NATIONAL HEALTH SERVICE (FUTURE STRUCTURE) (Hansard, 11 February 1970)

§ The Secretary of State for Social Services (Mr. Richard Crossman)
With your permission, Mr. Speaker, I wish to make a statement.
I have today published a Paper on "The Future Structure of the National Health Service". Copies are available in the Library of the House. In addition, in view of its importance, I am sending a copy to every Member.
The Paper records three decisions which the Government have reached on the health services in England. First, they have decided, as already announced, that the National Health Service will not be administered by local government.
Secondly, the Government have decided on the administrative boundary to be drawn between the Health Service and the public health and personal social services which will continue to be run by local authorities. The health authorities will be responsible for those personal services where the primary skill needed is that of the health professions, and the 1256 local authorities for those where the primary skill is social care or support.
This boundary will be further defined in the Bill, to be published tomorrow, arising out of the Report of the Seebohm Committee.
Thirdly, they have decided that, in order to achieve better co-ordination than is at present possible, the number and areas of the new health authorities should, in general, match those of the new local authorities proposed in the White Paper on Local Government Reform in England, that is to say, the unitary areas and the metropolitan districts outside London. There will be special arrangements for London.
In the light of these three decisions, the Paper puts forward revised proposals for the future structure of the Health Service. Apart from the three decisions, the Government are not committed to the proposals. They are open to comment, and they will, of course, be fully discussed with interested organisations before firm decisions are reached. That is why we are publishing a further Green Paper.
Our basic purposes are:

1. to unite the National Health Service and to integrate its separate services locally;

2. to co-ordinate the National Health Service and the local government public health and social services;

3. to involve local communities in the running of the National Health Service district services and, in general, to decentralise responsibility to the maximum extent compatible with the retention by the central Department of its proper function of ensuring maximum value for the resources spent on the Service.

§ Mr. Maurice Macmillan
Normally, as a publisher, I should congratulate the right hon. Gentleman on going into his second edition, but I am not sure that one can do so in the case of this Green Paper.
Judging by the right hon. Gentleman's statement, it might be described as a Green Paper with blurred edges, rather than a Green Paper with white edges. It seems that it departs slightly from the concept of the unified approach to people as a whole by health and welfare 1257 services, but no doubt we must wait for the Bill tomorrow to see to what extent this is so.
May I ask four questions. First, how are these new authorities to be constituted with regard to representatives from the right hon. Gentleman's Department, from the professions and from local authorities? Second, when the right hon. Gentleman refers to decentralising responsibility, what degree of independence does he envisage for them? Are these authorities to be allowed to choose to some extent the policy over small hospitals, cottage hospitals, and the like? Are they to have any command over resources, different from the system which operates now?
Third, the right hon. Gentleman referred to involving local communities. How will he do this? Is it in money-raising for the local authorities, or is it entirely on the lines of what happens now?
Lastly, can the right hon. Gentleman let us know any reactions that he may have had from the consultations which have so far taken place, and perhaps give us some idea of the timetable which he envisages for future consultations?

§ Mr. Crossman
I thank the hon. Gentleman for his comments. Perhaps I could deal, first, with his last question, about consultation. There have been no formal consultations on this Green Paper, but a great deal of informal consultation has taken place. Immediately on its publication the formal consultations will begin, because this is to be a consultative document. I hope to publish a White Paper before the end of the summer, because the past year has been spent in a great deal of discussion.
Dealing with how the authorities are to be composed, we shall have a completely new departure. The regional hospital boards under Aneurin Bevan were 100 per cent. selected by the Minister. This is a system which I find difficult to defend, and it is now being abandoned. In future, one-third of them will be appointed by the local authority concerned, one-third by the profession, and only one-third will remain with me as the Minister.
On the question of the degree of independence to be enjoyed, I think that the 1258 Green Paper should be studied to see what we mean. If the 100 per cent. grant is continued, it is obvious that budgetary control must stay with us, but we intend each authority to put forward its own budget, which will be an integrated budget covering hospitals, community services and general practitioner services. Everyone will have a fully integrated service, so I do not think that I need reply to the hon. Gentleman's first observation that we have departed from the notion of an integrated service.
The authorities will be able to make decisions on the hospital programme, but we intend to retain regional councils to deal with regional aspects of hospital planning, ambulance services, and such like.

§ Dr. Summerskill
Will my right hon. Friend bear in mind that these proposals are particularly welcome because they remove the barriers between the three parts of the Health Service? They recognise throughout that the family doctor team is the centre of the Service, but they are particularly welcome because they propose the abolition of the totally undemocratic and self-perpetuating system by which members are appointed to regional hospital boards and hospital management committees.

§ Mr. Crossman
I am grateful to my hon. Friend, though I do not go all the way with her in her strictures. Having sought to do the job of selecting every member of every hospital board, I realise that Aneurin Bevan demanded the impossible of his successors, even if he achieved it himself, which I sometimes doubt.
The removal of the barriers is a major aspect of the change. We envisage an integrated service much more closely linked with the community, centring on the family doctor, with adequate access to each hospital and to the local community services.

