No scheme gets through the British Parliament without opposition, and the Health Service Bill is no exception. The far-reaching changes proposed rouse many fears and therefore many points of opposition, but there is very little common ground and no unity whatever in the various interests opposing the scheme. The need for a new health service is so great and the Coalition wartime Government was so far committed to a scheme that the Conservative Party has been at great pains to make it clear that they oppose in detail only, and that they agree the Government has a clear mandate for the service proposed.
In the Second Reading debate in the House of Commons Mr. H. U. Willink, former Minister of Health, moved that” this House, while wishing to establish a comprehensive health service, declines to give a second reading to a Bill which…… ” and then followed certain objections we shall discuss below. Mr. Willink went on to say that the Conservative Party agreed with the Labour Party “in being resolute in favour of 100 per cent, service. We resisted any criticism of that…………….. I dissent from not one single syllable of the first few lines of the Bill. I think it is right that it should be, in future, ‘ the duty of the Minister of Health to promote the establishment of a comprehensive health service ‘.”
No attempt was made by any speaker in the House of Commons to oppose a national health service or the principle of a 100 per cent, service for the whole nation. The case made out was one for a different administrative structure, and in particular an accusation that the present scheme “retards the development of the hospital services by destroying local ownership …. and which weakens the responsibility of local authorities without planning the health services as a whole.”
This motion was debated for three days and finally defeated by 359 votes to 172. Throughout the discussion it was remarked that the Opposition were so aware of the weakness of their case that they did not do it justice. Mr. Clement Davies, Liberal Member for Montgomery, said it reminded him of 1911 and “the opposition to the 1911 Bill. Exactly as this amendment is to-day so it was then. They could not say ‘yes’ and they dare not say ‘no’ so they invented a sort of new Middle Conservative way of trying to get the best of both worlds. Obviously ‘the intention was to wreck the then Bill while paying lip service to the necessity of creating a new medical service available to the poor of this country. I have listened again to the words that have been uttered here, and they have certainly been rather mild in their criticism.”
It has been often remarked that the opposition to this 1946 Bill is almost the same as to Lloyd George’s National Health Insurance Bill in 1911. Indeed, Mr. Clement Davies said that ” this amendment is almost exactly in the same terms as those which were moved against ” the earlier Bill.
When we turn to other sources of opposition we find that the parallel with 1911 is continued. Parliamentary opposition was halfhearted; professional opposition appeared strong and almost unanimous but was in fact merely the vocal expression of a small minority within the profession. One writer in 1911 declared that “the medical profession has found by bitter experience the principle of a capitation fee to be in the interests of neither patients nor medical men” ; in 1946 the British Medical Association demands a capitation fee system because a salary “would not be in the interests of either patients or doctors” !
In 1911 also the B.M.A. issued a set of “principles” which they demanded should be observed in setting up any health service ; in 1946 they issue seven very similar “principles” which are merely an expression of opinion and do not even fringe upon what would generally be regarded as principles. It is, however, around them that the B.M.A. builds its fight against the Bill, but since they were issued three have been dropped to some extent either because the Bill concedes them or because they do not constitute a very sound basis for a fight.
The four upon which the Government’s proposals have a particular bearing are :—
- The medical profession is, in the public interest, opposed to any form of a service which leads directly or indirectly to the profession as a whole becoming full-time salaried servants of the State or local authorities.
- Doctors should, like other workers, be free to choose the form, place and type of work they prefer without Governmental or other direction.
- Every registered medical practitioner should be entitled as a right to participate in the public service.
- There should be adequate representation, of the medical profession on all administrative bodies associated with the new service in order that doctors may make their contribution to the efficiency of the service.
The reader may be left to judge whether these are principles or not, but it should be noted that the first is merely an argument against a particular method of payment of the doctors, a method not suggested in the present Bill, while the three others are claims that doctors should retain certain privileges. The second is conceded in full in the Bill, which places on doctors precisely and solely the restriction placed on “other workers,” that he or she cannot demand a job when there is no work to be done.
