I beg to move:
“That this House takes note that the appointed day for the National Health Service has been fixed for July 5th; welcomes the coming into force on that date of this measure which offers to all sections of the community comprehensive medical care and treatment and lays for the first time a sound foundation for the health of the people; and is satisfied that the conditions under which all the professions concerned are invited to participate are generous and fully in accord with their traditional freedom and dignity.”
The House will recollect that this Debate was requested from this side of the House, and not by the Opposition. There is some significance in that fact. During the last six months to a year there has been a sustained propaganda in the newspapers supporting the party opposite, which has resulted in grave misrepresentation of the nature of the Health Service and of the conditions under which the medical profession are asked to enter the Health Service. There has been even worse misrepresentation, sustained by a campaign of personal abuse, from a small body of spokesmen who have consistently misled the great profession to which they are supposed to belong. I make a distinction, and I hope that distinction will be maintained throughout the Debate, between the hard-working doctors who have little or no time to give to these matters, and the small body of raucous voiced people who are alleged to represent the profession as a whole.
So much misrepresentation has been engaged in by the B.M.A. that the doctors who have voted or are voting in the plebiscite are doing so under a complete misapprehension of what the Health Service is. It has been frightening to speak to some doctors and to learn the extent to which their representatives have failed to inform them about the facts of the case. I have even spoken to representatives of the doctors who have attended the various conferences which have been held in London, and at which the members of the negotiating committee were supposed to have reported their discussions with me, and they themselves did not and do not understand what the facts are.
From the very beginning, this small body of politically poisoned people have decided to fight the Health Act itself and to stir up as much emotion as they can in the profession. I have before me a letter written to the “Scotsman”:
“Parliament, through the National Health Service Act – State Medical Service Act’ would have been a more descriptive designation – has vested certain totalitarian powers in the Minister of Health. The Minister has not been slow in revealing these powers in his scheme of things to come. Stripped of the goodwill of his practice, subjected to ‘negative’ direction, denied the right of appeal to a court of law against dismissal from service and salaried from Whitehall – such is to be the lot of the physician of the Socialist future. In brigand-like fashion this would-be Fuehrer points an economic pistol at the doctor’s head and blandly exclaims ‘Yours is a free choice – to enter the service or not to enter it.”‘ I have quoted from one of the more modest of the letters, because I am not anxious to raise the temperature just now. No doubt, hon. Members have seen letters which are even more virulent than that one.
The history of the Health Service Act is a very long one. It started with the National Insurance Act in 1911-12. Then in 1920 there was the report of a committee under Lord Dawson. Then in 1943 it was revived, and in 1944 there was a Coalition White Paper. Then there were protracted discussions with my predecessor. Then there was a Government White Paper in 1945 and the National Health Service Act, which took 32 days in the Commons and 10 days in the Lords.
I would like to make one personal reference. It has been suggested that one of the reasons why the medical profession are so stirred up at the moment is because of personal deficiencies of my own. I am very conscious of these. They are very great. Absence of introspection was never regarded as part of a Celtic equipment; `therefore, I am very conscious of my limitations. But it can hardly be suggested that conflict between the British Medical Association and the Minister of the day is a consequence of any deficiencies that I possess, because we have never been able yet to appoint a Minister of Health with whom the B.M.A. agreed. My distinguished fellow country-man had quite a little difficulty with them. He was a Liberal, and they found him an anathema. Then there was Mr. Ernest Brown who was a Liberal National, whatever that might mean, representing a Scottish constituency. They found him abominable. As for Mr. Willink, a Conservative representing an English constituency, they found him intolerable.
I am a Welshman, a Socialist representing a Welsh constituency, and they find me even more impossible. Yet we are to assume that one of the reasons why the doctors are taking up this attitude is because of unreasonableness on my part. It is a quality which I appear to share in common with every Minister of Health whom the British Medical Association have met. If I may be allowed to make a facetious transgression, they remind me of a famous argument between Chesterton and Belloc. They were arguing about the cause of drunkenness, and they decided to apply the principles of pure logic. They met one night and drank nothing but whisky and water, and they got drunk. They met the next evening and drank nothing but brandy and water, and they got drunk. They met the third night and drank nothing but gin and water, and again they got drunk. They decided that as the constant factor was water it was obviously responsible – a conclusion which was probably most agreeable to Bacchic circles.
