§ Motion made and Question proposed, That this House do now adjourn.—[Mr. Pym.]
§ Mr. George Thomas (Cardiff, West)
On a point of order. I wish to seek your guidance, Mr. Speaker. We are advised that the proposed subject for debate today is the Consultative Document on National Health Service reorganisation. May it be made perfectly clear that this is in the singular and that no indication has been given that we shall be discussing a similar document issued for Wales which has many differences from the English document. It is only the Consultative Document referring to the National Health Service reorganisation in England that will be discussed.
§ Mr. Speaker
That is a matter for the House. This debate is taking place on the Adjournment and, therefore, the powers of the Chair to limit the debate are circumscribed.
§ Mr. George Thomas
Further to that point of order and with every respect to you, Mr. Speaker, it is surely the long-established custom of the House that major subjects put down for debate are indicated to the Opposition and to the House as a whole. May we have an understanding from the Government, through you, Sir, that what the Order Paper says is what the Government intend?
§ The Lord President of the Council and Leader of the House of Commons (Mr. William Whitelaw)
Further to that point of order. The right hon. Gentleman will be the first to appreciate that, as this is a Supply Day, the business is as required and as put down by the Opposition. I understand—and my right hon. Friend the Secretary of State for Social Services has confirmed—that there will be an opportunity for the Welsh Grand 592 Committee to consider the Welsh document.
§ 5.1 p.m.
§ Mrs. Shirley Williams (Hitchin)
As the Leader of the House has just confirmed, the time to debate the Consultative Document on National Health Service reorganisation has been found by the Opposition. Before launching on a discussion of the document, I will begin by making a protest on behalf of the Opposition that we should have to find the time for a debate of the first importance on the Government proposals for the National Health Service. We should, of course, prefer to use our time to censure the Government for things which they have done with which we do not agree. I feel very strongly that for the Opposition to have to give their time, as a matter of public responsibility, so that a consultative document can be genuinely consulted about, is a travesty of the use of Government time in the House.
Having said that, I will look at the far-reaching proposals made in the document for the reorganisation of the National Health Service, which remains the most ambitious of all our social services and is in many ways unique. There are, undoubtedly, certain weaknesses in the National Health Service, for all the outstanding achievements that it has to its credit in the last 23 years. Most of these weaknesses flow from the organisational structure of the Health Service, which no longer completely meets the needs of the time.
I will indicate briefly some of the distortions that have developed in the National Health Service, and which were recognised closely in the Green Paper issued by my right hon. Friend the Member for Coventry, East (Mr. Crossman). The first of these is the continuing domination of the hospital section of the service, a domination which is perhaps reflected by the fact that in 1968–69–and there is no reason to think this has greatly changed—no less than 62 per cent. of the expenditure in the service was on the hospitals, and only 9 per cent. was on the general practitioner services. My right hon. Friend said on the last occasion—an occasion found in 593 Government time—when the second Green Paper was discussed, referring to the need for extra money for the reorganisation of the health service:… the major reason for this is that our services have become hospital-dominated to an extent which is not in the interest either of the patient or of the taxpayer."—[OFFICIAL REPORT, 23rd March, 1970, Vol. 798, c. 997.]Secondly, as we well know, within the hospital section of the National Health Service there has been a predominance, which has not much diminished, of the acute hospitals over hospitals for the mentally ill and the mentally handicapped. Above all, in the last two years the House of Commons, as representative of the needs of the most inarticulate minorities in our midst, has rightly pressed for a greater degree of priority for mental hospitals, not least the mental subnormality hospitals.
Thirdly, I think both parties will agree that there has been a relative neglect of community care, a relative weakness in local authority services to support the health service and, until recently, a relative weakness in the position of the family doctor service as well, although that family doctor service remains outstanding in the history of all the health services of the world.
We on this side of the House necessarily welcome the integration of the National Health Service, which is one of the features of the Consultative Document which bears on the work that was carried out in the first and second Green Papers of the last Labour Government. We also welcome the fact that the boundaries between the new health authorities and the local authorities are, at least at area level, to be coterminous. This provides the opportunity for closer cooperation between the personal social services, reorganised as the result of the Seebohm Act, and the National Health Service. But at that point our disagreements begin, and they are very fierce, with this new version of the Consultative Document.
I have already referred to the weaknesses in community care which is meant to a great extent to support those in the community who are handicapped, ill, or mentally subnormal. Yet, on this crucial question of closer co-operation between the personal social services and the health service, the document retreats from any decisions or recommendations into what 594 is described as a "working party". One of the striking things about the document is that whenever things get a bit rough it digs up a working party and puts off decisions for some other occasion.
On the question of day-to-day management, although the Consultative Document states clearly that it believes management of the Health Service to be of central importance, it again hides in an expert study, the results of which will not be made known to the House before the end of the period of consultation. On the crucial question of communications within the Health Service we are offered yet another working party, the results of which, again, are unlikely to be available before the end of July.
So my first point is that the Consultative Document is a travesty of a consultative document because there is very little consultation, very little time for consultation and some of the crucial recommendations will not even be available for consultation because they will not be ready in time. Because of this, and because the document has created a considerable degree of disturbance within the medical profession, within the local authorities and among others who wish to be consulted about it, I ask the Secretary of State why the Consultative Document has had so little circulation amongst those most concerned, why it did not reach individual hospital management committees and many executive councils, why a medical staff administrator of a major hospital has to this day been unable to get hold of a copy of the document from normal sources, and why it was not made readily available to all individuals, including the public who wished their views to be known?
Secondly, still on the question of consultation, why have the Government offered so little time? According to the Government, it will be the spring of 1974 before we shall need to bring the reorganised National Health Service into line with the reorganised local authorities. This means, if legislation were introduced in the House in the autumn of 1972, that there would be ample time for the legislation, ample time for discussion on it, and ample time for the administrative arrangements to be made.
But no, the suggestion, for some extraordinary reason, is that this crucial issue in politics shall only be discussed and 595 consulted about for ten weeks or slightly less, that by the end of July the period of consultation will be over on a document that was only issued at the end of May and which was extremely difficult to get hold of after that. Furthermore, after that stage, the recommendations coming forward from the working parties will deal with some of the crucial issues in the National Health Service but will not be open to consultation.
All of us in the House believe in consultation. We all believe in a move towards Green Papers and in greater discussion and democracy in our midst. But the Government must learn that if they talk about consultation they must mean consultation. There is all too much evidence on this occasion that they did not for one moment mean what they said.
One body which has made its views on this subject known and which, by its nature, is not particularly Socialist in composition is the County Councils Association. In a recent document which it circulated to members of the House, the association saidThe success of the proposed reorganisation will depend on finding answers to these outstanding problems…"—that was referring to the working party—… and legislation should await, if not the outcome, at least the basic proposals made by both these two groups. As these can scarcely be settled before the commencement of the coming Parliamentary Session, the association trust that legislation will not be introduced until the following Session in the Autumn of 1972.Therefore, I ask the Secretary of State to say that that will be done, that we will accede to the requests of responsible bodies for time to consult, and that there will be no question of rushing the House into legislation on this crucial issue with a pathetically short timetable.
§ Mr. Cranley Onslow (Woking)
Would the hon. Lady recognise that her views are not necessarily representative of all bodies concerned? I have here a document produced by a group secretary, which says, above all, that the degree of success will be considerably influenced by the speed with which this can be translated. It is vitally important to the people affected; people are involved with emotional feelings as they face an uncertain future. Does the hon. Lady wish to prolong uncertainty?
§ Mrs. Williams
The hon. Gentleman does not understand the Government's intention. It is the Government who say April, 1974. I am only saying that the provision of the time for consultation with the public is totally disproportionate.
On another crucial point, while still talking about this consultative aspect, the document is almost hopelessly vague on certain crucial issues. We do not know from the document, for instance, whether the Secretary of State will appoint all the members of the area health authorities. He says that he will appoint all members of regional health authorities, but when it comes to the area authorities the document is very ambivalent indeed. I am informed that the Secretary of State said at a Press conference that appointments would rest in his hands, but that is not what the document said. What it says is that local authorities will appoint some members and that the professions will appoint some members, but there is no mention of by what method they will do it. For example, if they put forward ten members when the Secretary of State only has three places, who will choose? The document is silent on this point, which is of central importance.
How will the Secretary of State select the representatives of the professions? What does he define as "professions"? Are the professions supplementary to medicine to be regarded as professions? Are the health service workers outside medicine to be regarded as within the ambit of the professions? We do not know because the document does not tell us. In this situation it is not surprising that in a leading article today, the Birmingham Post referring to the shortage of time for consultation and the vagueness of the document, says:All these signs are being interpreted as an indication that the Government has made up its mind…my hon. Friends will bear this out; we hear time and again that the Government have made up their mind in advance of legislation—… and legislation will follow predetermined lines. Somewhere the fact that this is a service for people who are ill appears to have been overlooked. The Government is not unifying the service. It is creating only resentment and despair.I turn to the major criticisms of the substance of the document. I have dealt, I hope relatively briefly, with the problems of consultation. The first of these 597 criticisms is that the document seizes upon a managerial model which to many of us seems inappropriate to what ought to be a personal and humane service. It uses such phrases as… the maximum delegation downwards matched by accountability upwards".But this is much more about management than about accountability. I shall come to that shortly. It muddles the question of who is meant to manage the service, whether it should be officers of the service, who presumbaly should be attracted by their management opportunities, or the members of the authorities, whose job, it seemed to us, was to protect the interests of the public in the National Health Service. It sets up a powerful centralised regional structure, which has not worked too well in the past, and therefore breaks down the responsibilities of the area health authorities. Without the opinion of the membership of the health authorities, it is utterly unsatisfactory.
My right hon. Friend said in the same debate on the second Green Paper that he accepted that in any reorganisation of the health service there must be more and not less local participation. That is the view of many of us. But in this Consultative Document, members elected by local authorities directly and members elected by the professions disappear completely in the interests of the appointments made by the Secretary of State. It is not surprising that the General Medical Services Committee of the B.M.A. has, in the last few days, announced its strong opposition to the disappearance of elected professional representation.
What the Government seem unable to grasp is that the health authorities must be seen to be and must be accountable to the public, and the only way in which they will be accountable is if the public are represented, directly represented with a constituency of their own and not one of the Secretary of State. There is strong support for this within the Conservative Party.
During that same debate on the Green Paper, Mk 2, to which I have referred, the hon. Member for Hertford (Lord Balniel), then spokesman on social services for the Opposition, said:Personally, I would prefer strengthening the public representation and also strengthening the professional representation and diminishing still further the Ministerial appointments."—598 [OFFICIAL REPORT, 23rd March, 1970; Vol. 798, c. 1017.]
How often it seems to happen to this Government that what they have said when in Opposition, and what many people have agreed with, disappears evidently under the pressure of Departmental views of one kind or another.
In addition, to that, the document does not tell us what is to be the structure of the professional advisory committees. We are told that they are to be powerful, but not who is to be on them. I ask the Secretary of State whether he is proposing that these advisory committees shall include as I have already said about the membership of health authorities, all sectors of the staffing of the Health Service, as has been requested time and again. Will the Secretary of State obey the practice recommended by his Government and set up a consultative committee in all hospitals with more than 250 employees, as laid down in the Code of Industrial Relations Practice, in Recommendation No. 7? If he is going to do that, there is not a whisper of it in the document, which is strange because this is what the Government recommend to private enterprise but will not carry out the activity themselves.
When it comes to area health authorities, which have already been downgraded, what guarantee can the Secretary of State give that busy chairmen of social service committees on local authorities, whose participation is crucial if we are to bring about this link between the two stages, will better serve the authorities, downgraded as those authorities have become? Can the Secretary of State reply to the question about whether and how the National Health Service is to serve the patient. Under the Green Paper, Mk 2, my right hon. Friend put forward two proposals. They were criticised—he will accept this—as not going far enough. One of these I have already mentioned; that was the one-third representation of local authorities on the area health authorities which had power under that proposal.
My right hon. Friend also recommended district committees part of whose members would be drawn from the community and which would have functions governing the day-to-day management of hospitals. All that has changed. The district committees have disappeared. The local authority direct representation 599 has disappeared. Who is to protect the patient in this situation?
The Secretary of State has produced an answer. The answer is called a community health council. This is the strangest bunch of administrative eunuchs that any Department has yet foisted upon the House—a kind of seraglio of the Secretary of State of utterly useless and emasculated bodies which have no powers. I am sorry—they can visit hospitals. How nice for them. So can most of us. They can, if they wish, produce an annual report, but nobody will read the annual report because the community health councils have no power to effect anything at all. They are to be appointed, just to ensure that they are totally powerless, by the area health authorities.
We on these benches know already that a really difficult member of a regional hospital board does not last long. In Birmingham two of the best and most difficult members have not lasted long. So if people are appointed from on top downwards one almost invariably ensures that the voice which represents the difficult one, the voice which represents the person who wants changes, the voice that is prepared to take on vested interests, is the voice that will never be heard, because it will not be appointed to these bodies. There is no guarantee in this document that we will ever see such people on these bodies.
I want quickly to mention one or two other problems which we think are very serious. We recognise that the Secretary of State has to maintain the independent contracting status of the general practitioners. We recognise how strongly they feel about it. We are sorry that, instead of making that independent contracting committee a special committee of the area health authority, the Secretary of State has seen fit to divide it off almost completely as the present arrangements indicate.
We are sorry, too, that the control over the capital development of the general practitioner service, including such things as the development of health centres and of group practices, is to rest with regional hospital authorities on which there may not be one family doctor represented. At least, we have no guarantee, that one will be there.
600 As I have already said, there is every reason to believe that the regional health authorities will continue to be hospital-dominated, dominated perhaps above all by senior members of the consultancy profession. We are very fearful that the general practitioner will be even more overlooked in this structure than he is in the existing one. This is the heart and centre of the service, and without that heart and centre the service could very rapidly deteriorate into something which was not primarily concerned with the patient.
I end with a few direct questions. Can the Secretary of State throw more light on the future of the community physician, because already in all too many areas community physicians are either hard to recruit or are leaving their jobs because they are not certain what the future offers them?
