NATIONAL HEALTH SERVICE

HC Deb 11 December 1973 vol 866 cc211-79

Mr. Speaker

Before I call the right hon. Member for Deptford (Mr. John Silkin) to move the motion may I inform the House that I have not selected the amendment standing in the name of the hon. Member for Ilford, North (Mr. Iremonger).

3.54 p.m.

Mr. John Silkin (Deptford)

I beg to move, That this House expresses its grave concern at the way in which the reorganisation of the National Health Service is currently taking place; regrets that the composition of the authorities is primarily appointed rather than elected; and calls upon Her Majesty's Government to postpone the coming into operation of the new service pending a full-scale inquiry. Before proceeding with the motion I have to say one thing. In reply to a question from my hon. Friend the Member for Halifax (Dr. Summerskill) last Thursday, the Leader of the House said that he thought that a statement on the ambulance service would be in order in today's debate. It may be, but it seems to us to have not much relevance to the reorganisation of the health service. We do not propose to deal with it and we hope that the Secretary of State will deal with the question on another occasion.

In March of this year during a two-day period the House debated the Second Reading of the National Health Service Reorganisation Bill. It was not apparently as well known to the Press that this was the subject of the debate as some of us would have liked. It appeared to the Press that it was a debate on family planning.

Unfortunately, in making this error it missed what was a vital and legitimate point of difference between Government and Opposition and one which now concerns us deeply. I refer to the manner and constitution of a reorganised health service. No one who knew anything about it disputed that the health service should be reorganised. The question was whether there should be the managerial concept which the Government had in mind or whether instead we should move towards a democratic system.

The Government had already stated their mind in the White Paper issued the previous year. I remind the House of their reasons for preferring the managerial to the democratic system. They are to be found in paragraph 96 of the White Paper. I will not burden the House by reading the whole paragraph but will relate what I believe to be the relevant sentences. The White Paper said: A diversity and a proper balance of relevant ability and experience are also called for. We do not disagree. It went on: These needs can best be met if, in the main, members are chosen for their personal qualities after appropriate consultations, not elected as representatives reflecting the views of particular interests. This is what the Government stated as their main principle. The months have passed since March and we are now able to see how far these principles have been put into effect. It is right that we should examine first of all the appointments made by the Secretary of State. If we look at the regional health authorities—and this I am sure would distress my hon. Friend the Member for Newcastle-upon-Tyne, West (Mr. Robert C. Brown) who has spoken so eloquently about women's rights—we find that only one member out of five is a woman. I will not labour that point too much. The Secretary of State may hear something from my hon. Friend the Member for Halifax should she catch your eye a little later, Mr. Speaker.

It is an extraordinary decision because the assumption must be that men have the relevant ability and experience in a ratio of 5: 1 against women. I would have thought that was quite untrue. In the administration of a health service women tend to know much more than men because they are concerned with the producing and rearing of children. It is the family aspect that is so vital in the health service.

If we look at the membership of regional health authorities generally we find that only 15 out of all the regional health authority members are trade unionists or manual workers. That is an average of one per authority. It is an extraordinary idea of where ability and experience are to be found in our community. I do not say that they should be in the majority, but 15! It seems to be a very small proportion. At least we can spare ourselves the terrible thought of what it would be like to be a woman and a trade unionist. Such a person's chances would be something like one in ninety.

Every member of the regional health authorities has been chosen on the basis of what went before. A total of 60 per cent. of the members of the regional health authorities are people who were employed administering the old hospital services. Of the area health authority chairmen, 59 out of 90 are business or professional people. I do not object to such people being chairmen of authorities. It seems they have as much right as anyone else. But that is a disproportionate amount.

I said that I should like to deal with the question of previous hospital service. Every chairman of the regional health authorities now appointed has been a member of a regional hospital board, hospital management committee or teaching hospital. Of the members of the regional health authorities, six out of ten have also had that experience. Of the chairmen of the area health authorities, also appointed by the Secretary of State, although after consultation with the chairmen of the regional health authorities, 82 out of 90 have previous experience in one of those three hospital sectors.