I think we can dismiss at once the suggestion that the disagreements with the medical profession are a consequence of the personal qualification or disqualification of the Minister concerned, and I have made reference to it now only in order that I might call attention to the sort of propaganda which seems to be recurrent in British politics where issues of principle are vulgarly personalised. It is becoming almost impossible for the citizens of Great Britain to see the differences of political principle through the smoke of personal misrepresentation. That is one of the reasons, but the least important reason, why the Government thought it necessary to have this Debate this afternoon.
It has been suggested by the spokesmen of the B.M.A. that we have not negotiated with them sufficiently, that if we had only been more approachable things would have been different. But there were long negotiations with Mr. Brown and long negotiations with Mr. Willink, and on every occasion the B.M.A. rejected the advances made. I have met the Negotiating Committee itself eight times, three times before the Bill was introduced and – I hope this will not be brought against me – most irregularly I met them three times whilst the Bill was before the Committee. I consider this was somewhat of a sin against constitutional practice because I do not believe a Minister ought to be running two committees at the same time, one in the House of Commons and the other outside. I did it in order to give them every opportunity of stating their case.
Since the Act I have met them twice, and since August, 1945, the officials of my Department have met representatives of the Negotiating Committee 28 times. There have been continuous discussions, so microscopic that I am almost weary of the issues involved because they have been so much investigated. But the Negotiating Committee on its side was never in a position to negotiate. It had received from its own committees, at its own request, instructions not to negotiate. Indeed – and I would like the House to note this – when I met members of the Negotiating Committee in December of last year for a two-day discussion, I was presented with a printed circular which they had themselves caused to be printed rejecting the Act before the final negotiations had taken place. All the main features of the Act are contained in that document; not merely remuneration, not merely basic salary, not merely the appeal to the courts, but every important provision in the Act had been rejected by the Negotiating Committee before negotiations were concluded.
I called the attention of the chairman of the Negotiating Committee to that fact and asked him what was the use of two days’ negotiations when one side had already decided to reject the whole scheme. The answer was that they had already made up their minds.
The hospitals section is included in the rest. This document is in the Library for hon. Members to look at – it rejects the Sections dealing with distribution, buying and selling of practices, remuneration, right of appeal to the courts, midwifery, the administrative bodies, public hospitals, hospital accommodation for private patients, facilities for diagnosis, statutory health committees, public health service, representation of the profession on the administrative bodies.
We are not now dealing with a body which is seeking to bring about the modification of principles in what they consider to be the legitimate interest of the members of the medical profession. We are dealing with a body organising wholesale resistance to the implementation of an Act of Parliament.
Furthermore, and I would like the House to note this, they had already rejected the Act before they knew the terms of remuneration for the general practitioner. They had not been told by me officially whether or not there would be a basic salary. They had not been told at this stage what was to be the scale of remuneration and, when they go around the country at the present time saying that one of the main causes of their decision is the basic salary, it should be remembered that they had decided to reject the Act before they knew there would be a basic salary in the remuneration.
In fact the whole thing begins to look more like a squalid political conspiracy than the representations of an honoured and learned profession and, I say this deliberately, when the bulk of the doctors in the country learn the extent to which their interests have been misrepresented by some of their spokesmen, they will turn on those spokesmen. In fact, one of the weaknesses of the B.M.A.’s present position is that they have mustered their forces on the field by misrepresenting the nature of the call and when the facts are known their forces will disperse.