Can the Secretary of State say more about the very unsatisfactory position in London where there are four regional hospital boards and, at present, no effective machinery for consultation among them? Can he say what will be the boundaries between the local authorities and the area health authorities in London?
Will the Secretary of State say more about the school medical service? There is deep concern about what appears to be the first act in the disappearance of the school medical service, which still, and perhaps even more now that the welfare education services are being run down, plays a very crucial part in identifying handicap in children at a very early age.
Will the Secretary of State say why there is no reference to an occupational health service, although the time is ripe, and over-ripe, for doing something about this? Will he say why nothing is said about an Ombudsman—a Parliamentary Commissioner—for health, whom we believe to be an essential safeguard especially now that the representation of the consumer has been so much weakened?
Finally, will the Secretary of State agree that the Consultative Document on the reorganisation of the National Health Service offers a reorganisation which is inadequate and a consultation which is a travesty, and, consequently, that it is time that the document was withdrawn?
§ 4.25 p.m.
§ The Secretary of State for Social Services (Sir Keith Joseph)
I wish to express gratitude to the Opposition for choosing the subject today. The hon. Lady the Member for Hitchin (Mrs. Shirley Williams) has been very helpful in exposing a number of the comments and criticisms that can be made of the document that the Government published recently.
It will be common ground between us that a debate like this should include a heartfelt tribute from the Minister who for the moment happens to have responsibility to the very large number of staff who serve the health of the public in the National Health Service and in the related local authority personal social services.
I am desperately aware of how relatively easy it is to talk and how extremely demanding it is actually to provide the services on the ground in the community, in the family practitioner service, in the domiciliary service, and in hospitals of all sorts. I therefore start my speech today with something that I know that no one in the House will disagree with—that tribute to the service.
I think I should next express a few words of apology. I think that the hon. Lady's criticism—a criticism which I know will be repeated from both sides of the House—about the distribution of the Consultative Document contained a fair point. Had I my time again, I would have broadcast this Consultative Document far more widely and made it more easy for all concerned to get a sight of it. However, I am satisfied now that everybody who wants to see it and who needs to see it has seen it, but I confess that perhaps I should have made it easier still.
I am being attacked by the hon. Lady for not giving more time for consultation. To some extent the Government's decision about the timing for the reform of local government controls the time when we must have the restructured Health Service in operation. It is true that this Consultative Document proposes a period of under three months for consultation. But, after all, it is the third document on the subject. The last Government presented two Green Papers, and my Department, big though it is, is practically 602 bulging with comments on those papers. We have a fair amount of knowledge of what the relevant interests think is right.
It is true that the differences in strategy proposed make it desirable to consult extensively again, and I shall certainly do my very best to prolong the period of consultation. Though this document is not Green, it has very green edges. I shall take this debate and the consultation with all those concerned very seriously.
It is common ground that the service to the public depends on the co-operation of large numbers of health and social service teams in local authorities and in health authorities. Our proposals for the new National Health Service offer a great, and indeed a new, opportunity for a partnership with local authorities—between the new health authorities and what will then be the new local authorities—over the whole range of services.
Making the boundaries of the health authorities coterminous with those of the local authorities responsible for social services will mean that for the first time in Britain two public authorities, and only two, providing closely related services will be working side by side looking after the same area and the same community. Their members and their staffs should share the same loyalties to that community. I emphasise that the regional and area health authorities will be completely new bodies. There is no question of the community services swallowing up the hospitals or, as is more commonly surmised, of the hospitals taking over the community and family practitioner services.
I stress that the new health authorities need to be so composed as to take a wide and unbiased view of their services, including the importance of preventive health measures. Local authorities will have their own members on the area health authorities. There will be the closest possible working links between the two bodies. Local authorities, therefore, will have a direct say both in the actual running of the health services and in local initiatives for health service development and investment programmes which interact closely with their own.
Local authorities will be able to draw on the area health authorities for medical, 603 nursing, dental and other health service support and advice. Similarly, area health authorities will turn to local authorities for support and help in the social work field, and probably in other fields as well.
§ Mr. Christopher Woodhouse (Oxford)
What will be the financial arrangements between the area health authority and the local authority? Will money pass between them for services?
§ Sir K. Joseph
No, it is not proposed that money should pass between them. Inasmuch as responsibilities which are now the local authority's will be transferred to the area health authority, there will need to be an adjustment of general grant.
Because the link—this is the very essence of the strategy which, I believe, we share with the last Government—with the local authority and the coterminous boundaries will be at area level, it will be the area which will be the operating unit. The chairmen of the areas will be appointed by the Secretary of State. There will be some members appointed by the coterminous local authority. There will be some members—probably three—appointed from among medical and nursing people. These appointments, and others, which will include a university member and, where there is a teaching hospital, someone on the teaching side, will be by the regional health authority after consultation with the interests concerned. There will be strong professional advisory machinery.
I had better make clear at this stage, in answer to the hon. Lady, that the area health authority will be allocated its budget by the regional health authority but will have, within that budget, and subject to its general strategy being agreed by the region, disposal of resources for such activities as health centres.
§ Mr. John Gorst (Hendon, North)
Should an area authority find itself in dispute on the budget allocated to it by the regional authority, will any appeal be possible over and above the regional authority, or will the area authority have to take complete instruction from the region?
§ Sir K. Joseph
I do not want to give any impression at all of an appeal procedure. But let us look at the realities.
604 The regions are responsible for allocating the taxpayers' money. That is categoric. But the area health authorities will be led by chairmen appointed by the Secretary of State. If an area is consistently dissatisfied with its treatment by the region, the Secretary of State will not easily be able to find an adequate chairman for that area. There will, however, be no appeal system against the region.
The principal criticism of the proposed membership of the key area health authorities is that the Government have chosen to put a management emphasis on the area health authority membership, and I wish to take this opportunity to spell out why this is perfectly consistent and, indeed, is indispensable for a humane and effective service to the public.
It is common ground that there are two important functions in an adequate service to the public: on the one hand, the taking of the right decisions and the carrying of them through, and, on the other hand, the need for a system by which the community's reactions to those decisions and the carrying of them through may be effectively ventilated.
The previous Government chose, with full explanation, to embody those two functions in the same management structure at both the area and, in their proposals, the district level. I wish to emphasise what may not be clear to all hon. Members. The unified National Health Service will be a huge and immensely complex enterprise bringing together what are now separately administered branches with their own distinct traditions and methods of working. The area and, for that matter, the regional authorities must be composed of chairmen and members with the capacity to assess, on the basis of expert professional advice, the need for health services of all kinds within their areas, to set targets and objectives, and to ensure that corrective action is taken where those targets and objectives are not being met.
The chairmen and members must see the health services not primarily in terms of their component parts—the hospitals, the family practitioner services, the community services—but comprehensively as promoting total health plans. They must, moreover, see them in the still wider context of services co-ordinated with those provided in the community by the local authorities.
605 These tasks will call for high qualities of leadership, persuasion, energy and drive, so that the professional people responsible for providing services are encouraged and enabled to realise the authorities' objectives. These are the essential qualities of management, and without them—without leadership, persuasion, energy and drive, all geared to the professional advice—we shall again have in the future, as we have now, very uneven services to the public.
§ Mr. Richard Crossman (Coventry, East)
How do the management qualities which the right hon. Gentleman has listed differ from the qualities required of an education committee of a local authority managing something just as costly; that is, the school education service, surveying it and seeing that it is well run? Is there something special about health which requires more management than is required, for instance, in school education?
§ Sir K. Joseph
I do not pose as an expert on the education system, but, as I understand it, within schools or as between schools there are many fewer different armies to co-ordinate than there are in the health and personal social services. We have here a long list, from the home helps, the social workers, the chiropodists, the bath attendants—all the array of those employed in the personal social services on the local authority front—right through the domiciliary health workers, the midwives, the health visitors, the district nurses, the family practitioners, the dentists, the chemists, the oculists, all the staff in the hospitals, the ambulance services, and so on. They all need co-ordinating one with another, and with the voluntary services. It is, I believe, a far more complicated matter than it is, with all respect, in the education service.
I come now to the second limb which is required for the protection of the public, that is, the method of ventilating the consumers' reactions. For this purpose, the Government have proposed the community health council. On this, as on the other contents of the document, we are very much open to suggestions.
The House may be amused to know that my notes contain the three phrases, "Not mute", "Not shrill", and "Not a eunuch". The hon. Lady and I have 606 both thought of the same possibility. She accuses the community health councils of inevitably being eunuchs. I believe that, as a result of the proposals I shall now explain, they will be effective.
First, they will be appointed for each district; areas that have two, three or four districts will have as many community health councils. Second, they will have access, accommodation for meetings, and facilities for producing a report. We all know that health authorities and the like are very vulnerable to well-directed—not shrill—public criticism by those in receipt of the services.
It is proposed in the Consultative Document that the members of the community health councils shall be appointed by the area health authority. I can see that that may not be the best answer. Perhaps the right answer is to have some of the members appointed by the area health authority, after consultation with various local interests, with the remainder recruited by different methods. For instance, it might be possible—I am only throwing out suggestions—that the local authority, whether the district in the provincial counties or the metropolitan district, should appoint some of the members of the community health council. Then it would surely be sensible to turn to voluntary organisations for some appointments, and particularly to consumer organisations.
It is very dangerous for any Secretary of State to embark upon a list of such organisations, because inevitably he misses some out. But to give the House some idea of what I have in mind I have a list of organisations, some of which might be approached for nominations for membership of the community health council in particular cases: the National Association for Mental Health, the Spastics Society, local councils of social service, the National Association for the Welfare of Old People, the National Association for the Children in Hospital, the Patients Association, the National Association for Mentally Handicapped Children, the Red Cross, the St. John Ambulance Association, the W.R.V.S., some of the youth organisations, and such bodies as the Women's Institutes, the Townswomen's Guilds, the 607 Royal British Legion and others whose activities range beyond the health and personal social services. The House will see that we are determined to make the councils effective representatives of consumer interests, which, if they put their criticism responsibly, the area health authority will be very ready to heed.
§ Dr. M. S. Miller (Glasgow Kelvingrove) rose—
§ Sir K. Joseph
I hope the hon. Gentleman will allow me to continue. This is a short debate, and I have been speaking for a long time.
I turn to the regional tier. The Labour Government decided at first to do without a regional tier and then, I think in the second Green Paper, introduced a regional council. The result of doing without a regional tier is to centralise the service much more than if a regional tier exists, because inevitably the management flows right out from the ministerial headquarters to 80 or so area health authorities, resulting, it seems to me, in a very dangerous delay in all decisions.
The regions, whose members will be appointed by the Secretary of State will be responsible for the general planning in each region, the allocation of resources, the planning of special services and the planning of facilities for postgraduate medical education. They will continue to programme—I should say that they will programme—plan and execute the large building projects. I deliberately withdrew the word "continue" because they will be regional health authorities, not regional hospital boards. It is all too easy to make that mistake, and even I occasionally still slip into it. They are regional health authorities, which will be geared to taking a much wider perspective of health and welfare than the regional boards that have been hospital-based.
They will have to widen their advisory services—here I am meeting a point made by the hon. Lady—to include community and family practitioner advice, to make sure that they in their turn can monitor the area's performance of its family practitioner and community health functions.
608 The teaching hospitals will be integrated in the regional and area system. I am discussing with the boards of governors ways to do that with the optimum benefit to the interests of all, including teaching and research.
In the interests of brevity, I am answering only some of the hon. Lady's questions. My hon. Friend the Under-Secretary of State will try to deal with the remainder.
We are in the midst of discussions with the Department of Education and Science on the School Medical Service.
There was much criticism of the Government's decision on referring a number of difficult questions to working groups. But it would not have been practicable to set up working groups on such difficult issues as the mechanism for collaboration between local authorities and area health authorities on the one hand, or the system of management at area and district level, on the other, without first producing a strategy. Only after producing a strategy could we consult and set up the working groups.
Here I must answer the criticism that we are going too fast. We need to balance two factors. A period of transition is one of great uncertainty for the staff involved, and the shorter we can make it the better. On the other hand, we must make a reality of consultation. I hope that the timetable we are to follow will produce the optimum answer on both.
It may not be practicable to get the main themes out of the working groups, which include a working group on London, in time for the White Paper. But that will not debar full consultation on the themes at the appropriate time with, amongst others, the staff and professional interests.
It is important that we should make preparations for the change-over date. There are two forms of preparation in which the House will be interested. We have already had the interim Hunter Report on community physicians, on the basis of which we are embarking as soon as possible on the arranging of seminars and courses for widening the range of knowledge and management skill of hospital, community and administrative specialists to match the wider responsibilities of the new area health authorities.
609 The second preparation which we must make is for the appointment of a staff commission so that all the staff may be satisfied that their interests will be safeguarded during the transitional period.
I should not like to finish even a short speech like this, on the new service as we see it, without emphasising once again that this country will never be able to afford to look after the health and welfare of the public entirely by paid service. The first line of defence must be the family, and the second line must be voluntary bodies. It is in support of the family and voluntary bodies that the new health authorities and the new local authorities will be deploying their health and social service functions.
After a year with the privilege of my present responsibilities and with full recognition of the gaps in the services and all that still has to be done, I repeat that we have in this country potentially the finest health and social service in the world. The bringing together within the same boundaries of reformed health authorities and reformed local authorities in a new partnership will make that potential come much nearer to reality.
§ Mr. Gorst
There was a passing reference to the position of teaching hospitals. I am sure that my right hon. Friend is well aware that 40 per cent. or more of doctors and dentists are training in teaching hospitals in the London area. Can he assure us that he has an open mind about the arrangements for London teaching hospitals and that he will be holding more consultations about this aspect of the document?
§ Sir K. Joseph
Within the strategy I have described, the answer is "Yes". I do not think I need repeat my peroration. I believe that this document will produce a better service for the public.
§ 4.50 p.m.