On the third, the B.M.A. itself has expressed very serious doubts in an official statement. They do not wish to appear to defend the inefficient doctor but merely desire to avoid a position in which “an applicant, although recognised and approved by the General Medical Council, might find himself or herself excluded from the service, either in particular areas or in every area.” They realise, however, that the sick must be protected, and in the same statement suggest that the Minister must have power to exclude “any medical practitioner whose continued inclusion would be prejudicial to the efficiency of the medical service.”
As to the fourth item, there are many points of view, but the Minister of Health has more than met the profession half way. Doctors and their professional colleagues are to constitute the Central Health Services Council, to be on the Regional Hospital Boards and the Boards of Governors of teaching hospitals, to have most of the seats on the Medical Practices Committee and half the places on the local Executive Councils. After publication of the Bill the B.M.A. could only claim that “the Government’s present proposals present some pointsof conflict with this principle.”
The main objection to a hundred per cent, service for 100 per cent, of the people was, at one time, that it would destroy “free choice,” the freedom of the patient to choose his own doctor. The B.M.A. has, however, largely dropped this point, for the first argument against it is that to-day free choice exists for only a part of the population and is exercised by an even smaller part. Indeed they found themselves faced with hundreds of examples of country areas where there is no choice at all ; and with the incompatibility of claiming a high rate of compensation for practices if in those practices free choice existed. The Minister of Health pointed out to the profession that “every time they argue for high compensation for the loss of the value of their practices it is an argument against the free choice which they claim. The assumption underlying the high value is that the patient passes from the old doctor to the new.” In other words, they do not have or do not exercise any choice.
But the final argument on free choice is that it is a fundamental principle of the Bill. It is laid down that every local Executive Council, on which professional men have half the seats, must make arrangements “for conferring a right on any person to choose the medical practitioner by whom he is to be attended.” As Mr. Clement Davies put it in the debate, ” What amazes is the fact that so much freedom ….. to the doctors. They have never had so much freedom as they have now, neither have the patients in the past. I am not talking about well-circumstanced people but about the ordinary everyday people. Never have they had so wide a choice as they will get when this Bill is functioning fully and properly, and when there is a better distribution of the medical services.”
The Bill makes two provisos to the right to choose one’s doctor— that it is ” subject to the consent of the practitioner so chosen” and, what is of vital importance to the efficiency of the individual doctor, subject to ” any prescribed limit on the number of patients to be accepted by any practitioner.” There is a third possible restriction and it concerns the provision, of an adequate emergency service. Obviously, if every G.P. is to have his daily, weekly and yearly time off duty there must be some emergency service, and when that is used then clearly the “doctor of choice” may not be available.
There are some who object to the application to medical practice of any form of “eight-hour day” or “forty-hour week,” suggesting that emergency illness will always upset any attempt to reduce and regularise the hours of doctors. The more general feeling, both among doctors and patients, is that for the sake alike of the doctor himself and the quality of service to he given there must be a departure from the existing position in which a doctor is always on call. No other trade or profession expects its members to be on duty every day and all day. It is clear that emergencies, medical surgical or obstetrical, call for alertness, readiness to make decisions, and calmness to carry them out ; and no doctor can be expected to exhibit those qualities after a busy day with a long and tiring evening surgery. The doctor on duty for emergencies should have no other duties; and the service should always be available on immediate call. In, a whole-time salaried service such arrangements would be easy to make; under the present Bill they may be made by any group of doctors in a Health Centre, but it will be for the local Executive Councils to work out the details.
The main objection of the B.M.A. now is to the proposal that family doctors should be paid by a combination of basic salary and capitation fees, which is regarded by some as a step towards a salaried service. To-day a doctor gets his income in many different ways, of which one is by capitation fees from panel patients. The doctor is paid a fixed annual amount for every patient on his list. The capitation fee has varied, being a constant matter of discussion between the B.M.A. and the Ministry of Health, and is at present 10s. 6d. Many doctors advocate that even in a 100 per cent, service the method of payment should be by capitation fees only, so that the remuneration of the doctor would be directly related to the number of patients choosing him—in other words, related to his “popularity” and to no other factor.
