HOSPITALS, BRIGHTON AND HEALTH SERVICES (REPORT)

HC Deb 08 August 1966 vol 733 cc1130-72

9.24 p.m.

Sir William Teeling (Brighton, Pavilion)

In raising the question of Brighton hospitals, I hope that I am not being too localised. The area with which I am concerned contains four constituencies and has a population of about 250,000 people. Its problems are very much the same as those which are developing all over the country, especially concerning doctors, consultants, the general medical profession and hospitals, as against the regional boards. That is the first reason why I want to raise the matter.

My hon. and gallant Friend the Member for Lewes (Sir T. Beamish) is, unfortunately, unable to be here this evening. The hon. Member for Brighton, Kemp-town (Mr. Hobden) has told me that he is supporting me, but is not well enough to be here either, so it remains for my hon. Friend the Member for Hove (Mr. Maddan) and myself to try to put the case for the Brighton hospitals.

There is also the fact that in Leicester and many other districts to which our consultants have been to talk to doctors they are equally worried about the way things are developing in respect of the regional boards.

There is a second reason, which I never imagined when this problem first arose about a year ago would occur. That is the present financial crisis. I never thought that I would have to stand up against a Labour Minister of Health at this time of crisis and beg him to spend much less money and, at the same time, give greater benefits. Instead of spending £20 million on dealing with a ramshackle old hospital and one or two others, I am asking him to spend £6 million on some bright new ideas, which, I would have thought, interested him. I should have thought that he would follow instead of oppose me on this problem. It is £20 million against £6 million, at a time when everybody is asking us to economise at all costs. He refuses to economise and says that the main reason is that it was all decided long ago.

Admittedly, a scheme was definitely decided and scrapped in 1964. The Government could scrap it in 1964, and just because they have now rushed things two or three months ahead they say that they cannot possibly scrap it again. Of course they can. Not only that: they have pretty well paid all the architects already. There are very few amounts of money which they could not pay off and still save about £13 million or £14 million. That £14 million could easily go towards building other hospitals which are so badly needed in other parts of the country. I should be grateful if the right hon. Gentleman would try to explain why this is not happening and cannot hapepn.

The third reason for bringing up this question is that I want it to go on record that a group of youngish doctors—in their forties and early fifties—have thought out, in a selfless way, how the people of Brighton and Hove can suffer less and have better equipment in their hospitals and can be generally looked after. They have gone abroad to Scandinavia, the United States and other places to get the most modern ideas.

What they have come up against is a regional board of people in their early, middle and late sixties and in their early seventies.

I can appreciate the Minister wondering why he should worry about this, when he has so much else to do. He may feel that this board should deal with it. When I first came into the House as a young man, I was told that if I ever had any doubts about what I should do I should always do what the Whips suggested. I am not suggesting that the Minister is doing only what the Whips suggest, but I do say that he is taking what he thinks is the easiest way out, because he does not want to quarrel with the elderly gentlemen who have been looking after the regional board for years, but who really know precious little about Brighton and Hove. I will come back to the chairman. He doubtless knows quite a lot about Brighton and Hove, but the others do not.

Another reason for bringing this matter up is to discuss the undemocratic side of the present system. The right hon. Gentleman gave me an Answer in the House today in which he said, "No" when I suggested that we might do something to bring in people who were locally connected, locally elected and locally knowledgeable on medical matters, not only in Brighton and Hove but all over the country. Would he tell us in some detail why these things cannot be done?

These are the main reasons for raising the question, and I will now point out the problems. A little lecture to the House on the geography of Brighton and Hove will do no harm. It is a long area with the Downs behind it. It is very thickly populated and is becoming fast much more thickly populated. We had good hospitals in the 1880s, 1890s and the early twentieth century, very suitable for the people of those days, but since then these hospitals have become extremely out of date, and I defy the Minister to point out much that has been done in any of them to make them modern.

It was decided about 1959 that we should have a new accident centre in the Sussex County Hospital and a little improvement in one or two of the other hospitals. It soon appeared to most of us that this would be a stop-gap arrangement, like plastering up a house which was falling down to keep it going for another few years. It seemed that once we had plastered up the accident centre we should be told that so much money had been spent there that we could not possibly open a new central hospital.

During the last three or four years we have developed a new university in Stanmer Park, Sussex University, and there is a possibility of having there a central hospital in an area which is easily accessible both to Hove and to the other end of Brighton. Why cannot we have the hospital there? It is this feeling which inspired our doctors to try to have the hospital in that centre. We feel that if too much money is spent on accident centres at the Sussex County Hospital at one end, or in Hove at the other, we shall not be given enough money to build a hospital in the middle of the area. That is why we are anxious, before too much money is spent on these accident centres, to see whether we can change our minds and do something for the central hospital with all the modern aids which have been offered by these doctor friends of mine.

I do not pretend to be a doctor, or to be intensely knowledgeable of hospital buildings, but, having heard these people talk and met others in the town who support them, I feel that they are right and that I should bring before the House the point of view which almost everyone in Brighton and Hove regards as right. May I quote from a letter which these people sent to the British Medical Journal on 11th June this year: The consultants' plan was overruled by the South Eastern Metropolitan Regional Hospital Board in favour of three district hospitals, two of which were to be built on the cramped site of the Royal Sussex County Hospital and the Brighton General Hospital by a process of serial demolition and rebuilding. In fact, to date the only detailed plans to be drawn up are based upon a redevelopment of the Royal Sussex County Hospital, where there is the new accident centre and casualty department and work such as boilerhouses which are necessary for subsequent phases, for which only outline plans have been developed. They say: When in April, 1965, the Regional Hospital Board decided to postpone for two years the building of the accident centre the consultants immediately and virtually unanimously decided to ask the Regional Hospital Board for a complete reappraisal of the general hospital plans. They felt strongly"— and how right they were— that in 1965 this plan was even more inadequate and out of date than it had been six years earlier. Some people do not seem to realise that in America, Scandinavia and elsewhere, in six or seven years, they can make brilliant inventions for hospital development and plans which some of the members of the South Eastern Regional Board simply could not imagine. The older members never go abroad. They take their holidays at places like Bournemouth. These doctors, on the other hand, go abroad, to places like America, and study, and when they return they bring back ideas which are of great moment. However, when they put their ideas to the regional hospital board the board refuses to discuss them, as happened with this memorandum.

The doctors got together the consultants of the whole area who agreed, by 53 to 3, to support the memorandum. During my discussions with the Minister of Health I was told that I had no backing for this case. Does he consider that 53 to 3 does not represent the back- ing of the consultants of the area? Having gone that far, they took expert advice from the leading hospital architects and quantity surveyors and a fresh memorandum was drawn up. This was considered by the regional hospital board on 14th April at Guy's Hospital. The representatives of the board heard what we had to say and reserved judgment. However, eventually they turned us down, but without giving any reason whatever. I trust that tonight the Minister will give that reason and say why the board would not support us.

The right hon. Gentleman may not know that these quantity surveyors and architects were the exact same ones who were working on his scheme. They decided that they could do theirs for £6 million, as against £20 million. Coupled with that, it should be remembered that one site of the Royal Sussex Hospital is proposed to be built at the far end, the eastern end, of Brighton, which will mean that one will have to go right through Brighton to get to it. It will mean that many people, particularly those coming from Hove, will have to travel through the heart of the town, and in October, through the midst of the Labour Party conference, to get to the hospital. It might even be a Labour M.P. who is taken ill and who may not be able to get to hospital. Sad, but true. It will all be due to the Minister of Health.

What is the reason for these consultants not wishing to agree to the regional hospital board's scheme? It should be remembered, first, that at the Sussex County Hospital there is a steep gradient leading to this area and that the cramped space means that each phase will result in a monolithic skyscraper being built at a cost of £3 million, and that will happen with each phase. Using nodular construction techniques, a similar space could be adapted for the building of units costing about £250,000 each. I am, therefore, not trying to spend money, but to get more the money being spent, and, at the same time, to save money. Rebuilding on this site would mean medical staff and patients being very inconvenienced. This is particularly important from the point of view of patients, because bulldozers and other demolition activities will be going on, with all the noise and dust that is involved when large-scale building operations are in progress; and this will last for nearly 15 years.