§ Mr. Richard Crossman (Coventry, East)
Anyone who has been a Minister and has prepared a draft plan must be very careful not to have author's pride, especially when we are dealing with the National Health Service. Looking back, one of the things which I very much regret is that we did not establish a Royal Commission parallel to the Commission on local government to do the initial 610 spade work and research in the health service. When we got to work we lacked the strength of the authority of people from outside who would work for a couple of years, and it all had to be done by ourselves. I am aware that many people from outside did work, but anybody can be wrong about this matter because one of the most difficult jobs is to get it right.
We agree on the virtues and the faults, and we must be sure that we preserve the virtues and eliminate the faults. We all agree that the greatest virtue of the health service is the general practitioner service. In a way, it is the least organised part. It seems to run on its own with the minimum of interference from anyone else. I am deeply critical of the community services, but when we compare them and what we do for the old people by way of meals on wheels, and so on, with the situation in other countries, they are not so bad. Such personal services are performed with great human feeling. The only trouble is that they lack money.; they are appallingly under-financed.
The same is true of the general practitioner service. It is a wonderful service, but much more money should be spent on it. There should have been a bigger campaign for health centres. It is not a question of saying, "These are fundamentally the wrong services and we will change them." On the contrary, I am deeply convinced that, apart from the hospitals, about which I have reservations, we are on the right lines.
I come to the central flaw. There is a split between the local authority service and the health service. One is paid for out of rates; the other is paid for out of taxation. There is a hopeless division between the community services and the medical services, inevitably resulting in hospital domination, on the one side, and either inadequate funds or haphazardness, on the other, because it depends on what the local authority will spend. Whether a service achieves anything worth while is a matter of pot luck in any local authority because there is extremely weak central control over the local authority community services.
The second virtue of the hospitals is that if a person is desperately ill there is no country in the world where he will be as well looked after as he will be in this country. The service fails when a 611 person is not desperately ill. It is hopeless when a person has piles; it is marvellous when a person has an incurable cancer. We must look at this matter and see whether we have failed in looking after the healthy. Preventive and community services to keep people out of hospital are hopelesly under-manned and under-financed. Money has been poured into the hospital services, but even so they are short of money.
We must deal with the terrible problem of the gap between the local authorities and the health service. It is easier for me to say this now that I am not in office but there is, in reason, no case for saying that the new great local authorities, with very extensive powers, should not take over the health service. That would be infinitely more logical. It would have solved at one stroke the appalling division between the local authorities and the health service. There would have been proper democratic representation we know why it is not being done—because the medical profession vetoes common-sense in this respect—
§ Mr. Crossman
I was about to say that the second reason is that the Chancellor of the Exchequer would not allow the new local authorities sufficient taxes to carry the cost of education and health, the two most costly locally-financed services. To carry the cost of them would mean a major change in the fiscal system by which local authorities were given almost a prior claim on taxes. As Hedley Marshall showed recently in his pamphlet, there would have to be a local income tax to enable them to raise the money. If there was any sense in the world, the health service would come under the new local authorities, with their extensive new powers and responsibilities.
§ Dr. Gerard Vaughan (Reading)
Does the right hon. Gentleman agree that the social services provided by the local authority will be only 10 per cent. of the total financially and staff-wise, whereas the hospital services and general health services are 90 per cent.? Therefore, he would be fitting the tail to the dog and asking the tail to take over the dog.
§ Mr. Crossman
I would not be fitting any tail to any dog. In creating the new 612 local authorities, we should have decided to transfer to them a major social service which had been taken over by Aneurin Bevan. There would have been a reallocation of powers as between central and local government. For people who believe in decentralisation, this would have been a great opportunity to show confidence in local government. Theree is nothing new in what I am saying. I accept that it could not be done because of the medical veto and the inability of any Government to raise taxation by the necessary amount in the next two or three years.
Whatever we do will be a compromise, which is not very satisfactory. The worst fault recorded by the public—and it has been confirmed by every comment made on the first and second Green Papers—is the insensitivity of the Health Service to local feeling and patient criticism, the remoteness of the service, its bureaucratic nature, its refusal to understand local needs, the setting up of hospitals with no transport to them, the creation of great marble palaces and the closing down of well-loved small hospitals, and the constant disregard of patients' personal feelings for the sake of the convenience of the consultant.
Every report has concentrated on the need to bring about local participation. I felt that this was a directive for me—that whatever we did we had to make the system less bureaucratic. The centre of the bureaucracy was not at the Elephant and Castle. That is too gentle and kind a place to be bureaucratic. I have never seen more nice people doing very little very well, but they were certainly not running the health service or the hospital service, because the satraps round the health service—the self-appointed oligarchs supposedly appointed by us but who appoint themselves time after time—
§ Sir K. Joseph
I do not know what the situation was in the right hon. Gentleman's time at the Department. but I can testify that these people work extremely hard now.
§ Mr. Crossman
Absolutely eager beavers, but the control rests in the 14 regional hospital boards, and that is what is wrong. It is ironical. The Treasury says that the health service must be well organised and that the damn democratically elected local authorities waste money 613 and there must be people responsible to the Minister; and yet the Minister knows as well as I do that the control exercised by the Secretary of State for Education and Science is infinitely closer and more effective over the costs of local authority education than the control which he or I could ever exercise over these confounded tax masters. Here we dole out £60 million or £70 million and say, "Spend it as you damn well like" and we know that there is no real control, and the Treasury has not seemed to grasp the fact that because we appoint somebody that is not the end of the matter. We can appoint whom we like, but we cannot get rid of him. We are not allowed to, for one thing. Certainly it is all against the game. The fact is that Ministers come and go but those people stay. The area of effective control is in the regional centres, the regional hospital boards, and they can afford to say what they like and the Minister can do nothing about it, nor can anybody else—except when the odd, awkward woman appears on a board and makes some protest to the chairman. I got a few protesters on the boards. I thought they would add a little pepper to the spices and other condiments. I did not think my successor would be so surly as not to keep them or make sure that they would not have power.
What did we do? We said to ourselves that the central aim must be to strengthen control at the top, to strengthen control at the bottom, and to thin out in the middle—to castrate the satraps, which is where the centres of obnoxious power lay. What does the right hon. Gentleman do? He weakens the top, weakens the bottom, and inspissates the centre with bureaucracy. I never saw such a scheme. They are given a budget, and they allocate the budget to the areas, and the areas divide it up among the districts. There could not be a better method of getting paper wasted.
It is a scheme for people all busy planning. They are appointed to be efficient managers—real busybodies. It is not going to make things easy. They are the sort of people who say of any proposal, "We shall have to examine it". They are not like housewives who represent the public; these managers will say, "We are not going to represent the public. They are a damned nuisance. We are going to have no nonsense about 614 that, We are real managers." In this way, the Health Service will have every single one of its worst characteristics strengthened. What happiness there must have been among the hospital boards when I disappeared. What cheers there must have been.
The Secretary of State, for whose integrity I have the highest regard, is sometimes in his impetuousity a bit naïve, and he makes a little mistake in thinking of regional boards as local health authorities. There will be 14 boards—is it not extraordinary?—and 14 lots of architects doing the building of the service, and are they not going to be the same architects of the same old cadre? There were before 14 planning regions. I was at the Department a little longer than the right hon. Gentleman has been, and I know the names of those authorities already and the names of all the key officials and who they will be, because they are there already. Will the right hon. Gentleman say that the buildings will be changed? Of course they will not be. Will it look very different? It will be the same thing with a little added to it, but it will be the same imperceptive bureaucratic machine with a lot of civil servants as well as hospital people. That is what it will be. The right hon. Gentleman says that his is the originating, activating Department, but the regions will do the monitoring of the budgeting and will have effective management and monitoring powers in each area, and a lot of paper will be spent on that, too. They will be the same groups, if I know anything about it, and so we shall have the same set-up given different names and with a few additional powers. There will be the regional hospital boards in. another form. The powers are concentrated where they ought not to be.
I wanted to make sure that people in the community services shared in the work, people who cared more about the community services, and I wanted to make sure that the money was there and that there would be people with a vested interest in community services as against the hospitals.
§ Sir K. Joseph
Does it not follow that the right hon. Gentleman's Department would have had to distribute all the money and would have had to have large regional units of civil servants?
§ Mr. Crossman
That is exactly what they tried to tell me: I recognise the speech the right hon. Gentleman has made. It is too late now to tell him what he should have said back, but what he should have said was, "Go across to Curzon Street". There there are a lot of civil servants who run an education budget for 80 or 90 local authorities, and they manage it well. Of course, it is true that there is not the same tradition of effective control in the Health Service as there is in the Department of Education, but if it can be done there I believe that by a certain circulation of talents and a pushing across the river of certain people, like results would be obtained. People could be taken from the Department of Education. We could have our organisation, with our budgeting, as we did for hospital building. We borrowed ideas from the Department of Education and we lifted people from there and brought them over. That sort of thing has always been done in Government. If there is a Ministry overseeing a budget of 80 local authorities it is ridiculous to say that it could not be done elsewhere. There is no great difficulty about it.
Perhaps the Treasury does not like it because it is new, but I would have had more effective central control, central control of the budgeting, and I would have had communication between me and the areas. I would have had weak regions and direct contact with the areas so that the areas would feel they could come straight to the Minister, and feel that they mattered. They could have come straight to me, as the local authorities go straight to the Secretary of State in Curzon Street. The areas would have been powerful in that way.
§ Mr. R. C. Mitchell (Southampton, Itchen)
My right hon. Friend has made comparisons with the Department of Education and Science. Is he aware that many people in education services think that the Department is a complete failure and that if it completely disappeared no one would notice?
§ Mr. Crossman
That shows how dangerous it is to comment on something which one does not know too much about. But I had been asked whether it was possible to exert budgetary control over 80 local authorities. I was pointing out that it is possible, and that it has 616 been done for education. Perhaps it is the job of the units to do it.
It is my central anxiety, Secretary of State, that you are maintaining basically the present structure, thickening it and extending its powers. When you should have destroyed that area, it is the area you are strengthening. I say in all seriousness that that is a terribly bad thing to do. You made a speech when you went round the other day to which I was very sympathetic.
§ Mr. Crossman
I apologise, Mr. Deputy Speaker. It shows how long I have been absent from the House.
But the Secretary of State made an excellent speech on the subject of hospital building. He expressed courageous anxieties about these white palaces and huge centralised hospitals. But these are exactly the sort of things which the institutions he is setting up—the management men—will adore. That is what they want—bigger, better, more bureaucratic-ally administered places. They want to get rid of all the small-scale hospitals which are close to people and are what people like, and get really efficient, business-like places. We shall get high-rise hospitals more and more—a paradise for business men and architects.
I went into the Department, as I am sure the right hon. Gentleman did, believing that the job was to go in not as manager but as a representative of the people. I believed that I was there to ensure that the managers remembered the people. There is a basic flaw in the system. The job of the hospital management committee or the regional hospital board or the health committee is not to manage. That is done by the officials. It is the officials who should be the efficient managers. The people over them ought not to be managers.
There is a horrifying sentence in the Consultative Document:The authorities will be kept small and management ability will be the main criterion for the selection of members.When I went round the National Health Service, who did I find were really effective on these boards? They were a lot of housewives, women who knew where 617 the shoe pinched and who had time to go round and see people and to know what the patients were thinking. Will these top-level business men have the time or the interest to go into all these things? No. They are exactly the sort of people who should either be full-time officials or not be on the boards at all. The boards ought to be representatives of human beings, of patients, of fathers and mothers—there to see to it that the managers are kept in control and tamed, made to serve the public and to make the buildings places in which people can live instead of places where people feel like dying.' That must be the aim.
If the right hon. Gentleman has his way, if he disregards the strong criticisms by the county councils and many other people, and goes on with this terrible policy of inspissating the middle bureaucracy, he will destroy the best things in the National Health Service and strengthen the worst things in it.
§ 5.14 p.m.
§ Dr. Gerard Vaughan (Reading)
I shall not take up many of the points which were made by the hon. Lady the Member for Hitchin (Mrs. Shirley Williams) because I want to be brief, but following such a stimulating and superficially persuasive contribution from the right hon. Member for Coventry, East (Mr. Crossman), I cannot resist saying that he is putting forward a case in defence, I suppose, of a rather dormant baby of his the second of the Green Papers. One of the features of the last few months and of the last few weeks in particular has been the audible sigh of relief at the reception of the Consultative Document and the realisation—and I congratulate my right hon. Friend on this—that it was truly a Consultative Document, that it was an action document. That was unlike the previous two Green Papers, valuable as they were, for they led to no action at all.
Contrary to what has been said, I think that one of the helpful things about this is knowing that we are aiming towards a definite date when there will be a link-up in the timing of the National Health Service changes and the local authority changes.
Delightful as were the criticisms of the right hon. Member for Coventry East about inspissation, along with his advocacy 618 of putting difficult women on committees and of the admirable features of housewives, the feature which is at fault at the moment, as all of us in the National Health Service know, is the lack of modern efficient management. This is a highly complicated service. At the patient's end, it is a highly personal and individual activity, but to run such a very complex service one must have people who understand complex business methods.
§ Dr. Tom Stuttaford (Norwich, South)
There is quite a difference between business administrators and medical managers. We want medical managers to be paid officials, and we do not want business administrators to be on the various new councils, regional health authorities or local area health authorities.
§ Dr. Vaughan
I am discussing the lack of modern business methods among officials who have to run the service. Here we have an idea which I am sure the medical profession would not want to argue about. There are some very good medical administrators, and I hope that there will always be a place for them. But what is needed is top level general administrators, whether they come from the medical side or from a career structure amongst administrators in general. This is a very important point.
I had hoped that we would be able to do away with the regional boards—regional authorities, if you like. If there is one thing which is at fault at the moment, it is the regional administration. Anyone who deals with regional administration—particularly people like engineers, architects and hospital suppliers—will say that it is almost impossible to get a decision quickly.
§ Dr. Vaughan
I suggest that we want to place administration in fewer people's hands. Reluctantly, I have come to the conclusion that my right hon. Friend is right and that what is needed is a management trained person at regional level, with a committee of experts to advise him. We want a single person or a small group of people who can deal effectively with administration and make decisions on the spot. I would like to pursue this aspect very strongly. I do not think 619 that they need necessarily be medical people. I think the majority of the medical profession would be only too glad to give up having to do administration and to be able to concentrate much more on their job—the practice of medicine.