Hospital experience is a very good thing, because so much of the National Health Service is concerned with hospitals—but surely not in that proportion. If the Secretary of State has forgotten his own White Paper, perhaps I might remind him of it: In practice, however, the fragmented administration we now have throws barriers in the way of efforts to organise a proper balance of services—hospital and community—throughout the country. It goes on: The administrative unification of these services will make a firmer reality of the concept of a single service. But should all the chairmen of regional health authorities and 82 out of 90 area chairmen have this sort of hospital experience? Where is the community interest, the proper balance of which the White Paper spoke?

There are currently 170 local authorities dealing with community health services. There are the people who are experienced in community health services, who could give that proper balance. It is right to take those with hospital experience, but equally right to take those with community experience.

The area authorities were designed to cope on an administrative level with the social services, because, rightly, it was understood that health services and social services came together. It is often very difficult to define where one begins and the other ends. But what has happened is the most extraordinary development that has ever been seen in the organisation of the National Health Service.

In London, the areas which have been chosen cut right across the borough boundaries, so that, in social services, what started as a reasonable, and indeed a practicable, way of running the health service has become a nonsense. Thus, of the areas in London, six have two boroughs, two have three boroughs and one has as many as four—Newham, the City of London, Hackney and Tower Hamlets. One could imagine the enormous conflict that is bound to arise where there are four borough social service departments and only one area.

Sir Elwyn Jones (West Ham, South)

Since my right hon. Friend has mentioned Newham, is he aware that Newham has its own social services department, is a local education authority and a housing authority and has hospitals? Is this not a classic case in which its existence and continuance as a single area would seem to be justified?

Mr. Silkin

My right hon. and learned Friend speaks, as always, with sparkling clarity. It stands to reason—but clearly, not to the Secretary of State. Incidentally, the prize for absurdity goes not to that creation but to the joining of Southwark, Lambeth and Lewisham. I have a slight interest in Lewisham, since my constituency lies in the borough. Only a third of the members of that area health authority live anywhere near the new area. That is by the way: the main point is that these three boroughs, which are joined into one area, are cut into four districts, so that the individual social service departments are themselves divided. This is because the whole of this basis of reorganisation, whatever the White Paper says, has been hospital-oriented and not social service-oriented.

Mr. Nigel Spearing (Acton)

My right hon. Friend mentioned a difficult case in South-East London. Does he realise that, in North-West London, not only does one see the characteristics that he has described but part of my constituency and that of my hon. Friend the Member for Ealing, North (Mr. Molloy) will be administered by another health authority altogether? When I wrote to the Secretary of State asking him to justify this, he was apparently unable to give a reason. When he takes power away from the area health authorities, should he not say why he is doing so?

Mr. Silkin

The only consolation that I can offer my hon. Friend is that perhaps his borough and mine might share the joint prize for absurdity.

What I have spoken about in London occurs of course outside London, for example, in the non-metropolitan counties. I should like to give one illustration—I could give many more. In Kent, the social services are administered at county level but are, rightly, split into 15 social services divisions. I have never thought that this is as good a way as letting the districts run the social services themselves, but at least an attempt has been made to bring the social services to the community. But those divisions are divided among six health districts. The inevitable result must be total administrative chaos.

Mr. David Crouch (Canterbury)

No.

Mr. Silkin

The hon. Gentleman will just have to wait and see.

Our motion asks that the reorganisation be postponed pending an inquiry. We regard this reorganisation, before it has begun, as a total failure. But to look at it from the Government's own point of view, the arguments in favour of postponement seem overwhelming. The reorganisation is supposed to be complete by 1st April 1974. Everybody knows that, in whatever section of the health service one cares to look—whether in the hospitals, to which Lord Reigate drew attention in another place the other day, or anywhere else—the time scale has been totally disrupted.

The Secretary of State had to define the very districts in the area health authorities. I understood that one of the principles that the managerial system laid down was delegation downwards. It is a new kind of concept, at any rate in relation to McKinsey, that we should now have delegation upwards, from the health authority to the Secretary of State. That is an illustration of the total lack of time and the muddled way in which this has been done.

Worse still, not one medical officer has yet been chosen for any of the 90 areas. How they are to be in operation by 1st April, I do not know. In each of 17 areas there is no administrator and no financial officer. These, too, have to be picked. Perhaps worst of all, because of the possible implications, in the health districts the post of district community physician has not yet even been advertised. The district community physician, as the House is well aware, has to be skilled in the control of infectious diseases, communicable diseases and food poisoning. He has to use local authority personnel. Under reorganisation, local authorities have a voice in his selection. Circular 34/73 states in paragraph 30 that local authorities, the police, the area health authorities and—it will relieve the mind of the House to know—the Department of Health and Social Security itself, must know the name, address and telephone number of the district community physician by 31st March 1974.