There are four main issues on which the B.M.A. say they join issue. They say, in the first place, that they cannot accept the abolition of the sale and purchase of practices. The abolition of the sale and purchase of practices was recommended by the profession’s own health commission. They voted for the abolition in their own plebiscite and all I have done, and all the Government and the House have done, is to put in the Act recommendations about this step based on the best medical information. We regard it as being inconsistent with a civilised community and with a reasonable health service for patients to be bought and sold over their heads. When I am told that all they desire is that patients should have the best medical treatment, how can that be argued when a doctor succeeds to another doctor’s panel not on account of personal qualifications but on the size of his purse? How can it reasonably be argued that there is any effective free choice of doctor when the doctors negotiate the terms between themselves and the patient knows nothing at all about it? This system exists in no other country in the world. It is a blot upon our medical system.
I ask the Opposition whether they accept or do not accept the abolition of the sale and purchase of practices. We should like to know. We should like the Opposition to tell us – because I think that these matters ought to be made quite clear – whether they are in favour of doctors being able to buy and sell their panels in the public service. It is very necessary that we should know. It is very necessary that we should know the body of opinion behind this practice so that we can estimate what it is worth. One of the main reasons why we are having this Debate today is not merely in order that the Government can clear up their position, but that the Opposition shall have the opportunity of making their position clear, too. After all, the second body of importance next to the Government is the Opposition, and I do not think that the nation ought to be denied the counsel of the Opposition in this matter. There cannot be, as far as we are concerned, any question at all that a Health Service which we consider to be reputable must not retain the buying and selling of private practices.
The doctors have said that their second objection – indeed, many of them said that this is the one thing that is offending them – is that they will not accept a basic salary as part of their remuneration. The first time that a full-time salaried practitioner service was put before the medical profession was in 1943, in the days of the Coalition Government. It came from Mr. Ernest Brown. I hope the Opposition will note that. This principle, to which such exception is taken, which is supposed to reveal such Socialist partisanship, which is supposed to embody such regimentation, did not come from a Socialist Minister of Health but from a Government composed of Conservatives, Socialists and Liberals, and was put forward by a National Liberal. And I rejected it; I thought it contained too much of the element of regimentation.
There were some hon. Members on this side of the House who expressed the view that competition for patients on panels had the effect of degrading the standards of the service, and that, consequently, it was much better to have a full-time salaried service. It was argued out on Committee stage and on the Second and Third Readings, and it was decided that that was not what we were going to do. But what I made clear during the passage of the Bill was that young doctors ought to have the opportunity of living decently whilst they were building up their practices. At the moment, the only way in which a doctor can get into general practice is either by becoming an assistant to a principal, and accepting very important limitations when he takes up his work, or by borrowing sums of money and, therefore, for the first 15 to 30 years of his professional life, loading himself with debt, so that when he is approaching his patients he is not in the state of mind in which a doctor ought to be.
We not only desire in this scheme to relieve patients of financial anxiety; we desire to relieve the doctor of financial anxiety when he approaches his patients. It is one of the most deplorable features of the existing system that young doctors, when they go into practice – and they are by no means boys, but men of 24 to 30 years of age, with young families to feed and educate and clothe and look after just at that time when the young doctors ought to be freest of financial burdens, they have financial burdens put upon them. We consider, therefore, that a salary, only of £300 – but, nevertheless, a salary of £6 a week – plus what he can get from capitation fees, would be a financial support for the young doctor whilst he is building up his practice. It is perfectly true that if a general practitioner believes that this element of basic salary is repugnant, and by its very existence makes him into a State salaried servant, he need not take it. He can give it back. The Chancellor of the Exchequer would be delighted. It will be of interest to see how many general practitioners find this so dishonourable to the traditions of the profession, so besmirched by the element of regimentation that they will hand it back as though it were poison. There is nothing at all to prevent a general practitioner from handing it back if he likes. But it would be a most complicated arrangement if we had two capitation fees running simultaneously in the Service. We can see how extremely complicated it would be if we consider what effect it would have on the national and local pool available for the payment of general practitioner’s remuneration. One of the concessions made, which has not been italicised, is that for the first two years we shall pay into the pool a sum equal to 95 per cent. of the total population of the country, because the general practitioners will be assumed to be at risk for a large number of people who will not have signed their lists at all. To work that basic salary under conditions of that sort would be extremely difficult and cumbersome.