There are two small areas to which I hope more thought will be given. One is a plea for the future of health visitors to be looked at more carefully. There is enormous anxiety among health visitors. They are highly trained and a valuable part of the community, but they fear their rôle will be lost in the new structure. Then there is the peculiar position in London, particularly with the teaching hospitals. Here, I suppose, I have a personal bias and a vested interest. I accept entirely the need for a community medical service; in fact, this is one of the essentials at local level; and I had thought that the teaching hospitals would have to be integrated into area teaching hospital boards. But the worry is that there will be a clash in those areas between the need for up-grading parts of the community medical service and the need for maintaining a high level of teaching and research. I was very sorry to hear the answer given to my hon. Friend the Member for Hendon, North (Mr. Gorst) that there will be no system of appeal for a teaching hospital which finds it has to lower its standards because another part of the community needs extra funds from the regional board.
There are 12 teaching hospitals in London, and this is a peculiar situation. They are centres of excellence, they have an international reputation and we depend upon them for developing the highest levels of our training and teaching. We also have the smaller specialist hospitals. We had the example recently of Queen Charlotte's, a specialist teaching hospital which is in danger of losing its teaching function because area needs do not justify the continuation of the number of its beds. I am afraid that this danger will increase. The danger is of letting the community service side dictate the teaching hospital end. There are problems in London about geographically fitting together the teaching hospital areas and the local authority areas, and I hope that my right hon. Friend will look at this aspect very carefully.
§ 5.22 p.m.
§ Mr. Kenneth Lomas (Huddersfield, West)
I begin by declaring an interest as a member of the National Union of Public Employees, which recruits a considerable number of members from inside the National Health Service. Some of the comments which I shall make will reflect the union's viewpoint, and it is right that the union's views should be taken note of by the Secretary of State when he brings forward the proposed White Paper. I am a little confused about whether this white Consultative Document is a Green Paper with white edges or a White Paper with green edges, but it is not a consultative document in the truest sense of the word. It has already been admitted by the Secretary of State that the document was not available to those who needed it.
Comments were made at a meeting of the Huddersfield Executive Council held on 11th June which were reported in the Huddersfield Examine on 12th June under the heading:'Travesty of democracy ' over new plans for Health ServiceComplaint was made that copies of the document had been officially supplied to only certain national organisations and professional bodies in the Health Service.Mr F. Gill said that if consulation on the document was wanted there should be an opportunity for all concerned with the Health Service to express their views.Was the document, he wondered, intended to have a wide circulation? He thought that to issue it in the way it had been was a travesty of democracy.The Chairman, Mr. O. Sumerville, said he agreed with those views.The Department certainly should have made the document available to as many organisations as possible. I am glad that the Secretary of State admitted the error of his ways, and I hope that, in future, note will be taken of the views of organisations.
I do not think anyone denies that the National Health Service is in need of reform. Since it has been nearly 25 years in operation, a case can be made for looking at the structure of the health service to see what can be done to improve it, but I doubt whether the proposals in the Consultative Document will do anything to make the health service a more democratic organisation. There is not much democracy in the service at present, but under the proposals in the 621 consultative document there will be even less.
The Royal Commission on Local Government suggested that the National Health Service should be brought within the scope of a reformed local government system. My trade union and I were in favour of that idea because we thought that local authority control would give a better chance of establishing closer relationships between the health service and the personal social services, and that that, in turn, would lead to a much greater degree of democracy and democratic control in the health service.
That view was rejected by the Labour Government some years ago, not just because of the doctors—and I agree that they were an obstacle—but also on the grounds of finance. As a Green Paper on local government finance is to be published fairly soon, this will give an opportunity for the Government to consider the possibility of involving local authorities in the health service.
There is much that I could say about the Consultative Document, but I will confine myself to trying to persuade the Government to create a more democratic system in the health service. I doubt whether I shall be successful, because the Government are hell bent on the concept of managerial efficiency and professional expertise, and are not concerned with the wider issue of seeking to ensure that the people who work inside the health service should have a say in the running of it. The Secretary of State made a virtue of the Health Service being so complicated that it needed more efficient management and professional expertise. This is true to a point, but the greater the diversity of the service the greater is the argument for representation on it of all sections of the Health Service to provide a pool of knowledge.
I sincerely hope that this preoccupation which manifests itself time and again in the Consultative Document will not debar the ancillary workers from taking part in the running of the service. Without ancillary workers, the hospital service would collapse, and they are entitled to a say in the running of the service in any new structure that is created. I doubt whether the proposals in the Consultative Document take much account of this important point.
622 The proposed composition of the new authorities holds out little hope for any participation by those who work in the service. The regional authorities will be entirely composed of members and chairmen appointed by the Secretary of State, and the area authorities will be composed of members appointed by the local authorities, the universities and the regional authorities. So a great opportunity to introduce more democracy into the health service has been missed.
The document puts more power into the hands of the Secretary of State; it concentrates too much power of patronage in his hands. The end result is likely to be a self-perpetuating oligarchy, which is just what we should resist in seeking to reform the service. The National Union of Public Employees has always contended that any administrative restructuring of the service must make adequate provision for extending democratic control.
The second Green Paper, which we debated in the House on 23rd March, 1970, recommended that one-third of the area authority membership should be appointed by doctors, nurses and dentists, one-third by the local authorities—
§ Notice taken that 40 Members were not present;
§ House counted, and, 40 Members being presen—
§ Mr. Lomas
I hope I may now be allowed to continue. I cannot understand the mentality of hon. Members such as the hon. Member for Ilford, South (Mr. Cooper), in calling a count, unless they do not want to discuss the important subject of the National Health Service. It is ridiculous to interrupt a speech and waste the time of the House in that way; though I have seen the hon. Member concerned behave in a similar way before and I suppose we should forgive him his sins.
When we debated the second Green Paper on 23rd March last year, it was then said that one-third of the area authority members should be appointed by doctors, dentists and nurses, one-third by local authorities and one-third by the Secretary of State. That did not go far enough. It did not include people below the rank of nurse, such as the ancillary people who carry out a great deal of the 623 work in the hospitals and without whose efforts the hospital service would fall. An assurance was given during the Labour Government by a former Minister, John Dunwoody—who is now no longer a Member of the House but who will be with us again—that the matter would be looked at again to see whether some means could be found to ensure that people in the Health Service were incorporated in the body of people to be appointed by the Secretary of State. That was not only my view, but it was the view of my union and of the T.U.C. These proposals were not accepted, and it was suggested that there should be additional representation for other categories of worker who could be drawn from the unions represented on the staff side of the Whitley Councils. This is one way of making the service more democratic.
On the other hand, the present Government seem totally to reject the representational basis proposed in the previous Green Paper, and they say, in effect, that such a basis for appointments to the area authorities would be incompatible with the principle that management ability should be the main criterion for the selection of members. We are in the Health Service dealing with human beings and with individual problems. It is therefore very important that any restructuring of the National Health Service should be used to ensure a greater degree of participation not only by those employed in the service but by those who use it. We should ensure that patients who are involved in the service should have some say in the running of it.
It should be incumbent on all hospital management committees to set up a proper consultative committee with their hospitals. At the moment this is permissive under the 1946 Act, but, in my opinion, it should be made compulsory. If such a duty is good enough for the Secretary of State for Employment it should be good enough for the Secretary of State for Social Services.
The Government should take due note of paragraph 7 of the Consultative Document of the Code of Industrial Relations Practice:Any establishment with more than 250 employees should have a consultative committee 624 with an elected membership representing all sections of the establishment and sectional sub-committees where appropriate. Management should take the initiative in setting it up, in consultation as appropriate with employee representatives and trade Unions concerned.The Secretary of State for Social Services should take a leaf out of that code of recommendations and act accordingly.
It is not use talking about democracy unless one is prepared to practise it. Community health councils are to be appointed rather than elected by those to whom they are responsible. This is a bad principle, and, indeed, this is a bad document—not so much for what it says, but for what it leaves out.
Any question of appointing a hospital ombudsman has been forgotten. No mention is made of the fact that the school medical services would be integrated, and this is a black mark against the Consultative Document. The failure to include arrangements for an occupational health service is almost criminal. Since we know that so many working days are lost through illness, surely the occupational health service should have been included. For every day lost by a strike, 100 days are lost through illness.
If we recognise the problems that beset the National Health Service we should set up an industrial training board to train people to take positions of management and responsibility. I condemn the Government for producing a document which will not bring about a democratic system and will do nothing substantial to help the service. At the same time I should like to pay tribute to the 750,000 people who work in the health service in such a devoted way. I hope that we shall see a change of heart by the Government and that this will soon bring about a more efficient, better and humane National Health Service.
§ 5.36 p.m.
§ Dr. Anthony Trafford (The Wrekin)
The House will not be surprised to hear that I welcome the Consultative Document and the fact that action is to be taken on the ground that uncertainty has continued long enough. It is true that all the emphasis in the document is on management and, however good management is and however sound the structure, this does not necessarily produce a good service. Even in the most personal services in handling patients, a modicum of 625 efficiency is helpful, and a badly managed service can lead to difficulties.
I enjoyed the speech of the right hon. Member for Coventry, East (Mr. Cross-man), and I enjoyed the iconoclasm that was contained in it. The only trouble was that he fired torpedoes and then left the Chamber, as though he had suddenly lost interest in the Health Service. It would be reasonable for him to have argued against the imposition between the Department and the area board of a regional tier if he had extended this argument to suggest that a different form of management should take place and that the community councillors should be strengthened and all the representative bodies placed in the middle abolished. In other words, there should be a reverse appeals procedure, and solely official direction of the service. This would be a tenable position. One of the features I find attractive in the document is that it removes the anomaly which at present exists where the people who are supposed to be responsible for administering the Service are at the same time those to whom appeals would be made. It is difficult for everybody to be judge and jury in their own cause.
Whatever reforms may do to relieve anomalies and inequities, they should not be made purely for their own sake. This is how the document and its implementation will be judged. There are four major deficiencies in the present service. These are management; maldistribution of resources; lack of flexibility; and the problem of finance. The latter has not been touched on this afternoon, and I will not pursue the matter further. The first three of these features are the ones on which the proposed reforms should have considerable effect. It was once thought easy to define health and ill-health, but in fact this is not so and there are various gradations of health. It is not easy to define the objectives towards which the N.H.S. should be aiming. It is almost impossible to distinguish in practical terms between the needs and demands of the population in health matters.
It is a well known fact that the more services that are provided the more they are taken up; in other words, demand escalates not only with supply but in excess of it. This often means that some form of rationing must be imposed, whether by some administrative means or 626 by long waiting lists, or whatever it may be. As the Secretary of State has said, it would be almost impossible ever to meet every demand of the public for health.
It is difficult to define the proper sphere of medicine today. At one time it was thought to be easy: one either had pneumonia or not; one either went to a doctor or did not. Today the effect of housing and of the total environment on a patient is often as of great importance as whatever appears to be his primary medical illness. In these days it is necessary to see illness not only as a personal misfortune or affliction for the person who is ill, but in its total family and social consequences. This necessary change has led to the concepts of community care. This has led to the changing rôle of the practitioner. The practitioner now often takes the view that he went to medical school to become what he calls a doctor, not a social worker, which he has been forced to become. Therefore, up to a point, he may have moved away from carrying out his preferred functions. One tends in those circumstances to see the demand for the creation of a social services department alongside and in part carrying out what are in a sense modern health functions. I agree with the hon. Member who said that he thought that an opportunity had been missed when the Social Services Act was passed, and that there is not now the possibility of combining these personal services and health into one service.
There is, however—I come to the point I mentioned about flexibility—a big deficiency of information upon which any health service administrator can act. This is best illustrated by an example given by the hon. Member for Hitchin (Mrs. Shirley Williams) when she spoke about health centres. A vast amount of attention and a certain amount of money and of drive has been devoted to the creation of the health centre as though it was the answer to the problem of community medicine. The data upon which this is predicted are extremely slender. It was always thought and argued that a health centre as a great centre of medical services would reduce the weight on hospitals, reduce the referral rate and the inpatient demand, which are the very things for which the right hon. Member for Coventry, East was asking.
627 The only survey which we have so far suggests that, far from that having happened, the opposite has happened and the numbers of referrals have gone up. I think that this lack of flexibility has meant that this experiment has not been able to be carried on and evaluated and, as a result, the proper decisions taken. Instead we have had to rely to a certain extent on guess work, which is not a very good basis for making long-term decisions.
I will not go into the question of hospital building, which again is a good example of how, without the proper feedback of data, the wrong buildings, built in the wrong way, designed for the wrong purposes for 1980, and taking an interminable time to build, have often been built in the wrong places.
The basis of medical function and activity inside a hospital does not apply only to the number of beds or doctors. Many people are concerned in the running of hospitals. I commend to my right hon. Friend the thought that he should increase the ancillary services greatly and reduce the number of in-patient beds.
A further example of this situation at the moment is the position of consultants. I am now talking of the bogeymen of whom the right hon. Member for Coventry, East spoke. There are 600 consultant vacancies. Yet the Department has suddenly decided to increase the number of consultant vacancies by 4 per cent. It sems curious to add numbers of vacancies when apparently people are not applying for these jobs. I entirely agree with the right hon. Member for Coventry, East and with my right hon. Friend that what is needed is a considerable shift of emphasis into the community so that the trend towards in-patient care and expensive hospital care is reversed.
I welcome the preservation—I suppose that is the correct word—of the regional tier. I believe that it will have a proper function. It has a function in the distribution and organisation of the rarer services that are needed. It can perform an extremely useful function, and I believe it will help to allocate properly the resources between areas. One of the possible weakneses of areas is that they could become too parochial. They have other problems, about which I am sure 628 other hon. Members will wish to speak. I think that the geographical drawing of the areas will be difficult. Kent is one example. It seems to me that there should be two areas there, not one.