§ Mr. Turton
The right hon. Gentleman spoke about decentralisation. Is he aware that the Bonham-Carter Report on the Functions of the District General Hospital has aroused deep misgivings among small hospitals in many parts of the country? Can he give an assurance that this Green Paper will not follow the lines of the Bonham-Carter Report?

§ Mr. Crossman
I am grateful to the right hon. Gentleman for mentioning the Bonham-Carter Report, because I issued that with a very careful letter emphasising that it was to be discussed and that it was not accepted Ministry policy.
It is clear that in large areas of the country district hospitals of these dimensions are "not on". I am thinking of Devon and Cornwall, and country districts. There are qualifications in the report, but if one studies them one sees that there is nothing original. I agree with the right hon. Gentleman. The Green Paper does not follow the philosophy implicit in certain paragraphs of that report.

§ Mr. Michael Foot
Since my right hon. Friend has referred to Aneurin Bevan and his part in the foundation of the Service, does he recognise that those proposals were made by Aneurin Bevan precisely because they were the only way in which the co-operation of the medical profession could be secured and that Aneurin Bevan had always envisaged, and indeed emphasised continuously in subsequent years, that the structure must be made much more democratic and that local authorities should be enabled to participate fully in that new democratic structure?

§ Mr. Crossman
I am grateful to my hon. Friend. I was not aware of the second pant of the point about the close relation with local authorities. I know that he is an expert in preparing the biography of this case. I welcome what he says because this is something that is needed. We must have full coordination between the social services of the local authorities and the health services.
I entirely accept the first part of what my hon. Friend said. It was essential to get the Service on its feet and to bring the consultants in and, secondly, to take the hospitals out of the hands of the local authorities. For this reason, we created the regions.

§ Dr. Winstanley
Is the right hon. Gentleman aware that we on this bench have no wish to equivocate or to score debating points about the Paper, which we warmly welcome and support as a genuine attempt to remove the damaging and dangerous divisions in the Health 1260 Service and which do so much to dissipate its limited resources? Will he confirm that if, as we hope, changes are made in the Maud recommendations parallel changes will be made in these recommendations?

§ Mr. Crossman
I think that I know to what the hon. Gentleman is referring. The most disputed question in the Maud Report and in our White Paper is the issue of one-tier or two-tier government. This report has been very carefully drafted so as to make room at district level for district organisation which is absolutely vital for local participation. Whether it should be one-tier or two-tier in the strict constitutional sense is something which we have deliberately left open in the Green Paper for further discussion. It must be looked at in terms of the merits of the Health Service, because the district level is the essential health level at which we either succeed or fail.

§ Mr. Gardner
I think that the whole House will welcome the marrying together of the various parts of the Health Service, but could my right hon. Friend say a little more about the members of the committees appointed by him? Has he it in mind to appoint at least some people who are specially qualified to represent the interests of patients?

§ Mr. Crossman
It is a matter for my right hon. Friend the Leader of the House, but I hope that the House will have an opportunity to debate the report. My hon. Friend's question is the kind of question which we had better discuss in debate.

§ Sir J. Vaughan-Morgan
First, is it the right hon. Gentleman's intention to retain in his own hands the appointment of the chairmen of the area health boards? Secondly, will this have any effect on the regional organisation of his own Department? Thirdly, can he assure us that all the area health boards will have the right of direct access to him and his Department?

§ Mr. Crossman
Each health board does its own budget and has direct access to the Department.
On the question of teaching hospitals which I know concerns the right hon. Gentleman, we have been very careful to preserve the rights of those who represent teaching hospitals. Although they will 1261 now come under the areas, they will be directly represented at district level and they will play a decisive rôle. This is one of the things which we have taken great care to preserve. The appointment of the chairmen is entirely in my hands.

§ Mr. Rankin
Would my right hon. Friend make it clear whether the changes which he has been dealing with embrace the Scottish Health Service which is usually operated separately from the English Service?

§ Mr. Crossman
I am surprised that my hon. Friend should ask that question. I would not dare to say a word about how the Health Service is run in Scotland.

§ Lord Balniel
This is the second Green Paper on administrative reform and we shall study it very carefully. However, what proposals do the Government have for bringing in additional financial resources through insurance, through local effort, or through the voluntary organisations, such as the League of Friends, which do such great work? Is it not a fact that the White Paper on Public Expenditure forecast a drop in the growth rate in expenditure on health and welfare? If so, how can we maintain standards, let alone improve them?

§ Mr. Crossman
The question of finance, particularly in relation to the local authorities, is mentioned in the report but is deferred to my right hon. Friend's Green Paper on Local Government Finance because I think that this is one of the sources from which we can draw fresh revenue.

§ Mr. Speaker
Order. I must protect the Business of the Day.