But the Secretary of State cannot deny that, in many cases throughout the country, out of 500 posts created, there will be those which have not yet been filled. Therefore, I ask the Secretary of State what happens if there is an outbreak of food poisoning. I know the answer is that we shall muddle through and that the matter will be dealt with, but that does not seem to suggest administrative efficiency.

I come to my final point regarding postponement of the reorganisation of the health service. Ten years ago, there was a Minister of Housing and Local Government who reorganised the London area. That Minister realised, because he was then young, virile and able, that a long time was needed from the moment all the chief officers were appointed to the time that the new service was running—the breaking-in period. Therefore, all the chief officers had been appointed by June or July 1963. As it was, when reorganisation took effect in April 1964 the then Minister of Housing and Local Government might have agreed with me that it was touch and go but that the changeover had just about worked.

But in the reorganisation of the health service, the vital 20 per cent. of officers have not yet been chosen. That is why we should postpone the operative date of the reorganisation. I suggest that the Secretary of State has a word with the former Minister of Housing and Local Government. Together they might come to a consensus on the matter.

Mr. William Molly (Ealing, North)

This is an extraordinarily important point. I remember that during the period to which my right hon. Friend referred, one of the arguments which was advanced—and which seemed at the time to be particularly cogent—was that, with the growth of London and of the social services, the new forms of administration which the Minister was then proposing would fit in neatly with all the things which might have to happen. We are experiencing the same attitude again with the National Health Service reorganisation. Either the right hon. Gentleman was wrong then or he is wrong now, or, possibly, he is wrong in both cases. He does not seem to have been right at all.

Mr. Silkin

I think the right hon. Gentleman was more right then than he is now.

If this is the situation, is it not right, out of common sense and from the Government's point of view—forgetting the difference in philosophy which we have with them—to postpone the coming into force of the reorganised health service? If that is right—and we believe it to be so—perhaps at the same time an independent inquiry should be set up to examine the whole structure and basis of the reorganisation of the health service. It is manifestly and totally wrong if, in order to fill the posts of chairmen of the regional and area health authorities, the Government have to go to the old hospital service. What is the point of trying to argue for integration if the Government are merely going back to the hospital services? There is no point in it.

I would not wish the Secretary of State to say that I was being destructive and not constructive. I have, therefore, three short suggestions on steps towards a transition to democratic control, which is manifestly the right way to reorganise the service. The first is that a substantial majority of members of the new authorities should be from local government and the trade unions, not from the old hospital service, and not from business and the professions, which is the present situation. Secondly, community health councils should be wholly composed of local authority members so that they could have executive control over the district management teams, which could then act as their advisers. Thirdly, I suggest that the Secretary of State has consultations with his right hon. Friend the Minister for Local Government and Development, following which there should be delegated to the districts—or the districts should be given—advisory powers to deal with social services in their areas. In this way, we would be preparing for what would be a truly integrated National Health Service.

I do not for one moment believe that the system as envisaged and as peopled at the moment will last. Whether the Secretary of State likes it or not, he has introduced an interim measure. It will be up to a Labour Government when the time comes to give the people of this country a true National Health Service.

4.16 p.m.

The Secretary of State for Social Services (Sir Keith Joseph)

In asking the House to reject the motion, I shall deal with the points made by the right hon. Member for Deptford (Mr. John Silkin) in what I regard as an unrealistic speech. It will be common ground that the reorganisation of the National Health Service must be one of the largest management enterprises ever undertaken, I would have thought, in the free world. In England and Wales alone the service employs more than 800,000 people, with a budget of about £3 billion a year.

The House will remember that reorganisation has been under discussion for a decade. A long series of papers have been produced, first under the Labour Government and then under this Government. Those who work in the service are entitled to have decisions made and carried through. There has legitimately been uncertainty for long enough. The vast majority of staff—except a very small proportion in the upper echelons of management—are likely, after 1st April next year, to be doing much the same work, in the same place, as they are doing now. Hon. Members on both sides of the House would like to have a faster growth in the money available to the health service but there is, and has been, a regular increase in the resources available and in the size and quality of the service. This has been such that the staff can count on a real improvement in their prospects of providing a good service to the public.