We have not yet had defined the functions of the chief executive of the area health authorities, and his status, origin and training. We should like to hear more about that.
On the flexible response to the proper collection of data and evaluation, I am glad that the teaching hospitals are to be integrated. We have had a very moving plea from my hon. Friend the Member for Reading (Dr. Vaughan), which I regard as one of special pleading, for the preservation of a particular privilege which has never been justified to my knowledge. Much criticism has been published of the teaching of medicine. We have had Royal Commissions on it. We know that it was bad and that it has been inadequate. Yet the least reformed area of the Health Service to date has been the teaching hospitals. They put forward the plea of research. It is excellent to spend money on research when it is productive of anything, but has anybody ever evaluated how much it produces?
Overall, I welcome the document. I hope that these reforms will be implemented. I make the reservation which my right hon. Friend stated: that management of itself does not make a service, but it can nevertheless give the prospect of so organising the service that it can make up some of the deficiencies which have been outlined and give a potential for an improved health scheme.
I was delighted that my right hon. Friend ended his speech with a tribute to those who work in the National Health Service. Every institution, business and service can always be criticised in detail. I have worked in health services in other parts of the world and I am glad that we have our Health Service and that I have been able to work in it. Despite its defects and deficiencies, I think it does an exceptionally good job. When these reforms are implemented, I sincerely believe it can and will do an even better job.
§ 5.48 p.m.
§ Dr. M. S. Miller (Glasgow Kelvingrove)
Everyone will welcome the intention to reorganise the National Health 629 Service. This possibility was catered for on at least two occasions when we were in government. But reorganisation should have a meaning. It is not a panacea per se.
I am highly suspicious of any document which lays such mighty stress upon managerial efficiency. My right hon. Friend the Member for Coventry, East (Mr. Crossman), in a brilliant exposition of the faults and flaws in the document—I do not think anyone on either side of the House can hope to emulate his speech—beautifully pinpointed the way that the document fails to carry out any of the main ideas which we had for the reorganisation and restructuring of the Health Service. He brought us back, again and again, to the reality that the health service is about people. It is not about metaphysical abstractions; it is about flesh and blood.
I find that managerial efficiency—a term which now sends a shiver down my spine—is often a euphemism for inhuman action. Managerial efficiency can be the enemy of kindness, thoughtfulness and care. Managerial efficiency is certainly no substitute for a determination further to develop the National Health Service and to restate clearly what the objectives of the service should be, and the kind of shuffling around which the Secretary of State gave us this afternoon of the nomenclature of area health boards, as opposed to regional health boards, regional authorities, and area authorities, is not good enough.
We on this side of the House know what is meant by the "reassessment of resources and revaluation of the effectiveness of our expenditure". We know that the saving made by not giving school milk to children under seven is supposed to be linked to the building of more primary schools, but everyone knows that one does not earmark money saved that way for another purpose, and in any case it would be an infamous way of providing school accommodation. Ask any school teacher, and he will confirm that trying to educate under-nourished children is a far more difficult task than teaching in an old school.
So it is with the National Health Service. Hospital building is fine and necessary, but not at the expense of other vital aspects of the service, and certainly not as a cold, clinical substitute for compassion 630 and a warm humane outlook. On previous occasions in the House I have drawn attention to the relatively low rate of expenditure on the Health Service compared with the national income which the country has enjoyed, if I may use the expression advisedly, under previous Tory Administrations. Between 1950 and 1963 there was a reduction in the proportion of our national income spent on the National Health Service.
What is this all about in any case? What are we aiming at with our Health Service? I perhaps differ slightly from my right hon. Friend the Member for Coventry, East when he criticised one aspect of the N.H.S. I think that we have a good Health Service. I do not think it is as bad in that one respect as my right hon. Friend seems to think. He is a man with tremendous authority in the field of administration of the Health Service, and who should know better than he what is needed in connection with the organisation of the Health Service?
I think we have a good health service, and here I agree with the hon. Member for The Wrekin (Dr. Trafford). But what are we aiming at? Are we aiming simply at the curing of illness when it occurs? If so, how do we define illness? Is it merely the absence of disease? What is the underlying philosophy of the Health Service? It should be concerned with positive good health. If we live longer, are we living a better life? Are we enjoying our lives? Do we have less, or more, tension in our lives? That is what the Health Service is about. That is what we should be concerning ourselves about in our Health Service.
What about our environmental conditions? Are they conducive to good health? What are we doing about pollution of all kinds? What are we doing about the motor car, the aeroplane, our cities, and our countryside? What investigations are we conducting? Why, for example, are there twice as many tonsillectomies in Oxford as in Sheffield? What are we doing about investigating the substances in our water supply which are often implicated in cardiac disease?
I think that what is wrong with this document is that, whereas policy and objectives should determine the structure of the National Health Service, and not the other way round, what we have here 631 is the impression that first we fabricate an impressive and elaborate organisation, and then we try to fit into that organisation what it is to do.
The vagueness of the document is disconcerting, even alarming. What real encouragement is being given to general practitioners to end their isolation from their colleagues in hospitals and in the public Health Service? Health centres and group practice centres are far too slow in their development, and I believe that there is a great deal of scope for much less pretentious provision in this field. Smaller group practice centres could be provided by general practitioners themselves, without waiting for local authorities to provide the money for them. I did that in my own practice long before the medical profession was as well reimbused as it is now. I did that in 1954.
In that connection, the average earnings of the average general practitioner in 1969 were more than £5,500 a year.
§ Dr. Vaughan
The hon. Gentleman is talking about gross and not net earnings, and the general practitioner has to meet many costs out of that sum.
§ Dr. Miller
Perhaps the hon. Gentleman will allow me to elaborate. In 1969 the average general practitioner was earning £5,500 a year. With indecent haste the Government increased that, and the position today is that he earns £6,500.
§ Dr. Miller
In addition, sums are added for the provision of premises, and for his secretarial expenses. I agree that he has to meet certain expenses from the total sum, but so does everybody, and it is not a bad sum of money from which to meet his relatively small expenses. He gets twice the amount of money that is paid to the average Member of Parliament, and, without being any way nasty towards the average general practitioner, I do not think he works twice as hard as the average Member of Parliament; but I am not complaining.
I do not minimise the contribution made by the family doctor, but, as the general practitioner receives a fairly substantial income, when will he be forbidden from practising from hole-and-corner surgeries of the kind that are used 632 by so many members of the profession? When will we insist that the completely inadequate facilities which he provides—a dingy waiting room, lacking in washing and toilet facilities, and with no provision for the comfort or convenience of his patients—are no longer good enough for his patients? I do not think that there is anything romantic, hygienic or therapeutic about them. They lack even the minimum facilities, and it is high time, if this is the best that some members of the medical profession can provide, that we had a fully salaried Health Service in this sector.
If we are talking about restructuring and reorganisation, another matter at which we should look is the drug bill. The monthly catalogue of prescribable drugs, which is issued to every doctor, lists well over 3,000 separate, but not necessarily different, medical substances. In 1969 in England and Wales nearly 250 million prescriptions were issued, at a total cost of more than £151 million, and an average cost per prescription of 62p. In Scotland there were 28 million prescriptions, costing just under £20 million, at an average cost slightly higher, at 68p. Last year the bill rose to more than £180 million, or more than 10 per cent. of the total cost of the National Health Service, and represented a very much higher proportion than did the family doctor services, which took about 8 per cent. of the total amount spent on the service.
The high cost of the drug bill is largely due to the change in prescribing habits of the medical profession. During the first few years of National Health Service more than half the prescriptions issued were for non-proprietary medicines. Today 94 per cent. of all prescriptions fall into the proprietary drug category, the average cost of which is anything from twice to five times that of a nonproprietary preparation. This is of great advantage to the American drug industry and to some continental firms, because 50 per cent. of all drugs prescribed in this country are from firms which are American-owned, 25 per cent. from continental firms and only 25 per cent. from British firms. I hope that my hon. Friend the Member for Halifax (Dr. Summerskill) will note that there are some on this side of the House who feel that this is another aspect of the Health 633 Service which should be looked at from the point of view of nationalisation.
The most apt quotation that I can give from the Consultative Document is:We are perhaps in danger of a surfeit of plans and prospectuses: there must be early decisions, so that enthusiasm for reform does not wither away.What reforms are proposed? As I have said, the National Health Service is about people. Are we to have proper stress on the prevention of disease? Are we to have a campaign for health education for positive health? What about the needs of the aged? This is a whole field which is crying out for further action. Are we to have a real effort to conquer cardio-vascular diseases and cancer? Are we to have an occupational health service, and a full National Health Service Ombudsman and not just a hospital Ombudsman? We must have more civility towards patients by all those who supply the service.
We have very little confidence in the Tory Government's handling of our National Health Service. The Conservative Party opposed it from the very beginning, and I feel that the objectives envisaged by the late Aneurin Bevan have very little chance of being achieved so long as we have a Tory Government. I may say, in common with those of my right hon. and hon. Friends who have spoken already, that I reject totally this lamentable effort.
§ 6.4 p.m.
§ Mr. Timothy Raison (Aylesbury)
My still relatively short experience of this House has impressed me with the generosity of the English silent majority towards the regional minorities. I spent this morning in the Scottish Grand Committee, which was considering the proposals for reforming the Scottish Health Service, and I had to observe a Trappist silence. The hon. Member for Glasgow, Kelvingrove (Dr. Miller) is at a considerable advantage in that he is able to express his views so freely on the reorganisation of the English service.
The hon. Gentleman brought out the fair point that this document has very much to do with management. My right hon. Friend makes it clear that his structure is designed to achieve a more efficient management of the National Health Service. Some people may cavil 634 at this. The point is that management for the health service is management of a very different kind from the sort of management that one applies to industry. As one of my hon. Friends pointed out earlier, the essential yardstick of profitability clearly does not apply. But, although it is management of a different kind, it is still true that it is management and that it is extremely important.
We all know by now that there are all sorts of examples of the way in which resources are misallocated or allocated perversely. The hon. Gentleman gave one example when dealing with the figures for the variations over tonsillectomies and adenoidectomies in the Sheffield and Oxford regions. There are many more examples. Another fairly well known one is the variation existing between different parts of the country in the amount of time spent by patients in hospital before they have operations. In some regions it is an average of 2½ days In others it is an average of 1 day. These kinds of considerations in the effective management of resources are tremendously important. Clearly, a day and a half cut off the time that people spend waiting in hospital for operations means a reduction in the number of justifiable complaints about queues for getting operations done.
Management then is very important, but the complication is clinical freedom. Often there is a clash between the concept of what might be termed efficient throughput and the traditional and vitally important notion that the doctor must treat patients as he thinks best.
We have therefore to look at the reorganisation partly in terms of whether it will provide a more effective system for management. I do not think that the sorts of problems that I have discussed of achieving a more effective throughput can be solved by some diktat. Clearly we have to ask ourselves whether the framework offered by the Consultative Document gives the chance of a better approach.
My first criticism of the document is that I believe, as other hon. Members do, that it gives too little scope for professional representation on the various boards. I take issue with the view that management ability will be the main criterion in the selection of members and 635 that it would be inappropriate for authorities to be composed on a representational basis. I suggest a different concept. The boards, whether area or regional, could be constituted more reasonably on the analogy of industrial boards—the supervisory and the policymaking board in industry.
It is right to have both the professions and the general public, presumably in the shape of local authority representatives, on these boards. It is right, essentially, because, if it is done, it will be easier to get doctors to accept the decisions that the board will have to make. Under the boards, we should have some sort of system of a chief executive. We shall not get greatly improved efficiency in the Service unless we are prepared to see brought in the equivalent of managing directors. Equally, doctors will not accept the views, the arrangements or the instructions of these chief executives unless the policy boards which in turn have laid down the policy under which the chief executives act have doctors represented on them.
I am glad that there is to be some representation of local authorities, anyway at the area level. Like the right hon. Member for Coventry, East (Mr. Crossman), I should like to have seen the Health Service come under a reformed system of local government. I remember in the dark ages before 18th June, 1970, when I was a mere journalist and the right hon. Gentleman was Secretary of State in all his glory, trying at one of his Press conferences to question him on this point. At the time, he said, "It is quite out of the question to have the two services merged." Probably he was right and that it was out of the question in practical terms. However, in 25 years' time, as this present Conservative Administration move towards the close of their period in office, it is probable that we shall see a new reorganisation of the Health Service. At the time of this next reorganisation, it may be that local authorities will be conbined with health authorities. That will be good for everyone.
The criticism which has been advanced that the present proposals are a little weak in democracy has some force. One would like to see a stronger democratic 636 framework. I am still worried about the regional tier. The top tier, the Secretary of State's tier, is accountable to Parliament. If it does anything wrong, we can criticise it. The area tier is not fully accountable, but it is somewhat accountable through the local authority representatives who will serve on it. But the regional tier in between seems to be unaccountable to anybody. There will be no way of getting at it and of trying to influence its decisions. I accept that there has to be some kind of regional framework, but I should have preferred to see the regional level on a consultative basis, a coming together of the areas with the representatives of the Secretary of State. I should have preferred executive powers to lie either formally with the Secretary of State or at the area board level. I hope that my right hon. Friend will look again at this point.
I have two other points to make. Firstly, I share the view that the general practitioner's position in the new service is still a bit vague. This is a Consultative Document and a White Paper is to come, but I hope that my right hon. Friend will be able to fill in a little more information. I hope that he will formally base the whole concept of G.P. service on family medicine. I am convinced that the school health service should go into the family or community medical service. It is important that children should properly be looked after, but the right people to look after them, examine them, inspect them and treat their minor ailments are their family doctors. If we could have a fuller integration of the family doctors into the area structure proposed, it would make it that much easier to bring the present school health service into the family service.
By the same token, I would not support the notion of an occupational health service. To create another arm of the service in the factories and offices is in contradiction to the notion that what we want is a family service. I hope that my right hon. Friend will be able to enlighten us more on that subject.