A hospital at the eastern extremity of Brighton would be badly placed. It is the main accident area. It will have to serve Hove, Portslade and, in time, Southwick and Shoreham. As the right hon. Gentleman is aware, this area will develop vastly in the coming years, with great increases of population. It will become the Greater Brighton area and for some years to come the whole of mid-Sussex will be served by this hospital.

The right hon. Gentleman must also take into account the fact that the eastern road runs past the hospital and is to be developed as a four carriageway ring road. This is in the Ministry of Transport's plans. This will cause traffic congestion and other difficulties because of traffic approaching Paston Place and coming from subsidiary roads from the sea front. Traffic noise is also a serious embarrassment to patients, as I believe happened in Bristol. There is no space for car parking. Allowing one car per visitor, we can expect 800 cars in this area, their drivers looking for parking space. There is no possibility of such accommodation. Inadequate space is available for the nurses' home and staff. The central supply department will be sited at Bevendean, at another hospital three miles away. The eye hospital and other departments will be linked to the main heating system, with a tunnel under the road. All this, when we have perfectly good space at Stanmer Park, when one could build at a quarter of the price.

The project is to be divided into five phases. No time limit is given for completion, and the most optimistic estimate is that it will take at least 15 to 20 years from commencement. That is the prospect. We are told that we cannot build any more quickly, but they can build more quickly in the United States and in Scandinavia. Why cannot we build more quickly a really possible and necessary hospital?

The other day, the Minister told me that I was quite wrong in suggesting that the £20 million and £6 million schemes were comparable. I have, therefore, gone into the matter in considerable detail and I find that the two sums are the values of the final plans of the respective schemes. Both cover the complete development for hospital services in this group. They are therefore strictly comparable——

The Minister of Health (Mr. Kenneth Robinson) indicated dissent.

Sir W. Teeling

The right hon. Gentleman shakes his head, but I am only asking to deliver my goods for £6 million and he is asking to deliver his goods for £20 million, and they are the same sized goods at the end. I think that they will be the same goods, but the trouble is that neither he nor I will be here in 20 years' time——

Mr. K. Robinson indicated dissent.

Sir W. Teeling

The right hon. Gentleman may not be Minister of Health then. He could be but, if he is, the outlook for all of us is that we shall have no changeover or new developments, and we will still have our doctors saying, "We told you so". The same people drew up the costings for the Ministry as advised my group.

The first phase of the Royal Sussex County Hospital rebuilding will cost approximately £2 million. It will, in effect, provide only a glorified casualty department, with two theatres, some radiology facilities and 77 beds. But, for the same sum, the consultant's plan would provide a viable hospital with 120 beds, four operating theatres, full pathological and radiological support, an accidentcentre, a casualty department and the facilities to deal with all emergencies in the group—medical, surgical and orthopaedic—as well as accident and trauma, which is all that the Sussex Hospital could deal with.

That means £4 million left over for a scheme which would complete our "new hospital", bringing it up to 480 beds, plus four extra theatres, diagnostic unit, O.P.s and further supporting facilities, as well as administrative offices. In addition, it would include the alteration of existing hospitals to fulfil their rôle under our plan. Surely the Ministry is being stupid or at least pigheaded in trying to think that this must happen in the way it has worked out since 1959.

And for the new group organisation at Stanmer Park would not cost anything to build on. Consultants would always be available when needed; and a second opinion would always be available—which it is not when we have three scattered hospitals. There will be less travelling, less time wasted and less fatigue—anyone going from one hospital to another in Brighton about lunchtime on an ordinary day of the week will realise how tired doctors can get travelling from one hospital to another.

Decisions on management in both inpatients' and out-patients' departments could be made within three days at most, and within 24 hours on average, with all the most modern facilities instantly available on the premises instead of being diffused. Operating lists would be better organised and streamlined, thus cutting down fatigue and improving results. There would be better facilities and throughput, making for reduced waiting lists. Out-patient diagnosis would be a matter of days instead of weeks, as now. Diagnosis would be more certain because of increased scientific aids, cutting out guesswork. We would have closer supervision of in-patients and junior staffs. This must lead to better patient care, better use of facilities, better training of staff, and thus higher standards. All these measures should save time and energy which can be used to maintain high standards of patient care. This is particularly difficult to achieve in present circumstances in the Brighton group of hospitals, and would be almost equally difficult under the hospital board's present scheme.

I turn to the question of regional hospital boards. How democratic are they? In one Answer the right hon. Gentleman told me that they are appointed by him on the basis of value or what he is advised they are good at. Naturally, I can look only at my own regional hospital board. We have a chairman of whom I am personally very fond. I like him very much indeed, but we must face the fact that he is 71. He is a very nice old gentleman, a big businessman in the town. When he gets thoroughly upset by everyone heckling him about what is happening, he just says, "How can I answer? After all, I am only a draper." He is a very good draper, but I think he is not much good at these modern medical problems, about which he knows very little.

I doubt whether he ever goes to see hospitals in other parts of the world. I should be very interested to know to which he has been. As he says, he is only a draper. The real power behind the throne is a doctor who was in practice before the war. He finished practice about 1941 or 1942, over 20 years ago. He is now, they say, a very good administrator. I am perfectly certain that he is, but he has been studying all this for years on his own and he is determined now not to change his mind on anything. He has made up his mind, and that is the end of it. Nothing can be done to budge him. He has complete influence over the chairman. What can we do about it? These two gentlemen are at the moment advising the right hon. Gentleman.

Over the months, indeed over years now, I have been asking the right hon. Gentleman to meet the consultants. He has refused point blank to see them. In many other countries one can walk into a Minister's room and talk to him. They do that in the United States. I admit that in South America one would get shot, but that is another problem. The Minister need not worry about that. I am sure that these consultants are quiet people whom he could talk to, except when he jumps into a car to come to my constituency to make a political speech. The regional board will not see them, either. We do not know what their scheme or plan is, or if it ever reached the Ministry. I am inclined to think that it did not reach the Ministry, and that certainly the last report and scheme did not reach the Minister. I should like to know why.

We have a perfectly good borough council in Brighton. A third of the council is elected every year. It has a health committee which is chosen each year. That committee is largely responsible for all the hospitals in Brighton and everything connected with them, but, although it unanimously supported the consultants against the Minister on this matter, and asked me to leave them to see the Minister, the Minister refused point blank to see them. He said that the reason was that the regional board had already made up its mind. It had made up its mind in 1959, I suppose, long before any of these new inventions which we are talking about came into force. That the local authority, which is elected regularly and frequently, has not the right to approach the Minister on a matter dealing with the health of the town, is undemocratic and monstrous.

I asked the Minister today why he could not put some people connected with local government and the medical profession on to regional hospital boards, and he said definitely, "No."

Mr. K. Robinson

The hon. Member will know that there are on the Brighton and Lewes Management Committee two councillors from East Sussex County Council and two from Brighton Council.

Sir W. Teeling

They are supporting me, but that is not on the regional hospital board.

Mr. Robinson

The hon. Member must appreciate that a hospital region covers a very large number of local authorities. They cannot all be represented on the regional board, but a number of them are.

Sir W. Teeling

One would have thought that a quarter of a million people could be represented. On the list of our board the Minister has members, including a Member of this House, from somewhere up in Lancashire. I do not see how he fits in. However, there it is.

I beg the Minister, before we finalise this issue, to remember that we are in an economic crisis and that in the years which have gone by he has been telling us that he could not do this, that and the other for Brighton and Hove because of economic crises. The doctors in the area do not, however, believe that this accident centre will really improve the situation so much locally at this time. If they can wait that little longer, they will get something much better and something much more suitable for the country.

I have heard that we are trying to have special hospitals for export, for people to come and study in Reading and elsewhere about the best type of modern hospital which we can produce, which will be useful for the export market and to earn dollars. Why could we not have one here in Sussex, at Stanmer, where Lord Shawcross is willing to help with his university and is prepared to do all he can to support us? Lord Cohen of Brighton, another of the Minister's friends, swears that this is the most neces- sary and worthwhile thing that we could have.