The Minister of Health has decided on a compromise between, the capitation method of the B.M.A. and the whole-time salaried service which is the Labour Party’s published policy. The compromise is, however, one that was much favoured at one time in, medical circles. The Medical Planning Commission in its “Model Health Centre” plan declared that a doctor in a health centre should be paid by a combination of three methods :
- a basic salary with special additions for special qualifications and length of service ;
- a capitation fee related to the number of persons or families on his list ; and
- any fees received in respect of services not covered by the capitation fee and any salary received for work outside the scope of the service.
The Minister of Health accepted all these points in addressing the House of Commons, but he has yet to announce what proportion of a doctor’s income is to be obtained by basic salary and what proportion should arise from capitation. “I do not believe,” he said, “that I can dispense with the principle that the payment of a doctor must in some degree be a reward for zeal, and there must be some degree of punishment for lack of it. Therefore it is proposed that capitation should remain the main source of a doctor’s income.” (Many, including the present writers, will regard that as a non sequitur. An increase in a doctor’s list is not necessarily, and to-day seldom, an indication of greater zeal.) But the Minister went on : “It is proposed that there shall be a basic salary, and that for a number of very cogent reasons.”
The first reason is the simple one that no doctor can do his best work if he begins professional life with a burden of debt on his shoulders. So long as capitation fees are paid the young doctor has to be kept alive while he builds up his list. It may be recalled that the Medical Planning Commission was very firm in its belief that young doctors should always be paid by whole-time salaries.
The other reasons given by the Minister have since been emphasised in the discussions on the Committee Stage of the Bill. They are that a basic salary can be used to attach additional payments for a great variety of factors while leaving the capitation fee, the emblem of the contract of service to the individual patient, which the doctor has signed and accepted, unaltered throughout the country. To a basic salary can be attached extra payments to get doctors to go into “unattractive” areas. It can be used for payment for all kinds of special qualifications and responsibilities.
There remains the supposed fear of doctors that basic salary, once accepted, will lead inevitably to a full-time salaried service. The Labour Party is, of course, committed to and has always remained convinced of the need for a whole-time salaried service. As Mr. Arthur Greenwood, the Lord Privy Seal, told the House of Commons, the Labour Party has “never repealed any of its policy and will continue to march on in the light of that policy.” The opposition of doctors to the salary method is not a basic objection but one way of saying they prefer capitation and private fees in order to keep up the saleable value of their practices. But as Mr. Somerville Hastings, M.P., has written (Medcine To-day and To-morrow, June, 1946) “It is not improbable that once the sale of practices is prohibited the doctors will be as keen to be remunerated by salary as they now are for payment by capitation.”
Other objections have been answered by the Bill itself. The1 B.M.A. feared that doctors might be “directed,” but Mr. Aneurin Bevan has himself stated “There is no direction involved at all.” The fear that medicine would cease to be a profession attractive to young men and women has been discounted by the large number of students, especially women, now applying for entrance to every medical school.
The fear that family doctors would come under local authorities (and their medical officers), or would lose their civil and political rights, are all answered by the administrative structure proposed. There is one point on which those of very different political persuasion have criticised the scheme, the failure to unify completely all the services under one planning and executive authority. The Minister of Health has declared that the seeming trichotomy or three-pronged form of administration is better than an artificial unity; and many regard the ad hocRegional Hospital Board as a first step to regional authorities on an elected basis replacing for some purposes the present local authorities. Mr. Bevan, however, denies the need for that and has declared that there is no confusion in the proposed administration. “The confusion is in the minds of those who are criticising the proposal on the ground that there is trichotomy in the services between the local authority, the regional board and the health centre.” And there we must leave the question,, which the service itself will test.
As this is written opposition has waned and, while those who previously opposed the scheme have not become enthusiastic, it is nevertheless true to say the scheme is welcomed by the public and will be worked by the doctors. All other health workers are enthusiastic for it, and a new profession will be educated in. the use of this service for the sick and for a satisfactory professional life.