Finally, before we go very much further, we must do some hard thinking about the structure of the service within the areas. We have got down to area level, but what is to happen within the areas? Probably the right analogy to adopt would be that of the education 637 service. In subdividing the area, there is a very tricky question as to whether to do that by districts, by geographical regions or by functions. Probably the right answer is to have a sub-committee to deal with the hospital side and another to deal with the community side. Again, each could have under it a strong executive officer to carry out the policy which it lays down.
I have made a number of criticisms. I am not entirely happy about the document as it stands. On the other hand, it gives us something to build on. An important point is that it shows clearly that it is the Government's intention to develop and strengthen the National Health Service rather than in any way to emasculate it.
§ 6.13 p.m.
§ Mr. Michael Cocks (Bristol, South)
I wish to deal briefly with the aspect of appointments. When the Secretary of State spoke about consultation with the various bodies, that sounded warm and cosy, but it is only what was said in the 1946 Act. I want to quickly examine how this has worked in practice.
I fully agree with the document when it talks about community health councils and refers to the importance of more effective representational mechanisms by which local attitudes can be known and safeguards built in. We should all agree that the service should be responsible to the general public but is appointment the best way to achieve this?
In the 1945 survey of health services, a map was produced for Bristol which showed that all hospital facilities were north of the river and none south of it. In 1971 the position is still the same. The population of Bristol north of the river is about 260,000, and south of the river it is 160,000. This gross total south of the river conceals an important change which has taken place since the war; a depopulation in the centre and a substantial growth of some 50,000 to the foot of Dundry Hill—at Withywood, Bishopsworth, Hartcliffe and Stockwood. This area has been promised a hospital since 1936. I recently raised this question with the Board and its excuse was that the present distribution of hospitals was inherited from the appointed day. I 638 accept that there is a semblance of an excuse there, but it is a feeble one.
The Board has responsibility for appointments to management committees. There are two very substantial hospitals on the north side of Bristol, Frenchay and Southmead, and these hospitals have claims for capital resources in competition with the south side of the city. I have become very curious in this matter and I have a handbook of the Regional Hospital Board 1970–71 with the addresses of the management committee members for those two major hospitals. I have checked those as best I can and I find that for Southmead Hospital, out of 22 committee members, 17 live on the north side of the river, none on the south side, two in North Somerset and three in South Gloucestershire. For Frenchay, out of a total of 15 members, eight live on the north side of the river, none on the south side, four live in North Somerset and three live in South Gloucestershire.
We have a situation in which 25 members of the management committee live on the north side of the river and none live on the south side. My hon. Friend the Member for Brecon and Radnor (Mr. Roderick) tells me that the odds of this happening by chance are 159,381 to 1. I believe the Regional Hospital Board owes the people on the southern side of the city some explanation for that. The situation is more serious than it seems because all the 25 members are in the north-west quadrant of the city, so the Board is, in effect, saying that three-quarters of the population of Bristol cannot produce one person suitable to be a member of a management committee. This is a serious position.
Consideration is taking place in the Bristol area at present about the future of the clinical area hospital system. Those management committees are being consulted, but no one on the south side of the city is getting a look in. If this system of appointment is to continue, we want to know whether the general public can have confidence that this sort of thing will not be perpetuated. If people are to support a system of appointment it must seek to be fair and truly representative not only of particular interests but of the areas where people live, the people who are the raw material on which the service is based.
§ 6.18 p.m.
§ Mr. Peter Fry (Wellingborough)
May I say how much I enjoyed the speech of the right hon. Member for Coventry, East (Mr. Crossman)? A new doctrine is now emanating from the Opposition benches that power must be moved from central government towards local government. Could it be that this is because it is only in local government that the Opposition will have any power for many years to come?
I welcome the Consultative Document, and I especially accept the need for a greater accent upon management, but there are two aspects of the document with which I am not terribly happy. The first, which has been mentioned many times today, is the composition of the area health authorities. I have a lot of sympathy with the County Councils Association when it says that it is concerned that the proposed structure and membership could lead to increased insensitivity to public opinion. As a Member of Parliament, one's acquantance with the present structure usually confirms that most of the criticisms of it are in this respect. Though no organisation, especially one as large as the National Health Service, can be perfect, most of the complaints we receive can be put into this category.
There is little doubt that what is needed is much more local contact between the service, the public and locally elected representatives of the people. There will always be considerable criticism of the calibre of some local councillors, but most of them are very conscientious and do a very good job. They are the ideal means of liaising between those three aspects in this most sensitive sphere.
As my right hon. Friend knows, I am a member of a group on this side of the House which has given some attention to the subject. We have suggested that the area authority should be somewhat larger than the 14 members plus a chairman mentioned in the document. We suggested an authority of, say, 21, with no less than eight members appointed from the local authorities. A minimum of eight is necessary in the new areas. This is because we considered that the links between the public, local government and the service are so important.
Although the document rightly stresses the importance of good management and 640 clear lines of responsibility, I am not so sure about the statement in paragraph 14 that all members of the authority will be selected for their managerial ability. I do not see why this is necessary. By all means pick the administrators on their management ability, but the area health authority is the decision-making body and the one which represents the public at large. After all, when it comes to getting something done a committee of one is always best. Therefore, the job of management should be left to the high calibre professionals whom I hope that we shall be able to recruit, and that would leave the wider implications to the members of the area authority.
My second point arises from the first. I am very sceptical about the proposed community health councils. They are summed up by these words in the document—It will produce an annual report.That just about sums up the effectiveness of the councils. I believe that the whole idea has been put forward because of the fears that I have already mentioned today and which have been voiced on both sides of the House. These councils will do little good and will become mere talking shops. We know what little effect similar councils in the gas and electricity industries have upon public opinion.
We should use the local authority members on the area councils and give them something to do. This is the only way to create people of high ability in local government. They would feel that they were doing a worth-while job. Let us give them responsibility. Let us not expect them to waste their time on a consultative council.
A much more effective way of promoting good public relations would be to use the hospital management bodies. People like to be involved with their local hospital. Let us make them more like school governors. There would be a much greater public and local interest in the working of the hospitals and the Health Service if governors were appointed in the same way.
Today too many managers sitting on hospital and other Health Service bodies have too little relation to the public at large. Most members of the public have not the faintest idea who they are. If 641 my suggestion were followed this problem would be taken care of.
I agree with the hon. Lady for Hitchin (Mrs. Shirley Williams) that an Omsbuds-man is needed in the Health Service to deal with the really serious complaints. If one were appointed, a much more democratic and sympathetic Health Service would be evolved.
Having expressed these two strong reservations, I welcome the document as at least a basis of discussion for a stronger and healthier Health Service for the nation.
§ 6.23 p.m.
§ Mr. Emlyn Hooson (Montgomery)
At this juncture in the development of the Health Service, which is a service in which we take great national pride, a very important question arises as to whether it is in the future to be based primarily on the hospital service or on a community medicine service. In the two decades for which the service has operated much more money has been spent on the hospital service than on the general practitioner service. The emphasis has been wrong. What has sustained the service throughout this period has been the work of the general practitioners, but this has been insufficiently recognised.
The Consultative Document places a great emphasis on the managerial side of things. The general practitioner service, however, has been the least managed of all sections of the health service. If we follow the pattern suggested in this document we are likely to perpetuate the emphasis from the Ministry point of view on the development of the hospital service rather than of the community medicine services.
For example, I am told that there are likely to be applications from 30 very well trained, first-class people for every consultant surgeon vacancy, whereas vacancies for general practitioners often cannot be filled. Thus there is a great lack of balance in development of the Service on this side.
The right hon. Member for Coventry, East (Mr. Grossman) very cogently stated that someone who is seriously ill in Britain is in the best country in the world to be in such a condition, because he will be looked after wonderfully. In other respects we are woefully lacking. People 642 who are ill but who are not completely disabled and not acutely ill—for example, people suffering from piles—are not so well placed.
The emphasis in this document is wrong. We will, if we follow this pattern, perpetuate the over-emphasis on the hospital services and pay insufficient attention to the development of community medicine in all its aspects. The managerial types will inevitably be attracted by the idea of the large hospital, and so on, and will have little sympathy, possibly, for the community medicine aspect.
The right hon. Gentleman rightly pointed out that good medicine in itself is a contribution towards human happiness. A well-managed, good service makes a contribution to the wellbeing of the potential patient. On the other hand, there is a gross over-emphasis in the document on management and far too little emphasis on popular representation. I cannot see why the good management cannot be provided by the professsional who is hired to do the job and who is accountable to people who are in close touch with the community. I cannot understand why in Britain there is always such a fear of the popular elected representative.
When, in reply to an intervention by the right hon. Member for Coventry, East (Mr. Crossman), the Secretary of State adumbrated the many aspects of the service and distinguished them because of the number of aspects from the education service, he was completely unconvincing. The greater the spectrum which the Service covers the greater the need for a sensitive body to show what the public reaction is to those services. That shows a greater need for popular accountability to popular elected representatives.
The hon. Member for Aylesbury (Mr. Raison) said that the document is a little short on democracy. That was the understatement of the year. The document ignores the democratic principle. There is no accountability save from area level to regional level and from regional level to national level.
The accountability which is truly needed, as this is a service which is so important to the people and as their welfare and happiness are at stake, is through those who are elected to represent the people. I am convinced that the document proceeds along the wrong lines.
§ 6.28 p.m.
§ Dr. Shirley Summerskill (Halifax)
Although the debate on the Consultative Document has been too short and, regrettably, not in the Government's time, we are left in no doubt about the strong feelings and criticisms of those who have taken part, at any rate on this side, and with a large amount of agreement from hon. Members opposite, such as the hon. Member for Wellingborough (Mr. Fry).
The document is totally unacceptable because its proposals are divisive, undemocratic and seriously incomplete. The Minister is a Fellow of All Souls, but I am afraid that for this particular thesis he rates gamma minus. Even his speech was a triffe vague and left many questions unanswered and important matters not thought out. A mere 10 weeks have been allowed for discussion and for verdicts to be delivered. The fact that the Secretary of State has kindly apologised for mistakes in distribution and inadequate circulation of the document makes it all the more necessary to have longer to discuss it. I am glad, at least, that there will be no repetition of the event which took place when a member of a hospital management committee rang up his Department to ask for the document, to be greeted with the response, "Who are you, and why do you want it?"
Whatever the reasons, a disregard of democracy has affected distribution and discussion of the document, matched only by the undemocratic nature of the proposals in it. It is regrettable that the opportunity has not been taken to redefine both long-term and short-term Health Service objectives, for a structure is useless unless it is based on a clear set of priorities and strategies to be pursued.
On this side, we cannot accept even some of the basic principles underlying the proposals. It is generally agreed that the aim is to abolish the tripartite structure and create an integrated unified service, but the reorganised structure proposed would produce exactly the opposite of what is urgently needed.
These proposals will be divisive in their result. The 23,000 family doctors who are the backbone of the Health Service, instead of becoming integrated with the rest of it, would still be divided from the hospital service. Special committees will be set up to manage the general 644 practitioner, so re-emphasising his status as an isolated private contractor rather then a member of a team working with other doctors and hospital service staff.
There is no encouragement for the development of health centres, which is where the future of general practice lies, a point well brought out by my hon. Friend the Member for Glasgow, Kelvin-grove (Dr. Miller) and the hon. and learned Member for Montgomery (Mr. Hooson). Integration in this field is vital, and an opportunity to create it has been missed.
At the same time, the Health Service, both national and local, will be cut off from local authority social services, yet everyone knows that it is essential that these ought to work in co-ordination and co-operation if there is to be effective domiciliary care and after-care.
Perhaps the most serious criticism of the document, which has been repeated again and again in the debate, is that it is permeated by a distrust of democracy. We needed urgently to abolish regional hospital boards and hospital management committees because, as we know, they are self-perpetuating, oligarchic, and undemocratic. But what do we have put in their place? First, we have regional health authorities, entirely appointed by the Minister, which would become all-powerful and unaccountable to anybody; in effect, regional hospital boards all over again, and likely to consolidate the dominant position held by the hospital service. Second, we have the area authorities, which look like being hospital management committees all over again, though probably worse because they will, in the main, be appointed by the regional authorities. Third, we have the community health councils, appointed by the area authorities.
All this will perpetuate some of the worst features of the present arrangements. It is a negation of democracy. The Labour Government's Green Paper proposed one-third representing local authorities, one-third the professions and one-third the Health Department. Under the present Government's proposals, the voices of elected local authority representatives will be seriously muted, as will be the voice of the ordinary patient. Here again, we have a totally undemocratic proposal, to hive off into a siding so-called "local attitudes", that is, the 645 feelings of the public and, last but not least, the patients. These will be represented on community health councils, which will be edentulous bodies, purely advisory and with no powers. Members will be appointed, and sacked, presumably, by the area health authorities.
We are told, condescendingly it seems, that the authorities would take full account of the views of the public they serve. But this is no substitute for elected representatives with power to act. Today, there is a greater demand than ever before by the consumer to participate in management, to be consulted, to have his views heard, yet we seem to be going backwards under these proposals, instead of forwards.
Consultative bodies of the kind proposed usually engender a sense of impotence and frustration in the people who serve on them. No doubt, the Government would prefer that the consumer did not interfere with efficient management. They hope that these bodies could act as a sop to participatory enthusiasm. But should the so-called experts be allowed to govern undisturbed by the complaints of local people or patients who are the very ones whom the National Health Service is supposed to serve?
For those employed in the health service, representation is sacrificed at the altar of management ability. Direct election is sacrificed at the altar of selection and appointment. Do the Government really believe that democracy and efficient management are incompatible?
The initial response of doctors and the health professions is lukewarm, to say the least, as the hon. Member for Aylesbury (Mr. Raison) pointed out. They protest that they would be grossly under-represented on the area authorities. Dr. James Cameron, on behalf of the family doctors, has told the B.M.A. Council:The basis of these proposals is central control…the aim is to provide an efficient business service. Doctors and patients are not considered.Dr. Christopher Lycett, for the public health side, has told the Council that business interests threaten to take over the health service.