Why cannot the Minister just for once give way a little and agree to having a board of inquiry or something similar to study the problem and to see exactly why we are spending £20 million instead of £6 million, which, no matter what the Minister says, will not be the best solution?

Mr. Speaker

I must remind the House that there are 28 subjects to be debated during this evening. I hope that hon. Members will co-operate by making speeches of reasonable length.

9.52 p.m.

Mr. Martin Maddan (Hove)

You could not have addressed those remarks to me as a rebuke, Mr. Speaker, because I have not yet begun. I should like to start by thanking the Minister for coming to answer this debate tonight. I hope that following what my hon. Friend the Member for Brighton, Pavilion (Sir W. Teeling) has said and the few facts which I shall give to underline his remarks, the Minister will regard this debate, as Dr. Johnson said of hanging, as something that wonderfully to concentrate the mind, and that in the case which is being presented the right hon. Gentleman will see reasons for a new understanding of the problem and why local opinion is so convinced that he is wrong and that he may, therefore, meet us even at this eleventh hour.

I must join in my hon. Friend's personal tribute to Sir Ivor Julian, chairman of the regional hospital board. It is certainly thought locally that the board's attitude is based on the attitude of the Ministry, and I am certain that the Minister would not in any way want Sir Ivor and the board to carry responsibility for the decision Which is the right hon. Gentleman's own.

I emphasise that although the hospital we propose is to be located in the municipality of Brighton, it would also serve, as the Brighton and Lewes Hospital Management Group serves, Hove as well as Brighton; and it is our view that patients from Hove and, indeed, further to the west—Portslade, and so on—would have a better hospital service under the Stanmer Scheme than under the regional board scheme.

The basis of the scheme is that patients should be segregated into those who are acute and need a high degree of care or diagnosis, and patients requiring an intermediate degree of care. It is clearly better that the acute patients should be treated within one hospital for the group where the resources, expert manpower and expensive equipment can be concentrated, rather than having this segregation in two or three separate hospitals within the group. It is significant that, even last week, owing to shortage of staff in the Royal Sussex County Hospital, the segregation of patients into acute and intermediate has had to be begun. Therefore, why do not we carry this through to its logical conclusion and get under one roof the expensive equipment and the concentration of expert manpower that are required?

I think it is significant that if we did have them under one roof, with the doctors almost perpetually in attendance, the patients' waiting time would be cut down enormously. At present they have to wait for some specialist facility or consultant to come, and 25 per cent. of the time spent by patients in hospitals locally is spent waiting. That is enormously expensive, very wasteful and bad for their morale. Incidentally, 60 per cent. of patients, who need only intermediate care, are in acute beds and that is also wasteful of resources and staff.

I would stress that the Stanmer plan was drawn up by consultants with representatives of every speciality concerned. Therefore, the right hon. Gentleman need not fear that if he were to adopt that plan there would be long delays and higgling and haggling about a lot of further changes—the sort of things which, as he knows, enormously delay the carrying through of hospital plans into actual buildings.

I wish to emphasise—when my hon. Friend mentioned this the right hon. Gentleman shook his head—that we cannot understand why he thinks we are not comparing like with like. I want to say why we are comparing like with like. We—my hon. Friend, the consultants and I—are concerned to see hospital provision for the complete care of acute and intermediate patients in the Brighton and Lewes Hospital Group area. The national hospital plan, which is based on the plan which my right hon. Friend the Member for Wolverhampton, South-West (Mr. Powell) brought out in 1962, envisages, inter alia, three general hospitals which do not exist at all. Two have to be completely rebuilt and one has to be started absolutely from scratch. The cost of carrying out the national hospital plan and the ancillary work—do not let us argue whether it is £18 million or £20 million—is in a ratio of three to one, compared with the complete plan embodying an acute hospital on the Stanmer site which would cost, let us say, £4 million—actually, it is a little less—leaving £2 million for the refurbishing of existing hospitals. Some of the smaller ones in the area could and should be closed.

Not only is the capital cost lower, but the revenue running costs will be less under the Stanmer plan compared with the plan advocated by the regional board and the Minister. Not just a few, perhaps not too intelligent, Members of Parliament but every independent person who has been concerned with this matter, be they doctors, architects, quantity surveyors, men of business and so on—whoever they may be—have all agreed with the case as I have stated it. We are talking about something that does not only have applicability to our area, and that is why it is worth spending a few minutes on this subject. It is important to the nation as a whole. At least half of the population could have hospital provision for a third of the cost which the right hon. Gentleman envisages, and therefore could have it very much quicker.

I do not want to repeat many of the things which my hon. Friend has already mentioned. But I emphasise that for Hove the accessibility of the hospital at Stanmer would be far preferable to the Royal Sussex County, and it must be better to delay a little to get the right answer than to crash through with the Minister's present scheme.

The Minister may say that there may well be some terrible accident and drat the present facilities in Brighton are very poor. I remind him that there is already a small intensive care unit, established during the last seven months, within the Royal Sussex County Hospital, and for an expenditure of only about £5,000 enough could be done to carry us through the extra year or so while we get the right answer.

I also emphasise that the general practitioners, through the British Medical Association, have given their support to the Stanmer scheme, providing as it does for G.P.s to care for their own patients in the intermediate care hospitals. The Brighton Corporation will give the site, all the local papers are in favour of the scheme and I should think that there has never been such an uncontroversial scheme in a locality as the one which the Minister will not adopt and which costs a third of his scheme.

Will the Minister say something about the continued reservation by the Hove Council of a site in the Borough for one of his general hospitals, in view of the acute shortage of development land in the locality?

Surely it is not too late for his to change his mind? In reply to my hon. and gallant Friend the Member for Lewes (Sir T. Beamish), he told us this afternoon that his mind was not open. But I hope that, in view of the development of the case that we have been able to make in this debate, he will re-open it. The compensation for the contractor who has been awarded a contract would be tiny compared to the financial benefits to our area and the benefit as an experiment to the whole country.

Mr. Speaker

Order. I understand that the Minister will reply to the first two debates together.

10.3 p.m.

Mr. Paul Dean (Somerset, North)

As I listened to my hon. Friends the Members for Brighton, Pavilion (Sir W. Teeling) and Hove (Mr. Maddan), I was struck by the close connections between the important local subject which they have raised and that which I propose to raise, which primarily concerns the coordination between the various branches of the Health Service and particularly the need for more effective locking in between the various branches than there is at present.

This is a vast subject, but I shall deal with it briefly in view of the large number of debates which are to follow. I am sure that the Minister will agree that, although attention tends to be concentrated on other aspects of the service, especially on finance and the payment of staff at present, its structure is a question of immense importance, particularly as we are dealing with an organisation which is vast in every sense of the word. We are dealing with expenditure of over £1,200 million a year and with one of the biggest employers in the country, many of whose employees are highly-skilled men and women whose services must be used to the best possible effect.

I have always believed that the spirit of an organisation and the men and women working in it are more important than the structure. One of our national characteristics is a mistrust of over-formal machinery. We tend to say, "Does it work?" rather than, "Does it look tidy?". Many of our institutions, including this House of Commons and Parliament in general, look very odd in theory but they succeed in working in practice.

However, many reports produced since the National Health Service was set up have drawn attention to the weaknesses in the present structure, particularly to the fact that there are, in addition to the Minister of Health, several other Ministers directly involved in various aspects of the health of the community and the fact that within the Health Service itself we have a tripartite structure, the general practitioner and other services run, as it were, off one engine, the hospital service run off another quite separate engine, and the local authority services run off a third engine.

The Coalition White Paper of 1944 proposed that there should be joint authorities for the whole Service, but that idea foundered very largely because the intention then was that these joint authorities should be based on the local authorities and the professions at the time were opposed to it. Then, in 1956, we had the Report of the Guillebaud Committee which suggested no major changes in the structure very largely because the Service was young and the Committee felt that it needed a period of stability to settle down. Nevertheless, even Guillebaud, in those comparatively early years, was unhappy about the division of functions, and the Committee pointed out that this led to many defects owing to lack of co-ordination within the Service as a whole.