It is precisely to provide a better service to the public that the reorganisation has been mooted by both parties in turn. The better structure which we believe will emerge from this reorganisation, despite the anxieties of the right hon. Gentleman, will give a much closer link with the parallel reorganised local government service. It will also give a much better scope for identifying the needs of the patients, and detecting and putting right defects in the service. Therefore, there will be much greater opportunities for staff to provide a more effective service to the public

One of the essentials of reorganisation recognised by both Governments is that there should be a transfer of the local authority health component to the National Health Service. That has been agreed, and has been an ingredient of the proposals of both the Conservative Party and the Labour Party. Local government is being reorganised, and the reorganisation comes into force on 1st April.

The House must accept that the reorganisation of local government and the reorganisation of the National Health Service must coincide in time, since one large component of the present local authority services is going, by common consent, to be transferred to the National Health Service. If the times of reorganisation were not to coincide, there would be nowhere for that reorganised local authority health component, staff and functions to go.

It would be a valid criticism, if it were made, that, since the reorganisation of the two services coincides, the dates of legislation for the two services should have coincided also. In a perfect world, the Government would have wished to introduce the local authority reorganisation legislation and the NHS reorganisation legislation in the same Session. But the world is not perfect. With the best will in the world, it was not possible, because of the legislative timetable, to introduce both Bills simultaneously, and, therefore, we are faced with a position in which the dates of reorganisation of the two services must coincide but we have had less time to accomplish the National Health Service reorganisation than ideally we would have liked.

Dr. Shirley Summerskill (Halifax)

The reorganisation of the Scottish Health Service starts in April next year, but the reorganised Scottish local government structure does not start until May 1975.

Sir K. Joseph

I am not answerable for Scotland, and I very much envy the fact that the Scots got their legislation in substantially earlier. I am acknowledging to the House that I regret that we did not introduce our legislation earlier. It is no good the right hon. Member for Deptford wagging his head sagely from side to side. Even he would not have been able to find, under his very vacuous proposals, any authority to take over the functions and the staff of the local government health services which cease to exist, under legislation which he scarcely mentioned, on 1st April next.

It would be no kindness, even if it were practicable, to defer the reorganisation of the NHS. It would only prolong the uncertainties from which health service staff have been suffering for too long, and we are faced inevitably with the local government reorganisation, which is crucially linked with NHS reorganisation, on 1st April.

The right hon. Gentleman has totally failed to tell us where, under his proposals for postponement, the local authority health functions and staff would go. It would be completely impracticable, even if the Government wished to do so, to postpone the reorganisation. In the light of this fact, and of the compressed timetable—I accept that point—that we have had since Royal Assent, it is sensible to concentrate, as we are doing, on the immediate priorities. That is our approach.

We have established the new authorities. Our job now is to see that they are staffed, to ensure a smooth transfer of staff, to promote the interests of the staff on transfer, and, above all, to maintain the continuity of service to the patients.

Mr. Cyril Smith (Rochdale)

Would it not be possible to obtain a smoother transfer of staff if the staff were to be consulted about that transfer? Has the right hon. Gentleman not considered the possibility of immediately setting up joint consultative machinery with the trade unions involved in the NHS in an attempt more effectively to arrange a smoother transfer of staff?

Sir K. Joseph

I shall be dealing at some length later in my speech with consultation.

The main difference between the Opposition and the Government is, and, I think, has been throughout the debates on the Act, with regard to the composition of the authorities. The Government's view is that the NHS is largely paid for by the taxpayers and, therefore, should be conducted by authorities responsible to a Minister who is himself accountable to this House. Those authorities look to the Minister for finance, and, therefore, should look to him for guidance on strategy and policy. The right hon. Gentleman's proposals would separate the control of finance from policy. They would presumably leave a Minister responsible to this House for the policy of the NHS and for its strategy, but would give to bodies quite separate from the Minister and out of his control responsibility for running the service.

Mr. Spearing

Like the education service.

Sir K. Joseph

These bodies would not, as in the case of the education authorities, be providing any money towards the running of the NHS. They would, therefore, look to the Minister for money but not necessarily meet his priorities for policy and strategy.