Another argument we have heard advanced is that the partnership agreements will be rendered very difficult and that it is hard to see what the Act means when partnership agreements remain after the Act has come into operation. The mind of the general practitioner has been confused by the B.M.A. propaganda in this respect; but there is natural anxiety among general practitioners as to what is the effect of the Act upon partnership agreements. In order to try to clear it up I have decided, with the co-operation of the Attorney-General and the Lord Chancellor, to appoint a legal committee to inquire into it and to recommend what they consider should be done. It is a most unusual proceeding. As a general rule, when Parliament passes a Bill and it becomes law, it is left for the courts to construe it. However, if any further light can be thrown on this matter, if competent legal opinion can find any way in which those Sections of the Act can be clarified, I shall be perfectly prepared to recommend the Government to have an amending Bill for that part of the Act to make clear where the general practitioners stand.
The other thing to which the B.M.A. take serious objection is what they consider to be the removal of their legal rights. Here, the representation has reached really staggering proportions. It has been said that a doctor has taken away from him his rights of appeal to the courts against unlawful dismissal. That is entirely untrue. A doctor will have exactly the same right of appeal to the courts against unlawful dismissal as any other citizen in the country. It has never been challenged during the whole of my negotiations with the representatives of the profession. They have never been able to show any part of the Act which takes away from the doctors those legal rights. But some of them want to go further than that. They want to have the right of appeal to the courts against dismissal from the service on the ground of misconduct or neglect.
I want the House fully to appreciate the significance of what is being asked. It is perfectly competent to go to the courts against a Minister on the ground that he has unlawfully removed any doctor from the Service. That remains. It is an entirely different matter if they want to take the Minister – whoever he might be – to the courts on the ground that he has acted wisely or unwisely, because whether a Minister has acted wisely or unwisely is for this House to determine, not the courts. If a doctor has the right to go to the courts to ask the courts to arbitrate, not on the law, but on the merits, how can that right be denied to anybody else – to the teachers, to the railwaymen, the miners, everybody, in both public and private service?
Under this reasoning, if there were this right to go to the courts of law, appealing not on the ground that the doctor has been unlawfully dismissed, but on the ground that he has been wrongfully dismissed in the terms of his contract, what would be the situation? The relationship of the judiciary to the legislature would be completely revolutionised. Day by day the courts would be arbitrating on a thousand and one matters on which they are utterly incompetent to judge. The courts are competent to judge the law and to construe the statutes; but the courts are not competent to say whether a foreman ought to get rid of a workman or a workman ought to dismiss an employer – because the converse is always the case, and under conditions of full employment it is as easy for the workman to dismiss the employer as for the employer to dismiss the workman. But if the B.M.A. had their way, if this queer constitutional doctrine were accepted, both would be tied together by an Act and with the courts. We should find ourselves in an entirely impossible situation. Therefore, we decided it was constitutionally impossible to give the doctors this concession.
However, when the Act was being drawn up and the protection of the doctor being considered, I gave this point special attention. I would have the House realise that, under the existing National Health Insurance Act, protection for the doctor is merely an appeal to the Minister. It is only that. The local insurance committee reports the doctor to the Minister; the Minister makes an inquiry, and the doctor is upheld or removed. That is the existing situation. That was the situation as it was left by my predecessor. Mr. Willink, in his scheme, had left the position under the new Health Service exactly the same as it is now; but I, of my own volition, decided that that protection for the doctor was not sufficient, on the ground that the new Health Service would be universal and that removal from the Health Service of the future would carry heavier penalties than removal from the National Health Insurance Act scheme. So I decided to put a tribunal in between the local executive council and the Minister.
The present position, therefore, is that, under the scheme the general practitioners are in contract with the local executive council, on which they have seven direct representatives – I emphasise, seven direct representatives – not appointed by the Minister, but elected by the doctors in the locality themselves. That is the first body to discuss the behaviour of a doctor. If, after examination, that body decide that a doctor ought to be removed, they report it to the Minister. At that stage the Minister can do nothing. All he can do is to refer it to this tribunal, the chairman of which is appointed by the Lord Chancellor, and on which there is another doctor and a layman. If that tribunal decides that the doctor should be retained, the Minister can do nothing at all about it, and the doctor is retained.