In 1962, we had the Porritt Committee, composed of representatives of the main professional bodies, which was quite clear in its views and criticisms. One of the main conclusions of the Porritt Committee—I quote here from paragraph 608 of its Report—was: The most vital need is to unify and integrate in the widest sense, all aspects of medicine in order to achieve the highest standard of medical care and to avoid the sense of isolation and frustration to which we have draw attention. Co-ordination and understanding between the profession and the administration is essential. No service can thrive if there is not a genuine partnership between these two vital elements. Our review has convinced us that a major fault in the National Health Service is its present tripartite administration, for this has led to difficulties in co-ordination and co-operation. That was the main conclusion of the Porritt Committee in 1962, and it drew attention to what it regarded as the chief weaknesses in the structure to which I shall now refer: first, a lack of central co-ordination between the various Ministries involved in aspects of health; second, the tendency for the main medical men to be isolated from one another, the general practitioner, the consultant in the hospital and the medical officer of health; third, the control of funds by different authorities in particular areas; fourth, the tendency for there to be insufficient unified planning and operational research.

The conclusion of the Porritt Committee was that there should be area health boards with executive responsibility for all the health services in their areas, the general practitioner and other services, the hospital service and the local authority services. It suggested that pilot schemes might be tried out in various parts of the country to test this idea.

I believe that there is weight in the criticisms put forward by the Porritt Committee, and by other bodies which I have not mentioned, from both the medical and the administrative points of view. But there is also the point of view of the patient. I give two examples. The first concerns the elderly chronic sick. Every hon. Member knows from his experience and correspondence that one gets demarcation disputes in dealing with the needs of the elderly chronic sick, in particular between the hospital service and the local authority services. The hospitals, naturally, want to free their beds for acute cases. Local authorities, under very heavy pressure, are reluctant to take on additional burdens, and also, perfectly naturally, they have one eye on the rates. Often it is the family doctor who gets the wrong end of the stick.

The family doctor may have a patient who needs care of some kind. He may go to the hospital, and the hospital often says, "We are sorry, but there are no beds available for anything other than acute cases." He may then turn to the local authority for supporting services in the home or facilities in an old people's home, and very often he gets the same answer there, "We are sorry, but we are absolutely full up and cannot help." But each of these cases requires individaul decision in the light of all the circumstances—whether it is better for the person concerned to go into hospital, to go into an old people's home, or to have supporting services in his own home. I believe that it is much more difficult to get the right answer when separate authorities are involved.

The second case that I want to mention is the maternity services. Here one gets duplication. The mother and her baby may well need the services of the family doctor, the hospital and the local authority services as well within a matter of weeks. There is a real possibility not only of confusion in the mother having to deal with three authorities but also of duplication of effort.

These are, I believe, weighty arguments against the present structure and in favour of the Porritt approach. On the other hand, there are many people knowledgeable in these matters who doubt whether a unified structure is the right answer. They point out that there is not sufficient evidence to suggest that the major upheaval that would be involved in the Porritt approach would be justified by results. They equally point out that local government is now being looked at by a Royal Commission, and that, because of that, any local structure would be very difficult to lay down at this stage when one does not know what local government boundaries will be after the Royal Commission has reported.

They also call attention to—this is a very strong point—the various ad hoc arrangements which exist at present to get a locking in of the three branches of the service. There are the health centres where one often gets a very close link between the family doctor and the local authority services. There are the general practitioner group services, where increasingly one finds a district nurse or the local health visitor, if not actually on the staff, certainly with a room in the centre, and working very closely with the family doctor.

Then there are the various joint appointments which exist—for example, the almoner of a mental hospital who is also the local authority mental welfare officer. They point perfectly rightly to these ad hoc arrangements which are helping, in some places effectively in others not so effectively, to lock in the various branches of the Service.

Perhaps the most important argument against the Porritt approach is that it would mean splitting the local health and welfare services. That, in my view, is the argument which carries the greatest weight, because, more and more, as one examines how the local health and welfare services are functioning, one finds that there is a close link between them, and I believe that to take the health functions away from the local authority and put them under an area health board while leaving the welfare functions with the local authority would be as open to objections as the present arrangement.

I believe that there is weight in this argument against Porritt, but I ask the right hon. Gentleman where he stands on these issues. Where does he think the balance of argument should lie? Is he a Porritt man or is he not? I noted with great interest that he has put a cautious toe in the water on these matters in his annual report, which refers to the informal group which he has set up to help him consider the long-term future development of the services. I understand that he has asked the group to advise him on the interaction of the various services one with another.

As I say, he has put a cautious toe in the water, because he has given the group no formal terms of reference and I hope that he will be able to tell us a little more about what its functions are. Is the group considering the Porritt approach and the advantages and disadvantages it offers? What has he in mind for this body in trying to assist him in the future developments of the services?

This is, to a very large extent, a long-term issue but there are various aspects of more immediate application. First, what is the right hon. Gentleman's view, irrespective of how he might feel about the whole Porritt approach, of the suggestion of pilot schemes? Does he propose to select certain areas to introduce a pilot scheme on the area health board pattern to see whether it is worthy of greater application? Secondly, what are his views on the proposal that we should have something on the lines of a national health service staff college to train medical and social administrators—people who would graduate with wide knowledge of all branches of the National Health Service and whose primary job would be to assist in the interlocking of the various services and their coordination?

Thirdly, what is the right hon. Gentleman's attitude to the proposal put by the Opposition that one of the immediate ways in which one could encourage greater co-ordination would be the appointment of inspectors of health and welfare to help maintain agreed standards of service and to spread all round the country the best practices which exist? The Minister will be more conscious than perhaps anyone else in the House of the tremendous differences of practice in different parts of the country. I wonder whether he has considered this as one way in which we might spread the gospel or the good news of those authorities who are in the van in particular aspects of the Service. He will recognise that this sort of inspectorate operates with success in, for example, the education service, the police service and the fire service.

These are immensely important questions. I was very struck by a letter which I had only today from a junior hospital doctor who spoke of the despondency and resentment in the doctors' mess and who said that there was no doubt that the Health Service was trembling at its roots for so much destroyed confidence and good will. He was, of course, referring primarily to the problems of the pay freeze, but I cannot help thinking that the problem to which I have drawn attention is equally important in the solution of the frustrations and difficulties which now exist in the Service. I hope that the right hon. Gentleman will be able to give us some indication of his thinking on these matters.

10.22 p.m.

Dr. David Owen (Plymouth, Sutton)

It is with great pleasure that I rise to speak on this subject and I am extremely grateful to the hon. Member for Somerset, North (Mr. Dean) for allowing us to have time to debate it. It is an indictment of the House that we can have the announcement of a ten-year hospital building programme and a White Paper on Health and Welfare community services and yet have no time made available to discuss these vital issues. Unless the country realises that the National Health Service is staggering and suffering acutely, we will wake up in five years' time to discover that the concept of a health service as envisaged by Aneurin Bevan has completely broken. It is time that the country realised that and was prepared, if necessary, to sacrifice to pay for it.

We must now analyse the Service dispassionately and without any belief in party doctrines or dogmas. It came into being as an imaginative and noble gesture, but some of this imagination left the Ministry of Health when Aneurin Bevan left it. The time now is not for a toe in the water, but for the Minister to plunge in—dressed or naked, I do not mind—for we have waited long enough. There comes a time for integration, when cajoling and when persuasion are not enough. When the structure itself is impeding progress and it is now time. The tripartite monster is a diversive element in the Service and is now actively impeding integration.

The hon. Member for Somerset, North, mentioned the geriatric service and old people and also drew attention to the chronically sick. He also rightly mentioned gynaecology and midwifery services. Could anything be more ridiculous than the present situation in which local authorities set up cervical cancer smear tests and clinics for contraceptive advice? The place for these is in the hospitals or the general practitioner service and are all part of an integrated service.

I would also like to draw attention to the mental health service. No one knows more about this subject than the present Minister of Health, who constantly pressed for more expenditure on mental health. Here again we are finding that the structure is impeding integration. It is difficult to actively pursue a policy of community services and community care when we have this divisive structure. It should be possible for hospital social workers to follow their patient right out to their home. It should be possible for us to have a combined system of notes whereby a general practitioner's notes are integrated with hospital notes.

