of joining a scheme for a health centre they may be deterred when they realise that the value of consulting rooms and facilities they have installed—sometimes at quite considerable expense, in their own premises and often in their own homes—will be reduced to nothing. We may find great resistance on this, particularly from some of the more senior general practitioners. I urge my right hon. Friend to consider the matter and see whether it is possible to arrange some sort of compensation for the loss and disturbance caused to general practitioners.
My hon. Friend the Member for Wandsworth, Central (Dr. David Kerr) made a point regarding the inclusion of dentists. In my constituency the ratio of dentists to patients is very low indeed, considerably lower than in other parts of the country. I have had approaches made from outside dentists about the possibility of moving into the area. They have asked what help could be afforded locally in obtaining suitable premises. I add my voice to those raised earlier on this matter. I cannot see why dentists should be excluded from the type of aid covered in the Bill. I urge my right hon. Friend to consider this point most carefully.
I am grateful to you, Mr. Speaker, for the time you have afforded me and I again compliment my right hon. Friend on the Bill. The improvement in the service offered to patients cannot be over-estimated. We have all had experi- 1422 ence of grim consulting rooms and waiting rooms over so many years. This Bill can be a major Measure in overhauling these conditions. One matter which has not been raised so far is that administration and keeping of records, which is becoming an increasingly important part of medical practice, will become infinitely easier with the facilities afforded by the Bill. Hospitals place tremendous emphasis on accurate record-keeping. The visits of patients to doctors—
§ It being Ten o'clock, the debate stood adjourned.
§ Question again proposed, That the Bill be now read a Second time.
Great emphasis has been placed by hospitals on the importance of record-keeping. Visits by patients to general practitioners are much more frequent than their visits to hospital and, therefore, the records much more difficult to maintain. This is becoming an increasing load on general practitioners. The health centres, which will be made so much easier to achieve by the Bill, will be a tremendous advantage in securing the more accurate maintenance of records by general practitioners.
I again congratulate my right hon. Friend and ask him particularly to consider at a later stage the two major points I have mentioned—first, compensation to doctors for disturbance, and, secondly, the inclusion of dentists in the provision of the facilities that he offers.
§ 10.1 p.m.
§ Mr. Robinson
I beg the House's pardon and yours, Mr. Speaker. With the leave of the House, perhaps I may answer the points which have been raised in the debate. I was saying that I am extremely grateful for the welcome the Bill has received on all sides of the House. Before I deal with the points which have been raised—first, those of the right hon. Member for Bridlington (Mr. Wood)—may I say how sincerely I associate my 1423 hon. Friends and myself with the tribute he paid to our late colleague, Dame Edith Pitt. Not only did I have a good deal to do with her when she was Parliamentary Secretary to the Ministry and afterwards when we crossed swords in debate, but I also travelled under her leadership on a Parliamentary delegation to Cyprus, when I got to know her extremely well. I am sure that all her friends will feel her loss very deeply.
The right hon. Gentleman asked me a number of questions. The first was what would happen to the Report of the Review Body. I am sure that he did not expect me to give him a very detailed answer to this. I can only tell him that he would not expect me to say what action the Government would take on the Report which they have not yet seen. They will decide the action to take as soon as the Review Body has reported. The right hon. Gentleman will not have to contain himself very much longer before that happens.
The right hon. Gentleman and the hon. Member for York (Mr. Longbottom) asked what would happen to the group practice interest-free loan scheme with the coming into operation of the Finance Corporation. The House might be interested to know that 618 loans have been approved, amounting to£3,640,000. The existence of the Finance Corporation need not affect in any way loans already made. If borrowers of the interest-free loans so wish, the loans could continue to be repayable to the executive councils and they will remain interest free. There will be consequential adjustments resulting from the reimbursement of practice expenses. The scheme will come to an end and in future borrowers will be expected to go to the Corporation for their finance.
There is a transitional problem of the loans, which I believe may total about£600,000, which have been approved but which will not be issued by the time the Corporation starts its operations. We shall have to work out in detail with the profession what is to happen in these cases, but I do not myself foresee any serious difficulties here.
We would not withdraw from such doctors the option of an interest-free loan if that was what they preferred. But I imagine that the right hon. Gentleman 1424 and the House will realise that the attraction of the interest-free loan is no longer, or will, we hope, under the new contract be no longer what it was, since notional rents and also actual rents paid will be directly reimbursed under the new contract. The interest-free attraction, therefore, becomes substantially less.
The right hon. Gentleman said that under the new system the encouragement to group practice was more incidental than specific, since not only group practices would be able to obtain loans from the Corporation. It is because of this that we have had to look for some new form of financial inducement towards group practice, and this is embodied in the new method of payment in the form of a supplement to the basic practice allowance to doctors who practise in groups—groups, incidentally, as defined by the old group practice loan scheme.