The Minister is brought into the picture only where the doctor himself invokes the Minister against the decision of the tribunal. The Minister can then order another inquiry, public or private, as the doctor requires, with witnesses if need be, and with all the apparatus of full investigation; and the Minister can then decide whether or not the contention of the doctor should be upheld. There is no professional body in Great Britain or the world where more protection exists than that. The fact is, I am myself beginning to wonder whether the public is sufficiently protected under machinery of that sort Certainly no doctor could claim that he is not adequately protected in those circumstances.
Let me ask this question, which I hope the doctors will read tomorrow: what would be the consequence of the sort of protection for which their so-called spokesmen are asking- compare it with this. Suppose that we did find it constitutionally practicable – which we do not- to give the doctor the right of appeal to the courts in these circumstances. Consider what a weapon of tyranny that would put in the hands of the Minister. Because remember, not only would the doctor have the right of appeal to the courts, but the Minister, being responsible to the House, would himself have the right of appeal to the courts for the removal of a doctor. In such circumstances any Minister would have very considerable powers of intimidation over the doctor, because he could take a doctor to the courts, force the man to undergo all the odium of publicity, to have his conduct examined, newspapers reporting it, all the circumstances of the case revealed to everybody, and his professional reputation besmirched.
The fact is that, if the medical profession could be given what they are demanding, then in six months’ time they would be cursing the people who asked for ft. In fact, in this matter lay people like ourselves have acted with a far greater sense of responsibility in protecting the doctor than their own professional representatives. Those are the main facts on which the doctors are at present making their complaint.
These are the four main grounds upon which the doctors have been alleging their opposition to entrance into the service. I apologise for keeping the House so long, but this is a matter of very great importance, and I am desperately anxious to get the medical profession into the scheme, enthusiastically and harmoniously, and I deplore the atmosphere which has been created in the last six months. I would point out to the House that so anxious was I not to take part in these polemics, that I made no public speech of any sort until the meetings in January, when the B.M.A. decided to reject the Act. Although, for between six months and a year, meetings have been held all over the country and the most extravagant things have been said, I nevertheless took the view that it would be better for me to say nothing at all at that stage, or I might have added to the acrimony rather than reduced it. Therefore, I made no statements of any sort. It may be that the mis-education of the doctors is partly my responsibility, and that if I had not left their education solely to those who are supposed to speak on their behalf, they might now know a little more than they do about the Act.
It may be said by the right hon. Gentleman the Member for Saffron Walden when he replies, more in sorrow than in anger, “Well, now, cannot we get together? Is it not possible, at this late hour, for some concession to be made to assuage the high feeling and try to bring about greater harmony between the Government and the doctors?” The Opposition might want to put themselves into the position of “honest broker”? a position, historically, very difficult for them to occupy; but it might appear to them to be congenial in these circumstances to take up that position. But, that would be to assume that there have been no concessions made to the medical profession, and that we should start off once more negotiating and making concessions. I want to point out to hon. Members in all parts of the House that these negotiations have been a long series of concessions from us, and none from the medical profession – not a single one. Indeed, one Member of the Negotiating Committee boasted that during these negotiations they had not yielded a single inch.
Consider what we have done. Consider the long record of concessions we have made. First of all, in the hospital services we have accorded paid bed blocks to specialists, where they are able to charge private fees. We have accorded, in addition to those fees for those beds which will have a ceiling, a limited number of beds in the hospitals where there is no ceiling at all. I agree at once that these are very serious things, and that, unless properly controlled, we can have a two-tier system in which it will be thought that members of the general public will be having worse treatment than those who are able to pay. That is a very grave danger, and it is a very serious and substantial concession made to the medical profession. We have also conceded that general practitioners and specialists can have private patients. That was repugnant to many of my hon. Friends. They hated it, because they said at once that we can have, if we are not careful, a revival of the old Poor Law system, under which the man who does not pay, does not get the same treatment as the man who does.