We are moving into the realms of computers, data processing and if we perpetuate a divisive structure we will not be able to take advantage of the very real advances in scientific and technological knowledge that we are experiencing. I plead with the Minister to make a decision that the policy of integration and unification of the Health Service will be the policy of this Government. Let us have no more committees, no more Royal Commissions. Let him decide to take one area of the country and start a pioneer scheme to show how best to integrate.

It has been suggested that Wales would be a very suitable area. It would fit in with economic areas of the Government and it represents a fairly wide range of industrial and rural life. One could also take Wessex, which has a very progressive regional hospital board. Let it be made clear from the start that we accept in principle the integration of health services.

In general practice, the Minister has already introduced a new contract which is a very real step in the direction of integration, but one will get dissatisfaction in medicine, the welfare services and among the social workers until we accept the new concept of health. This is vital. Health is no longer medicine, operations, cutting out disease, or even tablets. It now embraces social medicine, the environment in which people work, and preventive medicine. These new aspects are still growing and we must encourage them. This can only come from integrating services, from having the general practitioner working in a hospital, having the same contractual arrangements with the regional hospital board as his fellow consultants in the hospital. There should be a feeling that they are his equals. Hospital social workers operating sometimes in the community should also have the same contractual responsibilities.

Here I would say to the hon. Member for Somerset, North (Mr. Dean) that I would agree that if one's concept of an integrated health service was one in which the welfare services were excluded, it would be bound to fail. We must include health and social and welfare services. This means that we must look at the whole structure of government. There is a great deal to be said for having one person in the Cabinet as a Minister of Social Security, to speak for the Ministry of Social Security and the Ministry of Health. Meals on wheels and those other aspects of the welfare services must be very closely related to health.

Who else, other than a general practitioner, knows whether an old person is sick; who else can arrange for a suitable diet? Who is in a position to judge where there is great poverty and who should be in daily contact with welfare officers and workers more than the general practitioner? If we had such a concept it would attract young doctors and keep them in this country. It would provide them with a stimulus, and I would urge the House to consider this as a matter of the utmost gravity and as a situation demanding speedy action.

One of the great obstacles often put in the way of any change in the present structure is the argument that we shall be interfering with a democratic process; that we shall have again a system of too much centralisation and not enough local control. This is a fair point, which we must consider, but I suggest that it is time for us to stop mouthing platitudes about democracy and consider how it really works.

For instance, how democratic are the health and welfare services? The regional hospital boards are appointed. I do not complain of that. The hospital management committees are appointed, and so are the executive councils. There is the democratic election of local authorities, but we all know how few people bother to turn up to vote in local government elections, and how local government is in need of radical reform. I reject utterly the thesis that, before it interferes with this situation the House must await the outcome of the report of the Royal Commission on Local Government.

Health has been waiting since 1948, and it cannot go on waiting. I suggest that it is illogical to expect a local authority commission to report boundaries which are suitable for health. The problem we face is: where do we site our district hospitals? How large are these district hospitals to be? In my constituency we are just about to build a district hospital at Derriford. It would be madness to build a new hospital in Plymouth without planning for it to take its part in the integrated health and welfare services. The siting of hospitals, the building of hospitals, and the facilities offered by them should take account of the eventual integration of the services. That is why a decision in principle must be made now.

The way in which we site our hospitals and spend millions of pounds could well be regretted in 10 years' time. I say that we should grasp the nettle now. Contemplate a Ministry of Social Security with an overlordship over these two great ministries; contemplate regionalism translated into health. Have, on the regional economic councils and boards, health representatives. Make the regional hospital board areas fit in with the economic regions. Administer them with the same economic sub-regions as will be set up, and then cast an eye on democracy.

Where can it be more important than in health? Which, of all the national services, serves the community as much as health? I ask hon. Members to analyse how conscious the Health Service is in general of consumer reaction; how much has it embraced the concept of client control. In injecting a democratic element into any new and integrated Health Service we should look at the principle of consumer councils, operating on a far more active scale than at present, freely elected, and, if possible, set up not to engender party politics and party political decisions. Let them come from central Government, but let these consumer councils speak for the locality and speak for democracy.

They would be respected; it would be a great honour to be elected to such a council, and we would have people of all walks of life putting themselves up to speak for the community. We would also be able to recapture the principle of local participation that is so vital to health. This has to some extent been lost through the Health Service. The spirit has not died, but it needs rekindling, and it could be a valuable remedy for the manpower shortage in the Service. Many hospitals have already tried using voluntary workers and the results in terms of enthusiasm have been outstanding. This could help to overcome the present acute shortages.

The divisive administrative structure impedes progress. The isolation breeds intellectual sterility, not only among doctors but among social workers, and a lack of understanding and frustration among patients. Now is the time to act decisively and to set up a pilot control. This debate could be the start of a new concept of health in the community.

10.36 p.m.

Mr. Bernard Braine (Essex, South-East)

Thanks to my hon. Friends the Members for Brighton, Pavilion (Sir W. Teeling) and Somerset, North (Mr. Dean) and the stimulating speech of the hon. Member for Plymouth. Sutton (Dr. David Owen), we have had an interesting and valuable debate. It is clear that the National Health Service is going through a period of acute difficulty, that there are insufficient doctors and that their workload is increasing and preventing them from practising good medicine.

The population in my constituency has been increasing rapidly recently, and twice in the last few weeks I have had to write to the local evecutive council for Essex about the shortage of doctors locally. No doubt many other hon. Members have had similar experiences. This is not the fault of the Minister or his predecessors. The truth is that successive Ministers of Health have been unable to secure sufficient resources from the Chancellor of the Exchequer to sustain an adequate and expanding Health Service. But it may be that we could organise the use of our available resources more skilfully and productively than we do. That is why we are looking forward to hearing the Minister's reply to my hon. Friend's charges.

It is good to stand back sometimes to take a long cool look at our institutions and consider whether they shoud be im- proved. I believe passionately in the concept of a Health Service, but its strongest supporters would not maintain that it is functioning smoothly and could not be improved. If the tripartite system—of the general medical service, the hospital service and local authority services—works, it is not because of its inherent virtues, but because of the dedication and skill of the lay and professional people who work in it.

There is plenty of evidence that the system is defective. Co-ordination is difficult and this militates against the provision of the best possible service for the patient. Because the three parts are administered separately, there is often a feeling that doctors in each, with their supporting professions, are isolated from one another in the pursuit of what should be their common aim, the well-being of the patient. Because the three parts are financed separately, there is little incentive to use the resources in any one for the maximum benefit of all. I have often thought—I shall be interested in the Minister's views on this—that a much greater investment in the supporting services for general practitioners, who deal with over 90 per cent. of all illness, and in diagnostic and treatment aids for them would reduce pressure on the hospitals.

There are at least two unsatisfactory aspects of the present relationship between local authority services and other parts of the Health Service. First, the geographical areas covered by the three parts of the system are not always conterminous. The regional hospital boards, almost always, and executive councils, sometimes cover much wider areas than a particular local health authority. There is a widespread feeling in local government that it should have a greater say in hospital management, which is understandable when we recall that before 1948 many local authorities ran their own hospitals.

Secondly, while local authorities must submit proposals for new development in their health services to other interested parties, which include regional hospital boards and executive councils, and through them the local medical committees, there is no similar requirement, as far as I am aware, for the hospital boards and for executive councils to keep local authorities informed of developments in their own field.

Hospital authorities are often forgetful of the need to keep local authorities abreast of developments which are important to both. It is true that ad hoc liaison committees exist to deal with paricular services such as maternity and mental health, and these help, but they have no executive functions, and where they recommend the spending of money there may or may not be a conflict between separately administered and financed services with different ideas of what the priorities shoud be.

My hon. Friend described in detail how the tripartite system came about and mentioned the Coalition White Paper of February, 1944, which sought to avoid precisely the defects which are now seen to exist. That White Paper proposed that the different branches of the medical Services—hospitals, dentists, doctors, preventive health and welfare—should all be administered by joint authorities consisting of combinations of the larger local authorities. It was the professions themselves, particularly the consultants, who jibbed at the idea of control by local authorities, and so the proposal was dropped. I am not saying that it was wrong to drop it at the time. In the event, however, local authorities lost control over their own hospitals.