From my hon. Friend the Member for Huddersfield, West (Mr. Lomas) we heard the view of the trade unions. They are united—N.A.L.G.O., C.O.H.S.E. and 646 N.U.P.E.—in feeling that there is a lack of representation for the unions. The County Councils Association has expressed doubts about whether the proposed increase in central control will lead to the expected increases in efficiency. It is concerned at the prospect of growing insensitivity to public opinion.
It may be said that those are the views of particular groups, but I can illustrate the point by what is happening in my constituency of Halifax, an industrial town. The education committee has decided not to give its backing to these plans. The health committee also has strongly criticised the plans, in particular, the proposed under-representation of local authority members. The finance and policy committee in Halifax has accepted a report prepared by the town clerk of Halifax criticising the Government's proposals. I add that the Halifax Council is Conservative-controlled, so those are not the views of a lot of Labour people wanting to be difficult.
One point made in the town clerk's report is that the consultative documentpays scant lip-service to democracy in its proposal that 'some' members are to be appointed by the local authority. As a matter for consultation at present, the document is…lamentably inadequate".The town clerk refers to "objectionable" principles in the document and "unsatisfactory and inadequate" descriptions of other matters.
I trust that the Government will consider seriously these widespread criticisms of their document by people who work in the Health Service, who understand it and who have experience in it. They do not want control by bureaucrats. They do not feel that the Government's proposals really represent patients and public.
Every person who plays an active rôle in the Health Service should be represented in its organisation—consultants, general practitioners, technicians, health visitors, nurses, trade unions and local authorities. We have been hearing too much in this debate of managers, with little explanation of how they would be recruited, how their success would be judged, how many extra officials would have to be appointed and at what extra cost to the Health Service, how many hours they would work, and what would 647 be their career structure. We may have answers to those questions in the distant future.
I cannot see how the magic qualities of leadership, energy and drive, together with management ability, extolled by the Minister, can take the place of humanity and judgment and contact with patients and knowledge of their needs. That point was brought out extremely well by my right hon. Friend the Member for Coventry, East (Mr. Crossman). In their obsession with efficient management, the Government are treating the Health Service like an industry. The board of directors is to be insulated from the criticisms of both workers' representatives and the shareholders. But the health service is not about machines; it is about sick people. It is not about productivity; it is about the prevention and treatment of disease. The document tells us that the Health Service cannot prosper without managerial skill. We know which the patient will choose if we ask him whether he wants managerial skill or humanity and communication with those in authority. But the word "patient" does not even occur in the document.
The document is consultative in name only. Two crucial, contentious and fundamental matters are still to be the subject of working parties—to decide detailed managerial arrangements at both the regional and area levels and the mechanism of the liaison between the Health Service and local authorities. How can anyone give a view on a document in which what is left out is as important as what is put in? We hope that the Government will have a totally open mind on those points, in which case they will have to present a second consultative document when the working parties have reported, because people cannot make a sound judgment on the present one.
A significant but not unexpected omission is the lack of any mention of an Ombudsman, a patients' watchdog. We understand that the Minister has not made up his mind on the matter. Why not? When does he expect to make it up? May we know what his mind will decide when it is made up? We have been waiting a very long time for this decision, but the Government should not rush into legislation on a matter which 648 will affect the Health Service for years to come.
We have had two previous Green Papers which have provided a great volume of informed criticism which is bursting out of the Elephant and Castle. It is unbelievable that at the end of 10 years' debate on the subject a third document should be so totally unsatisfactory that legislation is still awaiting the findings of two working parties. In his foreword to the document the right hon. Gentleman has stated:… there must be early decisions, so that enthusiasm for reform does not wither away.He must accept that there is no enthusiasm for reform on the lines of the document. I share his appreciation and admiration of the work of all who are in the health service. It is no easy task to abolish the tripartite system and integrate the service. What must be created is a Health Service which is sensitive to changing needs and demands, one in which the men and women operating the service and the patients using it can freely communicate with the management. We need leadership in a framework of genuine democracy. That is why the Consultative Document is unacceptable and should be withdrawn.
§ 6.44 p.m.
§ The Under-Secretary of State for Health and Social Security (Mr. Michael Alison)
A large number of issues have been raised and many questions have been asked which I shall try to deal with. The main theme of the debate was that set out by the right hon. Member for Coventry, East (Mr. Crossman), who has substantial experience as well as considerable debating skill, which we all admire. I should start by considering that theme and seeing whether we can rebut it. We should rebut it if we are to have confidence in our proposals, as we on this side of the House have. The right hon. Gentleman was convinced not only that we had included too many links in the chain but that we had strengthened the wrong link. He associated all that with a powerful plea for greater sensitivity to the grass roots, for more consumer participation.
I shall try to demonstrate that we have put at least as much strength and weight at the area authority level as the right hon. Gentleman's own Green Paper did. There is no doubt that our prescription 649 represents a substantial, clear and definite transfer of power from the concept of the existing regional hospital board to our new area concept.
The key issue is money. We said that each area board should have its budget and that the budget should go right to us. The Government have put another authority between the Ministry and the area board, which they call a management authority, which will have a monitoring job and will control the area board in certain particulars. That is the basic criticism I am making, that the Government have left the regional board with a budget of its own, but then it has to chop that up into another budget for the area.
§ Mr. Alison
The right hon. Gentleman is not being entirely consistent. He has admitted in his concept of the area authorities, as he prescribed them in his Green Paper, that there would be certain functions which they could not perform, the super-specialties and so on. His prescription is, therefore, to go straight from there to the central authority. That is the negation of his principle of intimate consumer participation, of links with those most immediately affected. The right hon. Gentleman cannot have it both ways. If he wants strong consumer participation he cannot, as soon as we reach a point at which the most intimately involved unit of administration cannot deal with specialties, take an enormous leap to the highest authority. That is a contradiction of his basic thesis that there should be strong local consumer participation.
With the new area health authorities we are considering a group of 70 or 80 authorities which will replace the existing 300 hospital groups. It follows automatically that there will be a massive accretion of momentum to them in terms of power to plan, consider policy and so on. This new level of management is at least as powerful as anything considered by the right hon. Gentleman for the areas in his own prescription. The difference, admittedly, is that we interpose another link, which will be more responsive because it will be regional, not national.
I remind the House of some of the real powers and responsibilities which will lie with the area: the promotion of health 650 centres and group practice; the attachment of nurses to general practice; working out new schemes for health care of children from birth to adulthood, in liaison with the school and other local services. As between the hospitals and the community, there will be the planning and implementation of early discharge schemes; integrating hospital and home maternity services; improving the arrangements for early discharge from hospitals and the proper follow-up with home nursing care and better rehabilitation; closing the gaps between the general practitioner and the hospitals; providing better access to diagnostic services. All those matters are typical of the provisions which will now rest upon the fewer area authorities, which are at least as powerful as any the right hon. Gentleman proposed.
The right hon. Gentleman severely over-estimates the degree of consumer contact or local responsiveness inherent in his own proposals for area health authorities.
The participation which the right hon. Gentleman envisaged in his own authorities was divisible into three, as I remember it. There was to be local authority representation. But the right hon. Gentleman is kidding himself if he thinks that the local authority representation at the area level which he proposed, corresponding to the new upper tiers of the provincial counties, or the lower tiers of the new metropolitan areas, would be the very acme of the fullest and most perfect expression of responsiveness and consumer sensitivity to the feelings of local people.
The right hon. Gentleman represents a well built-up urban constituency; as one who represents a rural area, I assure him that my parish councillors tell me that not even rural district councils have any idea of what rural people think. How much less would the new local authority representatives from the much bigger upper tiers in the provincial counties and area conurbations be responsive under the arrangements which the right hon. Gentleman proposed.
§ Mr. Crossman
For participation locally, what we proposed was that there should be a district committee for each area immediately appointed. It would have half its representatives elected from the district. This was all extra. What 651 we have instead are the damned consultative committees.
§ Mr. Alison
Here is the right hon. Gentleman enumerating the extra tiers he proposed, precisely what he was criticising us for doing
§ Mr. Crossman rose—
§ Mr. Alison
No; the right hon. Gentleman has had his participation already. He does not like having his scheme slightly examined, but when it is examined it proves to be a great deal less convincing and more fragile than at first met the eye. He complained that there were too many tiers in our system and then he spelt out a whole series of tiers which were in his own proposals. We have succeeded in providing through the community health councils an exact replica, although in a different context, of the fourth tier which the right hon. Gentleman is proposing.
What were the other elements of representation in the right hon. Gentleman's area authorities? He was to have representatives of the professions. That is fair enough, but since when were the professions, because they were represented, in turn particularly representative of, or sensitive to—
§ Mr. Crossman rose—
§ Mr. Alison
Let me at least complete my sentence. Why should representatives of the professions, simply because the right hon. Gentleman decides to slot them in as a representative body, necessarily be all that responsive to the grass roots, to the Mrs. Mopps and Ena Sharples, who are meant to be those with the greatest need to be represented?
§ Mr. Crossman
If the hon. Gentleman wishes to know the answer, it is this. He is talking of having them as though they would be advisers. They were to be elected by the professions locally, by the local G.Ps., for instance. If he wants to know, he had better ask the B.M.A. and the G.Ps. whether it is better from their point of view to be represented by someone chosen from among their own people in the district, in the area, or just consulted?
§ Mr. Alison
The right hon. Gentleman tries to draw that little fig leaf across his 652 nakedness. They would be elected by the professions, but would they represent local populace feelings? I have tried to demonstrate that two-thirds of the right hon. Gentleman's area authorities would not necessarily be representative, and that the final one-third would be directly appointed by the right hon. Gentleman. There was nothing representative about that final one-third of the area representatives, who were to be the right hon. Gentleman's own nominees. They would either not be satraps, in which case the right hon. Gentleman would have lost control of them, in which case they would do him no good anyway, or they would be castrated satraps, in which case it is difficult to see what use they would be.
The right hon. Gentleman's marvellous prescription for an area authority split into three and meant to be extremely sensitive and responsive to the wishes and whims of local people was a complete myth and facade. It conjured up a hopeless compromise of which the nearest analogy was the old system of government in France, which was a mixture of compromise and vested interests resulting in debate, discussion and immobility and all it needed was some powerful authority to come down on top of it and the French got de Gaulle. The right hon. Gentleman's prescription for the reorganisation of the National Health Service was exactly that—an ineffective area authority which, in the end, would have to be taken over, directed and managed by a sort of Coventry de Gaulle.
This is simply not good enough. What we have said that we should have as an alternative is a proper balance between managerial effectiveness, with the proper checks and balances which are inherent in our proposals, and consumer representation. One thing which is clear about our proposals is that, as compared with the right hon. Gentleman's, there is in ours a machinery through which the community health councils for the district are genuinely involved in appraising and criticising. There is no doubt that, in the new system and with the list of powers and rights which I have read out, the councils will not only have access to the plans which the area authorities are proposing, but will have access to the officers and will have power to visit hospitals. They will represent 653 all the district local interests. [HON. MEMBERS: "Participation?"] I understood that the Labour Party was anxious that there should be a sense of participation. What we have provided is a clear scheme of responsibility on one side and power to examine and to send for papers and to criticise on the other with, above all, access to the hospitals and all the machinery which works at the local level.
In these proposals we have the clarification of the difference between "management on the one hand and the community's reaction to management on the other"—that is the key determining phrase—which one has, for example, in our system of Government. The power to stand apart from the Government, as we do in Parliament, but nevertheless having the right to appraise, to criticise and to consider is nothing less than the extension in principle and philosophy of the parliamentary system as we understand it to the new community councils. It is a clear division of responsibility between management and those who have the power—whether they have been appointed by my right hon. Friend, or elected, or appointed by local consumer bodies and voluntary organisations—the power to send for papers and to appraise and criticise and consider. This is a great deal more effective—
§ Mr. Alison
That is a nice question from the right hon. Gentleman who wields one of the biggest levers of journalistic influence in the country. He asks what those who have power without responsibility can do. There is no doubt that in this prescription we have an exact match of what we need for the clarification of managerial principles and for representation, more sensitively and at a much more direct district level than
§ anything envisaged in the right hon. Gentleman's proposals.
§ Tempting though it is to pursue the right hon. Gentleman into the blind alleys and the paths and trails into which he led the House in his excellent debating speech, in the few minutes remaining to me I must try to answer one or two questions. [HON. MEMBERS: "Now that there is not time."] I thought that it was right for me, as a junior Minister, to spend the bulk of the short time available to me trying to answer the philosophical, critical basis of the argument put forward by the first incumbent of the authority of the post of Secretary of State for Social Services.
§ The hon. Lady the Member for Hitchin (Mrs. Shirley Williams) asked about the occupational health service. In the sense of medical inspection of factories and the control and prevention of occupational disease this service is at present a matter for the Department of Employment. For some time there has been consultation with industry and with trade unions about improvements and developments in that service. As for bringing these important specialised services, which are so closely linked with industrial practice, within the scope of the National Health Service, as the previous Government decided in their Green Paper, we concluded that in this National Health Service reorganisation the service would not be expected to include the occupational health service with its essential connections with industry.
§ Mr. Joseph Harper (Pontefract) rose in his place, and claimed to move, That the Question be now put.
§ Question, That the Question be now put, put and agreed to.