This kind of propaganda contains the possibility of developing that atmosphere. I would warn hon. Members opposite that it is not only the British working class, the lower income groups, which stands to benefit by a free health service. Consider very seriously the tradition of the professional classes. Consider that social class which is called the “middle class.” Their entrance into the scheme, and their having a free doctor and a free hospital service, is emancipation for many of them. There is nothing that destroys the family budget of the professional worker more than heavy hospital bills and doctors’ bills. There is no doubt about that at all, and if hon. Members do not know it, they are really living in another world. I know of middle-class families who are mortgaging their future because of heavy surgeons’ bills and doctors’ bills. Therefore, it is absolutely vital, not only for the physical good health of the community, but in the interests of all social groups, that they should all be put in the system on 1st July and that there should not be some in and some out of the scheme. That is why I deplore the letter today in “The Times” from a distinguished orthopaedist, who talked about private practice as though it should be the glory of the profession. What should be the glory of the profession is that a doctor should be able to meet his patients with no financial anxiety.
I now come to the Amendment on the Paper, and may I say at once that the Government are prepared to add the Amendment to this Motion? I think that the language of the Amendment reflects the political sagacity of the Opposition. They are not anxious to enter the tilting yard led by such doubtful leaders as the B.M.A. They wish to avoid the tourney, and are prepared to stand on one side and gather up whatever spoils may come to them. If hon. Members look at the Amendment, they will see that it is one to which all Members of the House can subscribe. It:
“declines to prejudice in any way the right of individuals in all the professions concerned to express their opinions freely, according to their traditions, and in the interest of their patients, upon the terms and conditions of service under the proposed National Health Scheme.”
Who disagrees with that? A more innocuous collection of bromides I have never heard of or seen.
The sting in the Amendment is, of course, that it leaves out the last part of the Motion. If Members opposite think there is anything in the Act which interferes with the freedom of choice, they should say so; we should hear it. If they think there is anything in the Act, scheme, or terms of remuneration, which prejudices the doctor patient relationship, we should hear it. So far, we have not. We do not object, and never have objected, to the doctors expressing their opinions freely; we do not object to the B.M.A. recommending their doctors not to take service under this scheme. What we do take serious objection to is to organised sabotage of an Act of Parliament. We desire to know from the Opposition whether they support that. Do they support the B.M.A. organising resistance on 5th July, because I would warn them that the beginning of that road might look very pleasant but the end would be exceedingly unpleasant, not only for us but for Members opposite. It must be clear to everybody that if there is one thing we must assert, it is the sovereignty of Parliament over any section of the community. We have not yet made B.M.A. House into another revising Chamber. We have never accepted the position that this House can be dictated to by any section of the community.
We do concur in the right of any section of the community to try to persuade the House of Commons to change its mind. That is perfectly sound. The position we are taking up is that the B.M.A. have exceeded their just constitutional limitations, and that the best thing they can do now is to put on record their opinion that while they may disagree with the Act in this or that particular, or in general if they wish, nevertheless, they will loyally accept the decision of Parliament and continue to agitate for such revisions as they think proper. That is the right position for any section of the community to take up.
May I say this in conclusion? I think it is a sad reflection that this great Act, to which every party has made its contribution, in which every section of the community is vitally interested, should have so stormy a birth. I should have thought, and we all hoped, that the possibilities contained in this Act would have excited the medical profession, that they would have realised that we are setting their feet on a new path entirely, that we ought to take pride in the fact that, despite our financial and economic anxieties, we are still able to do the most civilised thing in the world – put the welfare of the sick in front of every other consideration. I, therefore, deplore the fact that the best elements in the profession have been thrust on one side by the medical politicians, who are not really concerned about the welfare of the people or of their own profession, but are seeking to fish in these troubled waters. I hope the House will not hesitate to tell the British Medical Association that we look forward to this Act starting on 5th July, and that we expect the medical profession to take their proper part in it because we are satisfied that there is nothing in it that any doctor should be otherwise than proud to acknowledge.
Source: House of Commons Debates, vol. 447, cols. 35/50, 9 February 1948.