Eight years after the establishment of the Health Service, the system was examined by the Guillebaud Committee. They were unhappy about the division of functions within the Service, but they thought—who is to say that they were wrong at that time?—it was too soon to make changes. Six years after that came the comprehensive review by a very distinguished professional Committee headed by Sir Arthur Porritt. My hon. Friend mentioned that Committee's recommendations, and I will not go over them again. Suffice it to say that the Porritt Report was an attempt to deal with what Guillebaud recognised as a manifestly unsatisfactory state of affairs.

It is true that since then we have had the hospital plan and the long-term development of the local authority health and welfare services, which were intended to improve not merely the quality of the personal health services of this country but their co-ordination. It is also true that one cannot accept the Porritt recommendations in their entirety. To do this would mean to separate the personal health services of local authorities from the welfare services. I agree that that would be utterly wrong. These are services affecting the interests of children, the elderly, and the mentally and physically handicapped. It would also mean taking the personal service away from the local authorities, and that would be wrong, too. For it would reduce the valuable rôle played by the medical officer of health and hinder the development of the preventive side of health. Moreover, local authority health and welfare services are under review at present. I can only hazard a guess as to what may emerge from these deliberations.

There may be recommended a family service—one service embracing child care, school health and welfare—and certainly all modern social thinking points in that direction. The argument seems to be in favour of more integration and less fragmentation of the personal services. On the other hand, the review may confirm what we already know; that there is wide disparity of provision as between one local authority and another. This is especially marked with the development of new services, and as new services develop we see some local authorities lagging behind with the more progressive ones forging ahead.

So, if I can bring the threads of the argument together, why cannot we secure the integration which Porritt recommended and which is so essential to the proper performance of the Health Service and the democratic control provided by local authorities? When the Service was established in 1948 it reversed the trend towards increasing local authority responsibility. That was probably due to the feeling that the manifestly unsatisfactory structure of local government made it unsatisfactory to carry the new Service. However, in recent years there has been a swing in opinion, partly because of the realisation that efficient units of local government of suitable size and resources are able to play an increasingly valuable rôle in promoting health and well-being, and partly because they are in close touch with the community's needs and the concept of care within the community rather than in institutions makes good sense.

I suppose that a cynic might remark that one reason for this change in attitude is that hospital authorities, based on a system on nomination rather than on one of democratic selection, have sometimes shown themselves to be out of touch with local feeling. My hon. Friend the Member for Brighton, Pavilion sought to illustrate this earlier. Certainly, the hospital service generally has had to turn more and more for co-operation to local authorities, and this has resulted in the provision of more home nursing and midwifery facilities. Further, a strong boost was given by the Mental Health Act, 1959, to the part which local authorities can play in reducing the hospital population.

There is, therefore, no reason to suppose that suitably sized units of local government could not assume still larger health functions. If, as a result of local government reform, we secure larger and more efficient units of administration, there is a strong case for the setting up of a health board, as Porritt recommended, within each county or county borough, linked with the local authority and charged with the duty of administering an integrated service.

Dr. David Owen

I do not think that it was a concept of Porritt that it should be linked with local authorities. The hon. Gentleman is putting forward a revolutionary and interesting idea. It might be bitterly opposed by the medical profession, although that is no reason for rejecting it. But are we to gather that the hon. Gentleman is now adducing official Conservative policy in suggesting the integration of the health services along those lines?

Mr. Braine

No. On this point I am not putting forward any official ideas. I am speaking for myself.

The hon. Gentleman is right in correcting me because what I was suggesting was not one of Porritt's recommendations. In suggesting the setting up of a health board within each sizeable county or county borough, linked with local authorities and charged with the duty of administering an integrated service, I am merely bringing together the concept of Porritt and the desirability of having some elected element brought in so that the whole structure can become democratic.

I am, therefore, throwing out these ideas in the hope that the Minister will do what the hon. Member for Plymouth, Sutton (Dr. David Owen) asked him to do; with or without clothes, to take a dive into the deep end and grasp the nettle—although I do not see how he could do both at once—and make the position clear. What we are trying to do is to persuade the Minister to respond to these suggestions.

Sooner or later, administrative reform must come; the hon. Gentleman admits that. He did not go into great detail, but I suggest that if administrative reform comes, and there is integration, it must be an integration that involves all three parts of the Service, not missing out the local authority health and welfare services. Indeed, I cannot envisage a situation in which the local authorities would agree to a surrender of their very valuable functions unless there was an integration in which they themselves could take part.

I come to the one suggestion that we on this side would officially make, and that is that there should be experiment. Why should there not be experiment? Do we not have regions and cities with great civic and regional pride, and with a great tradition of co-operation? I shall not name any specifically—we all have great cities in our mind. I look at the hon. Lady the Member for Liverpool, Exchange (Mrs. Braddock) at the moment—Liverpool might make an admirable place for experiment of this kind. We would welcome, therefore, some indication from the Minister that he has the imagination and the courage to think along these lines. With or without his clothes, we invite him to take the plunge.

10.52 p.m.

The Minister of Health (Mr. Kenneth Robinson)

We have had a very useful and interesting debate dealing with matters both general and particular in the National Health Service. It suggests to me a degree of interest in health which is not exactly reflected by the proportion of time which the House normally gives to the affairs of the Service. If it has done nothing else, the debate has, at least, conjured up a picture of the Minister leaping, clad or unclad, into an unnamed swimming-pool, bravely grasping a nettle in each hand—and that was, I suppose, worth sitting through the debate for.

First, let me deal with the matter raised by the hon. Member for Brighton, Pavilion (Sir W. Teeling). He will agree that the hospital service in Brighton has been the subject of much interest recently, and I am very grateful that my own concern for the service in this area is shared by a number of hon. Members. At the same time, I doubt very much whether the hon. Gentleman furthered what case he had by overstating it, as he did.

I strongly dissent from the hon. Gentleman's earlier suggestion that the difficulties experienced in Brighton were somehow typical of the country as a whole. This is not so. I think that the consultants generally recognise that we are getting ahead at an ever-increasing pace with the modernisation, long overdue, of our hospitals; and that we are today building as fine and as modern hospitals as any country, not excluding the United States of America.

The hospitals of the Brighton and Lewes Hospital Management Committee, despite, in many cases, out-of-date buildings and a heavy and increasing burden of work, provide a first-class service to the patient, and I am happy to pay a tribute to the way in which doctors, nurses and other staff of Brighton hospitals have worked, as they always do, for the benefit of their patients. I should not wish them to believe that the present differences of opinion on a particular matter reflect in any way on their devoted work.

I should explain the difference in emphasis between the hospital plan at Brighton, set out by the right hon. Member for Wolverhampton, South-West (Mr. Powell) in 1962, and the present proposals of the regional board as approved by me in the recently published hospital building programme. The earlier plan was for parallel development of the Royal Sussex County and the Brighton general hospitals over 15 years, and the building at the end of this period of a new district hospital at Hove. As with so many proposals of that time, it became clear all too soon that national resources—and, more particularly, the resources that could be allocated to the regional board—could not encompass the building or rebuilding of three major hospitals in this one hospital management committee area. Indeed, assuming that the population of the area will be about 350,000 by 1981—it is now about 267,000—three large hospitals would be too many. Two ought to be able to provide a very satisfactory service.

I want to say a word about the regional hospital board. The hon. Member for Brighton, Pavilion made a number of aspersions about the board and its members. He made a personal attack, which I regretted, on the chairman of the board, a very distinguished person who has given long service in a voluntary capacity to the Health Service; and on the senior administrative medical officer, who is a public servant and cannot answer for himself. I think that the hon. Member, on reflection, may feel that the personal attacks he made were not exactly in the traditions of this House. I repeat what I have told him privately, that I have full confidence in the board, in its chairman and its officers.

In another respect, I thought that the hon. Member was less than fair to the board. He put a Question to me the other day. I thought that at least he might have been gratified to learn that the average age of the members of the board was two years less than his age, but tonight he has spent a lot of time in suggesting that they are a lot of old fuddy-duddies. I do not know what that makes him.