The right hon. Gentleman referred to something which I had said in opposition—not the first time he has done it—about replacing loans by grants, and he asked why I had changed my mind. In fact, we are doing in this Bill what the profession asked us to do. The profession did not ask for grants from the Government; it asked for an independent corporation. The arrangements which we are bringing in now are in harmony with what the doctors wanted and, in those circumstances, it did not seem to me that there was any useful purpose to be served by asking them, "But will you not have grants instead?" They have made perfectly clear that they wanted an independent finance corporation. Of course, I could have answered the right hon. Gentleman by saying that we have introduced grants in the form of improvement grants for practice premises, but I know that he was referring not to that but to grants instead of interest-free loans.
Both the right hon. Gentleman and his hon. Friend the Member for York asked a number of questions about how the Corporation is to function, what its rates of interest would be, over what periods loans would be repaid, whether they would be transferable to successors in the event of death or retirement of a partner, would there be permanent or fluctuating rates of interest? All these are matters for the Corporation to decide for itself. It is a commercial body. It 1425 has a statutory requirement to break even over a period, and it has to work out its own rules and submit a scheme to Ministers for approval; but within that framework it will have the sort of free hand that any business organisation ought to have in running its own affairs.
For my part, I do not want to impose any ceiling on an individual loan. I certainly do not want to lay down that rates of interest should be either permanent or fluctuating. But, clearly, there are many ways of approaching these matters, particularly as the Corporation will start operation, or it looks as though it will start operation, at a time of high interest rates. It is our intention that loans should be repayable over a normal professional career for a family doctor. I think that one might say that that is at least 30 to 35 years, possibly more. But, again, this will, no doubt, be embodied n the scheme which the Corporation submits for approval.
We have assured the medical profession that it is our intention that, if a doctor dies or retires before he has completely repaid his loan, it will be open to the Corporation to consider an application for the outstanding balance to be transferred to his successor, although it may want to vary the terms, and, presumably, in practice the successor will often want more from the Corporation than the amount outstanding on the original loan.
The right hon. Member for Bridlington asked when the Corporation was likely to start functioning. Subject to the Bill going swiftly through both Houses, as I hope it will, we shall set the Corporation up as soon as possible. I want to see it in operation as early in the coming financial year as it can function. There is no desire on my part to delay its functioning.
The right hon. Gentleman also asked why we are not giving the Corporation power to build and own its own premises. The reason is to avoid the conflict which would inevitably have risen with existing public authorities which can do this. Local health authorities and executive councils already have these powers and it was felt wrong to duplicate them. After all, if a practitioner wanted to go into publicly-owned premises which are built and owned by somebody else he would, I hope, in asso- 1426 ciation with his colleagues try to get a health centre out of his local authority. As long as that power exists, there is no virtue in duplicating it in the Corporation.
I certainly welcome the right hon. Gentleman's support—indeed, the support of almost every hon. Member who has spoken—for the development of group practice. It is most heartening to think that there is unanimity on this point. I believe that there is certainly growing acceptance within the medical profession that this is the modern pattern of general practice. I think it will certainly be the case that group practice will have first priority on loans, but there is no suggestion, however, that loans will be limited to doctors who are in group practice.
The right hon. Gentleman also spoke about methods of remuneration. He asked why I have not been able to agree to an experimental scheme in which doctors could charge a fee for their services which would be wholly or partly reclaimed from the Government. This proposal was not in the original "Doctors' Charter". A proposal on these lines was debated and carried at one of the representative meetings of doctors and there was a suggestion that it should be added to the charter at a late stage in the negotiations. I had to tell the profession that in the Government's view this idea was wholly alien to the whole concept of the National Health Service as we see it.
The right hon. Gentleman was worried whether the idea of payment by salary would call into question, so to speak, the personal nature of the doctor-patient relationship. I do not see why this need follow. I remind him that about half the doctors in the National Health Service are on salary already—the doctors in the Hospital Service, from consultants downwards. I do not think that they regard their relationships with their patients as anything less satisfactory than the relationships with their patients of doctors paid on a capitation basis.
The right hon. Gentleman asked whether the regulations that will be made under Clause 10, prescribing the circumstances in which salary will be payable, could be subject to affirmative procedure. We felt that there were already ample safeguards. We shall consult the medical profession. We shall 1427 make it clear that this payment will only be made with the consent of the doctors concerned. The appropriate order will be subject to annulment. Prayers can be tabled against it if any hon. Member thinks that consultation with the doctors has been ignored. I would think that a sufficient safeguard. However, if the right hon. Gentleman feels so strongly on the matter that he wants to table an Amendment, we can discuss the possibilities in Committee.
When it comes to increasing the borrowing power of the Corporation, where possibly the liability of Exchequer money is involved, we have inserted the affirmative procedure for the necessary order.
My hon. Friend the Member for Wandsworth, Central (Dr. David Kerr) and my hon. Friend the Member for Halifax (Dr. Summerskill) seemed somewhat to disagree about whether the Bill would be an incentive to practise in health centres. I agree with my hon. Friend the Member for Halifax. I think that anything which encourages doctors to work together in groups will inevitably lead to more work in health centres. It is the breaking down of the isolation of the single-handed doctor which is the first important step to both group practice and health centre practice.
