§ Mrs. Castle (by Private Notice) asked the Secretary of State for Social Services if he will make a statement on his proposals for the reorganisation of the National Health Service.
§ The Secretary of State for Social Services (Sir Keith Joseph)A White Paper on the reorganisation of the National Health Service in England has been published this afternoon, and copies are available in the Vote Office. It foreshadows legislation to unify the administration of the National Health Service. New authorities with comprehensive health functions will be set up at regional and area level. In both forward planning and day-to-day administration they will work closely with the local authorities responsible for the personal social services and other services that are related to health. The changes will come into effect at the same time as the reorganisation of local government.
The entire purpose is to improve the service to all the members of the public who need health care, whether at home or in hospital, and whether they are acutely ill, or frail and elderly, or menttally ill, or mentally handicapped, or physically disabled.
To achieve this purpose the new structure will create for the first time a single health authority in each area, the area health authority, which will be responsible for both the community health services, including those provided by the family practitioners, and the hospitals.
Each area health authority will be required, with the help of professional advisory committees and working to national standards and priorities, to inform itself of all the health needs of its area; to plan for and provide the services to meet them in conjunction with its matching local authority; and continuously to monitor, adjust and improve services in order to raise standards and meet needs better.
To help it meet the needs of the public a number of new features will be intro- 350 duced. Thus health plans will be based on the needs of particular groups such as mothers and children, the elderly and the physically and mentally handicapped and ill. There will be teams focussing all the relevant skills and services for each such group of the public. There will also be strong community health councils, mainly composed of councillors and representatives of voluntary bodies to ensure that the area health authorities respond to the needs of the public.
The aim is, while protecting the clinical freedom of doctors and dentists and the needs of teaching and research, to ensure that the disparities such as have led in the past to the relative neglect of some types of illness or disability and to the imbalance between domiciliary and hospital care shall not continue in the future; and that drive and rising resources are rationally spread across all the country's health needs.
§ Mrs. CastleWhile thanking the right hon. Gentleman for that reply and regretting that he did not do the House the courtesy of volunteering this information, may I ask whether he is aware that a preliminary and inevitably hasty reading of the document reveals some disturbing and disappointing features?
In particular there is the right hon. Gentleman's insistence on introducing a two-tier structure of organisation which puts the regional health authorities, totally appointed by him, between him and the area health authorities generally. Does he appreciate that we believe that the area health authorities, being the closer to the community, should be the principal units of administration and not controlled and supervised by the regional health authorities in this way?
Secondly, is he aware that we regret his totally inadequate injection of democracy into the operation of the Health Service and in particular the fact that the regional bodies are to be appointed by him and the area health authorities predominantly appointed by the regional health authorities? Does he realise that in our view a majority of seats on those authorities ought to be reserved for the elected representatives of the people through their local authorities and for the elected representatives of those who work in the Health Service?
351 Thirdly, is he aware that we regret the failure in the document to take any new steps towards the introduction of an occupational health service, the complacency of the right hon. Gentleman towards the private sector in the National Health Service and the lack of proposals for dealing with the scandal of queue jumping by those who can afford to pay for beds? Finally, is he aware of the unsatisfactory nature of his proposals for a Health Service Commissioner? Is he aware that we have been pressing for a debate on his Health Service Commissioner proposals ever since he made his initial statement in February?
Will he now tell the House what opportunity he intends to give to us to examine all these proposals in detail before he drafts his legislation? Will he give the House an assurance that we will be able to have a full debate before any legislative proposals are finalised?
§ Sir K. JosephI agree with the right hon. Lady that the area health authority is the principal unit of the new structure and should be so. But the Government must have a link to speed decision and decide on the distribution of the taxpayers' money, and that must either be a regional health authority, on which the Government have decided, or regional branches of the Department. As for the membership of the area health authority, it will inevitably have the task of deciding how to spend the taxpayers' money as between many competing needs.
We judge that it is right therefore that area health authority members should not be primarily representative in any way but should be chosen for their capacity to judge, on the advice of their professional advisers, between the competing health needs of the services. On the other hand, it is important to provide a voice for the local public, and that more than ever before is provided by the community health councils of which I have spoken. The occupational health service is very important, but we cannot do everything at once and such services are primarily the responsibility of my right hon. Friend the Secretary of State for Employment. The House will know that I am due to make statements or to give answers to questions on both the private sector and waiting lists later this year. As for a debate, this is for the usual channels.
§ Mr. AwdryDoes my right hon. Friend know that there is great local anxiety about the future of the Bath clinical area and does he agree that there will have to be some special financial arrangements to preserve the integrity of that area? Will he be making such an announcement fairly soon?
§ Sir K. JosephI know that there has been such worry. I had hoped that it had been quelled to some extent by the ample consultations that have occurred. The area boundaries will not be barriers to patients as between them and their doctors in any way whatever.
§ Mr. PardoeWhile welcoming the creation of the unitary health authorities, may I ask the right hon. Gentleman whether he is aware that his statement and the document have two grave omissions? First what rôle and influence will the GPs play in these new area health authorities? The second point is to do with the absence of democracy. Why is this not being done as part and parcel of the reform of local government instead of as an extension of "ad hocracy" and ad hoc boards? When he says that it is necessary for the Government to have power to choose people to judge, will he say when in his experience did democracy cease to be the best way of choosing people to exercise their judgment?
§ Sir K. JosephGeneral practitioners will retain completely their clinical freedom and contractual relationship with the Department. They will play their part, through professional advisory committees, in the policy-making of the area health authorities.