The regional hospital board proposed in its review of its plans for which I asked last year two phases in the development in phases of the Royal Sussex County Hospital. This is not what the hon. Member described as the 1959 plan. The first phase is to consist of an accident centre, operating theatre and the X-ray department, all of which is urgently needed to enable the hospital to treat more patients more quickly. In addition, more beds will be needed to reduce the pressure on existing beds.

The first phase also includes a new boiler house for the whole redeveloped hospital and administration offices and some accommodation for non-resident staff. The whole of the planning for this scheme was completed over 1961–64 and the cost limit was agreed by my Department as long ago as May, 1964. Since then the scheme has been merely awaiting a place in the four years' financial programme. The cost of phase I of the development of the Royal Sussex County Hospital, including beds and equipment, is £1.6 million. I mention that as a contrast to the figures which have been bandied about of £6 million and £20 million. They have been widely canvassed, but their derivation has never been spelled out to me, certainly not the £20 million. This suggested alternative of £6 million and £20 million is a complete myth, as I hope to show.

In December last, the hon. Member gave me a memorandum containing suggestions for a different form of hospital development for Brighton. This was elaborated later in a plan which became known as the consultants' plan for, as the hon. Member said, a completely new hospital at Stanmer Park on a site adjoining the University of Sussex. The consultants' plan has appeared in two, if not three, different versions. I shall deal with the latest. It is not true to say that I have not seen it. The hon. Member for Hove (Mr. Maddan) handed it personally to me several months ago.

This consisted in brief of a scheme to build not a full district general hospital, but a highly intensive small hospital of about 480 beds in which patients would stay for not more than five days and then be discharged either to home or to other Brighton hospitals. The hon. Member for Hove talked of the virtues of segregating patients who need intensive care from those who need intermediate care. There is considerable virtue in segregating within a single hospital. This is not a new concept. It is being carried out in many hospitals in the country at the moment. It is a very different matter to think of segregating them in two different hospitals. Indeed, this concept of an exclusively intensive care hospital does not commend itself to my advisers or to me in general.

But I admit that at first sight the scheme did present some attractions. I was told that it could be built for only £3,700,000 as compared with something under £7 million for the first three phases of the Royal Sussex County proposal. Well, I am always anxious to keep down the capital cost of hospital provision to the absolute minimum so that the boards can get the best value for money consistent with the best service to the patient.

However, although I have been given no later details, I learned from the hon. Gentleman's Question on 25th July that the cost has now risen from £3,700,000 to £6 million. Moreover, my attention has been drawn to the fact that the consultants' plan does not include any proposal for building residential accommodation for the very numerous medical and nursing staff who would be needed to run the hospital. On a new site there would be no existing accommodation for such staff at all. Even in developing the Royal Sussex County Hospital the board has found it necessary to include extensive staff accommodation in later stages of the development.

I have mentioned this to illustrate that this was not quite the fully thought-out scheme which the hon. Gentleman represented it as being. It was also clear that their plan did not take into account the cost of upgrading the Royal Sussex County and Brighton General, which would still be required in a supportive or satellite capacity to provide medical facilities not provided by the new hospital and beds for patients who could not be discharged home after five days.

The plan would, in fact, entail three hospitals—the new hospital, the Royal Sussex County and the Brighton General—and I have already explained that two hospitals are all Brighton will need in the foreseeable future. Furthermore, there would be running costs of something like £1 million a year for the new hospital.

Nevertheless, so that the consultant's plan should have a fair hearing, the regional board was ready, with the management committee, to meet representatives of the consultants to discuss the merits of the two schemes and the meeting was held on 14th April. The board reported to me afterwards that it and the hospital management committee were agreed that the Royal Sussex County scheme had a number of advantages, not the least of which was that it could be started immediately.

Planning is a process which takes several years in the case of a large and complicated building such as a hospital, and it is one which requires a considerable degree of expertise. This scheme has been planned in detail over a period of four years and was ready to go to tender in March, 1965. To shelve it in favour of a completely different scheme, quite apart from other considerations, would have involved quite unacceptable delay in effecting urgently needed improvements in the hospital services in Brighton.

I accepted the regional board's recommendations. They coincide with the view I had myself formed after careful consideration of the consultants' plan by my Department which I set in train in response to the request of the hon. Gentleman himself. The contractor for the Royal Sussex County scheme has now been appointed and work is due to start on the site this month. Hon. Members opposite have attempted to draw comparisons between the two schemes, claiming that the consultants' plan will cost only £6 million and the regional board's plan £20 million. I have shown that the two concepts are quite different and that no basis for comparison of true cost exists——

Mr. Maddan

We cannot spend a great deal of time on this, but the right hon. Gentleman will know that as I rose to speak Mr. Speaker asked that we should be brief and I therefore was brief. That may explain why the Minister has failed to grasp what these plans are about. May I ask him, therefore, whether he would see me personally either later tonight or tomorrow morning so that I can go through the comparison again in detail and show that like is being compared with like?

Mr. Robinson

Much as I always enjoy talking to the hon. Member, I assure him that I really do understand what this is about. The thing has been explained, as far as it is capable of being explained, by the authors of the plan. It has been exhaustively looked at by my Department——

Mr. Maddan

No.

Mr. Robinson

—and I assure the hon. Member that there is no question whatever that like is being compared with unlike. Six million pounds is, apparently, the latest cost of the hospital, which has not been taken anywhere near the final cost stage of planning.

Mr. Maddan rose——

Mr. Robinson

I am sorry, I am not giving way again, because I assure the hon. Member that these plans have been exhaustively studied, and I am quite satisfied that the board has come to the right decision.

Mr. Maddan

I am only trying to help the Minister——

Mr. Robinson

With the greatest respect, I do not need——

Mr. Deputy Speaker (Sir Eric Fletcher)

Order. If the Minister does not give way, the hon. Member for Hove (Mr. Maddan) must resume his seat.

Mr. Maddan rose——

Mr. Robinson

I have not given way, except to the occupant of the Chair, as is customary in this House.

Perhaps I may now come to the point raised by the hon. Member about the site of the Hove General Hospital. It is still the intention of the regional board ultimately to provide a new district general hospital in Hove. I understand that the site in question has been informally earmarked by the local authority for hospital purposes, although not specifically designated. The position is that it will still be required in due course, but the site is still in the ownership of Hove Borough Council, which is entitled to use the land in any way it likes subject to the gentleman's agreement which it has made with the board. There is no objection by my Department and the board to the Territorial Association erecting a temporary building on the land.

Perhaps I may turn now to the more general matter which was raised by the hon. Member for Somerset, North (Mr. Dean).

Sir W. Teeling

Before the Minister leaves the question of Brighton, can he explain why, to expedite a decision, he is not prepared to see the consultants, who have worked so hard on the subject? If he would do this, everybody would be satisfied.

Mr. Robinson

Because the planning authority for the area is the regional board and unless I have lost confidence in the board, which is my agent, I will not spend time with a lot of amateur planners planning a hospital which, I am satisfied, would not meet the requirements of the area. I am speaking not simply as Minister, but as one who has been advised by people with great expertise in these matters. I know that the hon. Member is not satisfied. I did not expect him to be satisfied. I beg him to believe that this is now water under the bridge.

Perhaps I may now turn to the question of the Porritt Report, which was raised by the hon. Member for Somerset, North and on which the hon. Member for Essex, South-East (Mr. Braine) made a contribution. It is a little difficult when dealing with the hon. Member for Essex, South-East. When he speaks from the Dispatch Box, I naturally assume that he is speaking officially in the name of the Opposition, but halfway through his speech he rather disclaimed that and said: "For the next little bit of my speech, I am speaking officially". The hon. Member must decide what hat he is wearing and what bench he is speaking from before he contributes to these debates.

The hon. Member referred to one aspect of the Porritt Report. It covered 20 out of the 600 paragraphs of the total Report, but it is quite true that this is the aspect for which the Porritt Committee will always be best remembered. It relates to the co-ordination of health services. This is a problem which has always been in the minds of those responsible for running the Service and its various parts. Certainly it was in Aneurin Bevan's mind when he created the National Health Service after the war, and this can be easily seen by reading the OFFICIAL REPORT of those debates.