My hon. Friend the Member for Wandsworth, Central said that he was extremely disappointed with the slow progress of the formation of group practices. I assure him that the number of single-handed practitioners is still going steadily down and that in October, 1964, there were only 5,000 single-handed practitioners in England and Wales, more than 200 fewer than in the previous year.
§ Dr. David Kerr
I accept that the number of single-handed practitioners is falling, but I hope that my right hon. Friend will agree that they are forming practices of two doctors, or two or three, rather than practices of four or more.
§ Mr. Robinson
I do not have the figures for practices of four or more doctors. Certainly the number of partnerships of three or more is still going up, although, like my hon. Friend, I would like to see the rise a little more rapid.
§ Mr. Shepherd
Is it not the case that we cannot expect to see a very rapid rise in the number of large group practices because geographical conditions do not necessarily allow that to be done? There must be a limit to the number of very large group practices.
§ Mr. Robinson
There may be a limit, but we are a long way from that limit at the moment. I have always said that group practice should become the normal pattern of practice in urban areas, but I recognise that in scattered rural areas it is very difficult to form groups into a practice from a single group surgery.
My hon. Friend the Member for Wandsworth, Central and a number of others asked why dentists were not included in the Bill. This is a general medical practitioner Bill and so far I do not have the evidence that dentists have anything like the same need for these facilities as I fully accept that the doctors have. It might be argued that at some future date they might need them and so we should include dentists in the Bill, but my answer to that must be that Parliament does not altogether like legislating for hypothetical situations. I am having current discussions with the dental profession covering a wide range of subjects, and if as a result of that there is evidence of serious need among dentists for similar facilities, we can certainly consider providing them, either at some later stage extending the Bill, or by separate action.
On the whole, the provisions for salaried service were fairly well understood and appreciated by every hon. Member who spoke. There is no desire to impose salaried service on those who do not wish to have it, but I welcome, as do many of my hon. Friends, the fact that for the first time the profession itself has expressed a willingness to consider this as one of the methods by which family doctors could be paid.
My hon. Friend the Member for Wandsworth, Central, seemed to be under a misapprehension about the regulations prescribing the circumstances in which salaries would be paid. It would be my intention to lay not a number of regulations but just one general regulation prescribing a set of general circumstances for example, where doctors practise from publicly provided premises with publicly provided ancillary help and that kind of 1429 thing. I agree very much with my hon. Friend the Member for Halifax that the Bill will help young doctors to establish themselves in general practice, and by so doing I hope that it will make a contribution to reversing the trend for many young doctors to leave general practice. This is perhaps the most important thing that we can do—so to improve the conditions of general practice that the young newly qualified doctor will once again regard this as a very worthy way to spend his medical career.
My hon. Friend the Member for Ebbw Vale (Mr. Michael Foot) spoke of the situation in the Rhondda Valley. I accept that this is a very difficult situation, and it is one on which my Department has recently made a special study. At this moment we are actively pursuing ways of relieving the doctor shortage in that part of Wales. My hon. Friend the Member for Willesden, West (Mr. Pavitt) was quite right to be sceptical about the figure of 900 doctors supposed to be emigrating every year. This figure has been bandied about recently but we have no evidence to support a figure anything like this. The last figures I gave to the House on the estimated number of doctors emigrating was about 300 to 350 a year. That is high enough but this figure of 900 bears very little relation to the facts.
In the course of an extremely entertaining and apposite speech my hon. Friend the Member for Ebbw Vale gave us a fascinating glimpse of what I hope is going to be an important section of the second volume of his life of Aneurin Bevan. I am looking forward to this even more than I looked forward to the first one. He was quite right to point out that there were certain ironies in the situation in which we now find ourselves in the National Health Service, compared to what happened about 20 years ago when Aneurin Bevan opened the initial negotiations with the profession. The hon. Member for Cheadle (Mr. Shepherd) made some very forceful observations about the medical profession and its structure and methods of consultation. I will not comment on them but I am confident that they will not go unnoticed within the profession. That made me all the more sorry to have to disagree with him about the kind of general prac- 1430 titioner who would be likely to opt for payment by salary.
I can see no reason whatever for suggesting that this would be in any way an untypical doctor. It would be a doctor, as I suggested in my opening remarks, who just does not want to be burdened with the business of providing his premises and staff and organising them. He just wants to get on with treating patients and I think that he is likely to be just as good a practitioner as a man who is keen on the status of an independent contractor. I would like to congratulate the hon. Member for York (Mr. Longbottom) on what I believe was his maiden speech from that Box in his present shadow position. I hope that he occupies it for a very long time. [An HON. MEMBER: "Thirty years."] He asked me about sterile syringes for dentists. This is not immediately relevant to the Bill before us, but I am having discussions with the dental profession and I am sorry that he was unconvinced by my reasons for not extending the concession to dentists. No doubt if there is a strong demand for these syringes, the representatives of the profession will let me know about it. I am glad that he stressed the value of this Bill to the patients no less than to the doctors.
May I say once again that I am most grateful for the reception which the Bill has received. I hope that before very long it will be on the Statute Book.
§ Question put and agreed to.
§ Bill accordingly read a Second time.
§ Bill committed to a Committee of the whole House.—[Mr. Harper.]