As for the question of democracy, the area health authorities spend vast sums of public money. They do not carry out precisely the same jobs as local authorities. They will contain four local authority members to speak for the social services department, the finance department, the education department or any other department which the local authority wishes to be represented on the area health authorities. But I repeat that the primary purpose of this reform is the needs of the patient, the needs of the public, and in the world in which we live there are so many competing needs for the taxpayers' money that if we filled the area health authority with people 353 who have allegiance to another body they will not be as free as we wish to make decisions between the competing needs of the public. That is why we have devised the community health councils, which will be mainly composed of elected members and of representatives of voluntary bodies who will bring a totally fresh and new voice to ensure that the public's wishes and needs are continually represented to the decision-makers.
§ Dr. StuttafordWill my right hon. Friend tell me how he has altered his plans since the original consultative document came out in view of the extraordinary degree of opposition to them from members of the medical profession who are ultimately responsible for the health of the nation? Will he explain the difference between the public and the patients? Surely they are the same, and they are all voters.
§ Sir K. JosephI do not think that there was that degree of opposition to the consultative document from the medical profession. But, in the light of consultations and of the views expressed in the debate in the House, we have increased the emphasis on professional advisory bodies and we have increased the strength of the community health council.
§ Mr. PavittWill not the regional health boards, by having complete charge of the purse-strings and having to pass the budget and hand out funds, entirely pre-empt activity at area level? Will the right hon. Gentleman do something in the legislation to alter the transfer of power which rests so much in the medical profession? The right hon. Gentleman has left teaching hospitals and university places absolutely intact at a time when democracy needs to be spread further. Is he satisfied with the expenditure of £200,000 of taxpayers' money which led to Appendix 3 of the management study? Does he think that we have value for money in that study?
§ Sir K. JosephIf we do not have regional health authorities, we shall have to have regional departments of the Ministry. We have judged that we shall get quicker and more local decision-making by having regional health authorities. The teaching hospitals have a very great deal to contribute to the future of the health service, and we have 354 tried to achieve a balance between keeping their standards of excellence and integrating them with the regional authorities, which is our proposal in the White Paper. I am sure that the management study represented a very good use of public money.
§ Dame Irene WardIn this great new scheme, which many people will welcome wholeheartedly, is the position of the nurses, physiotherapists and people supplementary to medicine fully catered for so that they may take a full part in dealing with policy making? In the past some of these bodies have not had as much opportunity to put their point of view as is necessary, in my opinion, for the health of the nation and the proper running of the service.
§ Sir K. JosephThe answer to my hon. Friend is "Yes". Nurses will be on area health authorities and regional health authorities. There will be professional advisory bodies for the skills of which my hon. Friend speaks. I recently had a whole day conference with the physiotherapists, occupational therapists and remedical gymnasts, because I regard their potential contribution as very important.
§ Dr. David OwenWill the right hon. Gentleman give an assurance that he will be open-minded about Amendments to his legislation and that he has not made any commitment to the professions from which he will not feel able to move? When he is considering the question of the professionals, will he consider the newer professionals, such as technicians and scientists, who contribute greatly to the National Health Service? Will he frame his legislation in such a way that it will be possible in future to unify the Health Service under a single administraation, namely, that of the local authority?
§ Sir K. JosephI hope that the Government will remain open-minded, but we have had considerable consultations on the basis of the consultative document and have, I think, taken all conceivable points of view into account in arriving at our present decisions and proposals. Nevertheless, there will be another range of consultations as a result of the management study. The scientists are part of the health team, but I cannot agree with the hon. Gentleman that it 355 will be practicable in the foreseeable future to unify the service under the local authorities. We must rule that out of account altogether for the foreseeable future.
§ Mr. CockeramWill the Secretary of State ensure that in the reorganised National Health Service consumers' complaints are made, not to the body charged with administering the service and whose judgment can rarely be detached, but to either an independent body or an independent person who can make a more impartial judgment?
§ Sir K. JosephThere will be three channels for complaints: first, the Davis Committee, which will advise us on a better complaints procedure; secondly, the community health council, which will be the voice of the consumer; and, thirdly, the Health Service ombudsman. Therefore, I think that the consumer will have ample scope for complaint.
Mr. J. T. PriceEvery hon. Member will wish to see improvements made in the National Health Service, both administratively and organisationally, but is the Secretary of State aware that one part of his statement has shocked Members on this side of the House? Does he realise that his proposal further to diminish the democratic nature of the management of this vast and costly service will not commend itself to any of my hon. Friends or to civic administrators who know anything about the service? I imagine that this will be the crux of future debates in the House. It is being said, and it has been said for years, that much damage has been done to the service as a result of the difficult attitude taken by some of the professionals in the service on whom we have to depend for co-operation. If the House of Commons were elected on the principle adumbrated by the right hon. Gentleman in his new structure for the National Health Service, namely, a man's functional capacity, this House would be an even queerer place than it is.
§ Sir K. JosephThe House will be wise to take into account the fact that the service, as it has grown up, has tended to neglect some of the most vulnerable groups in the community—the frail, the elderly, those who suffer from arthritis 356 and deafness, the mentally ill and mentally handicapped, and the physically disabled. This has happened with all the massive good will which has been at work. The object of the new service is to try to guard against such imbalances. For that purpose, we separate the decision-makers from those who speak for the public. If we confuse the two functions, we return to the situation in which many people put on hospital authorities as elected members have ceased primarily to represent the public and have come to defend management.
§ Mr. SpeakerOrder. This is becoming a debate. Mr. Baker.