It is sometimes claimed that the problems of co-ordination have been recognised and identified only from the experience of particular difficulties. One might almost think that the concept of co-ordination was invented somewhere in the 1950s and then urged on the managers of the Health Service, who had hitherto been unaware of the problem. We do our predecessors an injustice in arguing in this way, and I could prove the fallacy if I had time.

My own view is that the true situation is very nearly the reverse of the theory I have just described. The creation of the Health Service was the biggest single step in securing co-ordination of the health services that this country has ever seen, or is likely to see in the foreseeable future. There is always plenty of room for improvement, but the opportunities for the individual patient—this matter is what concerns me—to take advantage of a co-ordinated service are out of all proportion to what he would have found before the Health Service, let alone before 1939.

To put the matter in perspective, we should look on the emphasis given in recent years to problems of co-ordination not so much as the identification of a glaring fault but as evidence that the continuing need to keep the organisation of the service under review is widely recognised, both within my Department and elsewhere. I hope that I have never shown signs of being too easily satisfied with the status quo, and I trust, therefore, that no one will take what I have just said as meaning that I think that all is well and that we do not need to do anything more. I well know that this is far from being the case. With all the preoccupations of one crisis or another—I doubt whether the Health Service has ever been without its current crisis at any given moment—the concept of strengthening the links between different parts of the service and the different kinds of service that an individual patient might need has never been very far from my mind.

We have made special arrangements for co-ordination in a number of major matters. We issued plans in May and June this year covering respectively the hospital building programme and the health and welfare programme, and both these documents represent a substantial degree of co-ordination of services. In producing their plans, the Health Service authorities do consult each other, even without the regular exhortations to do so issued from my Department.

The hon. Member for Essex, South-East was wrong in what he said about there having been no requirement to consult in the production of those plans. I hope that there is no authority that would reckon to produce a plan nowadays without discussion and consultation with other authorities and interested parties in its area.

Apart from these major planning exercises, work has been done on the coordination of particular kinds of services as between different participating authorities. Last September, my Department sent a memorandum to local authorities and hospital authorities on the subject of care of the elderly in hospitals and in residential homes. In the past, we did have what I think the hon. Member for Somerset, North called demarcation disputes in the care of the elderly, which were apt to provoke loss of time and sometimes of temper, and which, worst of all, might leave the individual patient without the care he needed. Here, too, if there was isolationism in the past, there is today a full recognition of the need for co-ordinated services and for genuine co-operation between those who provide them.

Similarly, we could look at mental illness and mental sub-normality. The need for close working links between the local health authority and general practitioner services was stressed in two memoranda issued from my Ministry in 1964 and 1965 on improving the effectiveness of hospitals for the mentally ill and mentally subnormal respectively, one in the time of the hon. Member for Essex, South-East and one in my time.

Mr. Braine

But does not the mere fact that the Ministry has from time to time to issue hospital authorities memoranda based, presumably, on the best practice indicate that there is a need for some co-ordination not only at the Ministry level, but even at the lower level?

Mr. Robinson

I have never denied that there is need for co-ordination. I am seeking to demonstrate that we are doing something about the need, and I shall go on to demonstrate that the solutions put forward in this debate are not necessarily the right or the only solutions.

Mr. Braine rose——

Mr. Robinson

No, I shall not give way again. There are over two dozen other subjects to be raised, and the hon. Gentleman must have some regard for those who are to follow.

The maternity services have been mentioned. There have been considerable developments here, also. I could give a number of examples, but, in view of the time, I shall not do so tonight. It is a fact that co-ordination is improving day by day, and I believe that everyone in the Service is now fully conscious of its importance.

The hon. Member for Somerset, North spoke about the Porritt Committee's recommendation that we should have area health boards, and he asked for my views on this. He did not quote something else which the Porritt Committee said about the need for operational research. I assure him that in the last year or two very many operational research studies have been started by or sponsored by my Department, and a good deal is going on in this field now.

I have been talking about co-ordination in a rather wider sense because, in my view, discussion of this subject usually proceeds on the basis of a common misconception, and I want to try to dispel it if I can. This misconception is that the royal road to co-ordination is by way of spectacular changes in administrative structure. The Porritt Committee suggested that the area health board was the best way to go about it. I agree that, when it comes to planning the services, integrated authorities would more easily produce integrated plans, although, as I have tried to show, separate authorities have now seen the virtues of consultation. But what some people, by what I think is a logical fallacy, tend all too quickly to conclude is that an integration of authorities is also the right means to provide continuity of care for the individual patient.

In general, the sort of problems which arise are those when a patient's care is handed from one doctor to another, from a doctor to a local authority worker or in some such way between two units of the Health Service, or even in the wider context of the social services generally. Whether such movements will work smoothly depends, in my view, not nearly so much on administrative structure as on willing co-operation between the individuals concerned. It is, in my view, right, therefore, that over the last few years we have concentrated in our efforts to secure constantly improving co-ordination on the individual local links between people and between units, links between the general practitioner and the health visitor, the medical officer of health, the specialist, the hospital, the old people's home, the training centre. All these individual local links can be strengthened and tested to provide the individual patient with the care he needs.

But, having said all this, I do not have it in mind to deny the importance of what the hon. Gentleman said, or what was said by my hon. Friend the Member for Plymouth, Sutton (Dr. David Owen), even if I cannot altogether accept his rather gloomy forebodings of the impending collapse of the Health Service. In the long term, there may well be a case for administrative changes, and we are thinking about such possibilities.

The area health board was not a concept invented by the Porritt Committee. The idea had existed in one form or another for quite a long time. Its particular difficulties were recognised, I think, even at the time when the Health Service was set up. One was that the regions, which have proved suitable units for planning hospital services, are too large for the administration of what are now local authority and executive council services, while an area suitable for the latter would be wholly inappropriate for planning a coordinated hospital service.

Another difficulty is the determination of who should serve on an area health board—a detail on which the Porritt Committee was utterly silent. At present, the three main Health Service authorities contain between them a very wide range of representation, and it would be very difficult, if not impossible, to fit them all into a single committee.

Dr. M. P. Winstanley (Cheadle)

I wonder whether the right hon. Gentleman could enlarge on that point, because it is one which I find very interesting? When talking about the Porritt Committee's recommendations for area health boards, it is clear that the Committee recommended merely the bringing together of the hospital services and the local authority services, leaving the general practitioner services outside altogether. I am glad to hear the Minister talking now as if the area health boards would bring all three sections together. Would he make the distinction clearly that he is departing from Porritt and going more on to the concept of all-embracing health boards?

Mr. Robinson

It must be made clear that I am not making policy statements of future intentions. However, if one were envisaging a major structure change, the case would be for co-ordinating all three rather than merely two parts of the Service.

I have been told a story—I do not know whether it is apocryphal or not—that Aneurin Bevan was asked why he did not introduce area boards and he said that he might have considered the idea had he been able to ensure that each such board could have the Albert Hall to meet in. That illustrates the difficulty of getting the great range of talent together that one needs represented on a single committee.

I would not want to exclude for all time the possibility of changing the present administrative structure of the Service or of introducing a more unified type of administration. It was suggested, particularly by the hon. Member for Essex, South-East, that one should not introduce a change universally, but try it out first in one or other area by way of an experiment. The point was also made by the hon. Member for Somerset, North. Different ways of conducting such experiments have been suggested. In some places—and I am thinking particularly of the medical services to be provided in the new development in the Woolwich-Erith area of London—experiments in co-ordinated community care are now being launched. That may be the right way to make progress.

The hon. Gentleman mentioned the long-term study group which I set up soon after coming to the Ministry. I can assure him that that group is bound to consider ways of securing closer integration of the services. I deliberately did not give it any formal terms of reference. With a collection of distinguished individuals like its members, it is far better to give them a free hand and a roving commission. I can assure the hon. Gentleman that they are making full use of their opportunities.

In conclusion, I would only say that our Health Service will not stand still. I agree that we must always be looking for ways to reform it, to improve it and to enable it to provide better care for the person who really matters, and that is the individual patient.