§ Question put accordingly, That this House do now adjourn:—
§ The House divided: Ayes 196, Noes 232.657
|Division No. 403.]||AYES||[7.0 p.m.|
|Abse, Leo||Booth, Albert||Crawshaw, Richard|
|Allaun, Frank (Salford, E.)||Bradley, Tom||Cronin, John|
|Allen, Scholefield||Brown, Bob (N'c'tle-upon-Tyne, W.)||Crosland, Rt. Hn. Anthony|
|Archer, Peter (Rowley Regis)||Callaghan, Rt. Hn. James||Crossman, Rt. Hn. Richard|
|Ashton, Joe||Carmichael, Neil||Cunningham, G. (Islington, S. W.)|
|Atkinson, Norman||Carter, Ray (Birmingh'm, Northfield)||Darling, Rt. Hn. George|
|Barnes, Michael||Castle, Rt. Hn. Barbara||Davidson, Arthur|
|Barnett, Joel||Cocks, Michael (Bristol, S.)||Davies, Ifor (Gower)|
|Benn, Rt. Hn. Anthony Wedgwood||Coleman, Donald||Davis, Terry (Bromsgrove)|
|Bennett, James (Glasgow, Bridgeton)||Concannon, J. D.||Deakins, Eric|
|Bidwell, Sydney||Corbet, Mrs. Freda||de Freitas, Rt. Hn. Sir Geoffrey|
|Bishop. E. S.||Cox, Thomas (Wandsworth, C.)||Delargy, H. J.|
|Dell, Rt. Hn. Edmund||Kinnock, Neil||Price, William (Rugby)|
|Doig, Peter||Lambie, David||Rankin, John|
|Dormand, J. D.||Lamond, James||Reed, D. (Sedgefield)|
|Douglas, Dick (Stirlingshire, E.)||Latham, Arthur||Rees, Merlyn (Leeds, S.)|
|Douglas-Mann, Bruce||Leadbitter, Ted||Richard, Ivor|
|Driberg, Tom||Lee, Rt. Hn. Frederick||Roberts, Rt. Hn. Goronwy (Caernarvon)|
|Dunnett, Jack||Leonard, Dick||Roderick, Caerwyn E.(Br'c'n&R'dnor)|
|Edwards, Robert (Bilston)||Lestor, Miss Joan||Rodgers, William (Stockton-on-Tees)|
|Ellis, Tom||Lever, Rt. Hn. Harold||Roper, John|
|Evans, Fred||Lipton, Marcus||Rose, Paul B.|
|Faulds, Andrew||Lomas, Kenneth||Ross, Rt. Hn. William (Kilmarnock)|
|Fisher, Mrs. Doris (B'ham, Ladywood)||Lyon, Alexander W. (York)||Sandelson, Neville|
|Fitch, Alan (Wigan)||Lyons, Edward (Bradford, E.)||Shore, Rt. Hn. Peter (Stepney)|
|Fletcher, Ted (Darlington)||Mabon, Dr. J. Dickson||Short, Mrs. Renée (W'hampton, N. E.)|
|Foot, Michael||McBride, Neil||Silkin, Rt. Hn. John (Deptford)|
|Fraser, John (Norwood)||McCartney, Hugh||Silkin, Hn. S. C. (Dulwich)|
|Freeson, Reginald||Mackie, John||Silverman, Julius|
|Garrett, W. E.||Maclennan, Robert||Skinner, Dennis|
|Gilbert, Dr. John||McMillan, Tom (Glasgow, C.)||Small, William|
|Ginsburg, David||McNamara, J. Kevin||Smith, John (Lanarkshire, N.)|
|Gordon Walker, Rt. Hn. P. C.||Mallalieu, E. L. (Brigg)||Spearing, Nigel|
|Grant, George (Morpeth)||Mallalieu, J. P. W. (Huddersfieid, E.)||Stallard, A. W.|
|Grant, John D. (Islington, E.)||Marks, Kenneth||Stewart, Rt. Hn. Michael (Fulham)|
|Griffiths, Eddie (Brightside)||Marquand, David||Stoddart, David (Swindon)|
|Griffiths, Will (Exchange)||Marsden, F.||Strang, Gavin|
|Hamilton, William (Fite, W.)||Marshall, Dr. Edmund||Summerskill, Hn. Dr. Shirley|
|Hamling, William||Mason, Rt. Hn. Roy||Swain, Thomas|
|Hardy, Peter||Mayhew, Christopher||Taverne, Dick|
|Harper, Joseph||Meacher, Michael||Thomas, Rt. Hn. George (Cardiff, W.)|
|Harrison, Walter (Wakefield)||Mellish, Rt. Hn. Robert||Thomas, Jeffrey (Abertillery)|
|Healey, Rt. Hn. Denis||Mendelson, John||Thomson, Rt. Hn. G. (Dundee, E.)|
|Heffer, Eric S.||Mikardo, Ian||Tinn, James|
|Hooson, Emlyn||Millan, Bruce||Tomney, Frank|
|Horam, John||Miller, Dr. M. S.||Torney, Tom|
|Houghton, Rt. Hn. Douglas||Milne, Edward (Blyth)||Tuck, Raphael|
|Howell, Denis (Small Heath)||Mitchell, R. C. (S'hampton, Itchen)||Urwin, T. W.|
|Huckfield, Leslie||Molloy, William||Walden, Brian (B'm'ham, All Saints)|
|Hughes, Mark (Durham)||Morgan, Elystan (Cardiganshire)||Walker, Harold (Doncaster)|
|Hughes, Roy (Newport)||Morris, Alfred (Wythenshawe)||Wallace, George|
|Hunter, Adam||Morris, Rt. Hn. John (Aberavon)||Watkins, David|
|Irvine, Rt. Hn. Sir Arthur (Edge Hill)||Moyle, Roland||Wellbeloved, James|
|Janner, Greville||Mulley, Rt. Hn. Frederick||Wells, William (Walsall, N.)|
|Jenkins, Hugh (Putney)||Ogden, Eric||Whitehead, Phillip|
|Jenkins, Rt. Hn. Roy (Stechford)||O'Halloran, Michael||Whitlock, William|
|John, Brynmor||Oram, Bert||Willey, Rt. Hn. Frederick|
|Johnson, Carol (Lewisham, s.)||Owen, Dr. David (Plymouth, Sutton)||Williams, Mrs. Shirley (Hitchin)|
|Johnson, James (K'ston-on-Hull, W.)||Padley, Walter||Williams, W. T. (Warrington)|
|Johnson, Walter (Derby, S.)||Paget, R. T.||Wilson, Alexander (Hamilton)|
|Jones, Barry (Flint, E.)||Palmer, Arthur||Wilson, William (Coventry, S.)|
|Jones, Dan (Burnley)||Pannell, Rt. Hn. charles||Woof, Robert|
|Jonts, Rt. Hn. Sir Elwyn (W. Ham, S.)||Parker, John (Dagenham)|
|Jones, Gwynoro (Carmarthen)||Parry, Robert (Liverpool, Exchange)||TELLERS FOR THE AYES:|
|Judd, Frank||Peart, Rt. Hn. Fred||Mr. John Golding and|
|Kaufman, Gerald||Perry, Ernest G.||Mr. Ernest Armstrong.|
|Kerr, Russell||Prescott, John|
|Adley, Robert||Brocklebank-Fowler, Christopher||Douglas-Home, Rt. Hn. Sir Alec|
|Alison, Michael (Barkston Ash)||Bruce-Gardyne, J.||Drayson, G. B.|
|Allason, James (Hemel Hempstead)||Bryan, Paul||du Cann. Rt. Hn. Edward|
|Archer, Jeffrey (Louth)||Buck, Antony||Dykes, Hugh|
|Astor, John||Bullus, Sir Eric||Edwards, Nicholas (Pembroke)|
|Atkins, Humphrey||Carr, Rt. Hn. Robert||Elliot, Capt. Walter (Carshalton)|
|Awdry, Daniel||Channon, Paul||Elliott, R. W. (N'c'tle-upon-Tyne, N.)|
|Baker, Kenneth (St. Marylebone)||Chichester-Clark, R.||Emery, Peter|
|Barber, Rt. Hn. Anthony||Churchill, W. S.||Eyre, Reginald|
|Batsford, Brian||Clarke, Kenneth (Rushcliffe)||Farr, John|
|Beamish, Col. Sir Tufton||Clegg, Walter||Fell, Anthony|
|Bell, Ronald||Cooke, Robert||Fenner, Mrs. Peggy|
|Bennett, Dr. Reginald (Gosport)||Coombs, Derek||Fidler, Michael|
|Benyon, W.||Cooper, A. E.||Fisher, Nigel (Surbiton)|
|Biffen, John||Cordle, John||Fletcher-Cooke, Charles|
|Blaker, Peter||Corfield, Rt. Hn. Frederick||Fookes, Miss Janet|
|Boardman, Tom (Leicester, S. W.)||Cormack, Patrick||Fortescue, Tim|
|Body, Richard||Critchley, Julian||Foster, Sir John|
|Boscawen, Robert||Crouch, David||Fowler, Norman|
|Bossom, Sir Clive||Curran, Charles||Fry, Peter|
|Bowden, Andrew||Davies, Rt. Hn. John (Knutsford)||Gardner, Edward|
|Boyd-Carpenter, Rt. Hn. John||d'Avigdor-Goldsmid, Sir Henry||Gibson-Watt, David|
|Braine, Bernard||Deedes, Rt. Hn. W. F.||Gilmour, Sir John (Fife, E.)|
|Bray, Ronald||Dixon, Piers||Godber, Rt. Hn. J. B.|
|Brinton, Sir Tatton||Dodds-Parker, Douglas||Goodhart, Philip|
|Goodhew, Victor||Loveridge, John||Roberts, Michael (Cardiff, N.)|
|Gorst, John||Luce, R. N.||Roberts, Wyn (Conway)|
|Gower, Raymond||McAdden, Sir Stephen||Rodgers, Sir John (Sevenoaks)|
|Grant, Anthony (Harrow, C.)||McCrindle, R. A.||Rost, Peter|
|Green, Alan||McLaren, Martin||Royle, Anthony|
|Grieve, Percy||Maclean, Sir Fitzroy||Russell, Sir Ronald|
|Griffiths, Eidon (Bury St. Edmunds)||McMaster, Stanley||Scott, Nicholas|
|Grylls, Michael||Macmillan, Maurice (Farnham)||Scott-Hopkins, James|
|Gummer, Selwyn||McNair-Wilson, Michael||Sharples, Richard|
|Gurden, Harold||McNair-Wilson, Patrick (New Forest)||Shaw, Michael (Sc'b'gh & Whitby)|
|Hall, John (Wycombe)||Maddan, Martin||Shelton, William (Clapham)|
|Hannam, John (Exeter)||Madel, David||Simeons, Charles|
|Harrison, Brian (Maldon)||Marples, Rt Hn. Ernest||Sinclair, Sir George|
|Haselhurst, Alan||Marten, Neil||Smith, Dudley (W'wick & L'mington)|
|Hastings, Stephen||Mather, Carol||Soref, Haroid|
|Havers, Michael||Maude, Angus||Speed, Keith|
|Hay, John||Mawby, Ray||Spence, John|
|Hayhoe, Barney||Maxwell-Hyslop, R. J.||Stanbrook, Ivor|
|Hicks, Robert||Meyer, Sir Anthony||Stewart-Smith, D. G. (Belper)|
|Higgins, Terence L.||Miscampbell, Norman||Stodart, Anthony (Edinburgh, W.)|
|Hiley, Joseph||Mitchell, David (Basingstoke)||Stuttaford, Dr. Tom|
|Hill, James (Southampton, Test)||Moate, Roger||Tapsell, Peter|
|Holland, Phillip||Monks, Mrs. Connie||Taylor, Sir Charles (Eastbourne)|
|Holt, Miss Mary||Monro, Hector||Taylor, Edward M.(G'gow, Cathcart)|
|Hordern, Peter||Montgomery, Fergus||Taylor, Frank (Moss Side)|
|Hornby, Richard||Morgan-Giles, Rear-Adm.||Taylor, Robert (Croydon, N. W.)|
|Hornsby-Smith, Rt. Hn. Dame Patricia||Mudd, David||Tebbit, Norman|
|Howe, Hn. Sir Geoffrey (Reigate)||Murton, Oscar||Thatcher, Rt. Hn. Mrs. Margaret|
|Howell, David (Guildford)||Neave, Airey||Thomas, John Stradling (Monmouth)|
|Howell, Ralph (Norfolk, N.)||Normanton, Tom||Thompson, Sir Richard (Croydon, S.)|
|Hunt, John||Nott, John||Tilney, John|
|Irvine, Bryant Godman (Rye)||Onslow, Cranley||Trafford, Dr. Anthony|
|James, David||Oppenheim, Mrs. Sally||Trew, Peter|
|Jenkin, Patrick (Woodford)||Orr, Capt. L. P. S.||Tugendhat, Christopher|
|Johnson Smith, G. (E. Grinstead)||Owen, Idris (Stockport, N.)||van Straubenzee, W. R.|
|Jopling, Michael||Page, John (Harrow, W.)||Vaughan, Dr. Gerard|
|Joseph, Rt. Hn. Sir Keith||Parkinson, Cecil (Enfield, W.)||Waddington, David|
|Kellett-Bowman, Mrs. Elaine||Percival, Ian||Walker-Smith, Rt. Hn. Sir Derek|
|Kershaw, Anthony||Peyton, Rt. Hn. John||Walder, David (Clitheroe)|
|Kilfedder, James||Pink, R. Bonner||Wall, Patrick|
|King, Evelyn (Dorset, S.)||Powell, Rt. Hn. J. Enoch||Ward, Dame Irene|
|King, Tom (Bridgwater)||Price, David (Eastleigh)||Warren, Kenneth|
|Kinsey, J. R.||Pym, Rt. Hn. Francis||Wearherill, Bernard|
|Kirk, Peter||Quennell, Miss J. M.||Wells, John (Maidstone)|
|Knight, Mrs. Jill||Raison, Timothy||Whitelaw, Rt. Hn. William|
|Knox, David||Rawlinson, Rt. Hn. Sir Peter||Wiggin, Jerry|
|Lane, David||Redmond, Robert||Wilkinson, John|
|Langford-Holt, Sir John||Reed, Laurance (Bolton, E.)||Woodhouse, Hn. Christopher|
|Legg-Bourke, Sir Harry||Rees-Davles, W. R.||Wylie, Rt. Hn. N. R.|
|Le Marchant, Spencer||Renton, Rt. Hn. Sir David|
|Lewis, Kenneth (Rutland)||Rhys Williams, Sir Brandon||TELLERS FOR THE NOES:|
|Lloyd, Rt. Hn. Geoffrey (Sut'n C'dfield)||Ridsdale, Julian||Mr. Paul Hawkins and|
|Lloyd, Ian (P'tsm'th, Langstone)||Rippon, Rt. Hn. Geoffrey||Mr. Jasper More.|