Mr. Laurie Pavitt (Willesden, West)

Within the present structure the local health authorities as of right have £250 million. What is happening to that?

Sir K. Joseph

The hon. Gentleman is a student of this subject. He knows that on reorganisation the rates cease to bear that cost and it is transferred to the taxpayers, so that, as from 1st April, that part of the service now being paid for by the ratepayers goes on the taxpayers' shoulders. I am being logical in this. The Opposition are being illogical and inconsistent.

Under the cry of democracy, the right hon. Gentleman proposes a number of steps whose significance I do not think he appreciates. He suggests that a body of elected members should be responsible for running the service. That body would find not a penny towards running it. Yet it would be expected, I suppose, to obey the policy of the Government of the day. There would be no link between them, however. Finance and policy would be totally separated.

The right hon. Gentleman has further revealed his hand today. I am sure that the voluntary bodies will be interested that he proposes that the community health councils should be composed entirely of elected members. The Government propose that the voluntary bodies should have at least one-third of the seats on these new watchdogs for the public, but they would be excluded by the Opposition if they were in charge of the NHS.

The Opposition flinched, during the prolonged and, I thought, very valuable Committee stage debates when the Act was going through the House, from the logic of their own thinking. They flinched from proposing that the service should be put under local government. They yearn to put it under local government, but they realistically accepted that it is not practicable, at any rate now.

The Opposition also flinched from proposing that the health authorities should be wholly elected. They never proposed that in Committee nor voted in favour of it. What they argued about in Committee, perfectly legitimately, was the rather smaller issue whether there should be four, five or six local authority members on an area health authority of 15 or 16 members.

Mr. John Silkin

I know that the right hon. Gentleman will wish to be fair. The first way in which he can be fair is to recognise that, after occupying the position of Government Chief Whip for three years, I am strictly a non-flincher. Secondly, it is a pity that he did not read—and I quite understand that he was not able to attend all the sittings of the Committee—the Committee reports carefully. Had he done so, he would have seen clearly set out that we accepted that we had a Conservative Government bent on a particular system of reorganisation. We realised that, since we were not in Government, we could not immediately put the National Health Service under local government control, and therefore suggested a transition or compromise which would be mid-way between his managerial, monarchical system and a real democratic system. We said it over and over again. The right hon. Gentleman should read the Committee proceedings.

Sir K. Joseph

I scrupulously read the reports of those sittings which I did not attend, and I certainly did not get that impression from the views of the Opposition. Therefore, the difference between us in the debates has been the number of members on area health authorities. I think that the House will accept that whether there were five or six local authority members on the area health authorities instead of the four that we now have would not make a hap'orth of difference to the transitional problems that we face in bringing about the reorganisation.

I turn to the membership of the authorities. I am responsible, as the right hon. Gentleman properly said, for the choice of the chairmen of the regions, the chairmen of the areas and the members of the regions. I chose—I am sure the right hon. Gentleman will give me credit for this—to the very best of my ability, taking into account the need for some experience of management. There are trade unionists who have been appointed because they have had experience of management. I chose after consulting with very large numbers of bodies—for instance, the universities, local authorities, the medical profession and the nursing profession—each part of the merging service. I had to take into account in appointing members of the regions the geographic factors. I consulted the TUC and the healing professions, such as the dentists and the pharmacists.

The right hon. Gentleman charged me with appointing as area health authority chairmen—a crucial post—a vast predominance of people with hospital experience. That is quite right. What the right hon. Gentleman had failed to perceive, however, was that a very large number of those who are now area health authority chairmen who have had hospital experience also have had local authority and executive council experience. There are 90 area health authority chairmen. Of those, 29 have had local authority experience. Sixteen of them have had executive council experience. Some of those are the same individuals as have had hospital experience. In other words, many chairmen have more than one kind of experience behind them.

The hon. Member for Rochdale (Mr. Cyril Smith) referred to consultation. Consultation has been our watchword from the outset. But the scale of this operation has been so vast and the range of subjects so detailed that the draft documents put out for consultation have represented a very heavy burden to those called upon to study them.

I pay tribute to the rôle of the trade unions and the staff associations. In all the countless discussions and consultations, these bodies have been nothing but helpful and constructive. Their practical commonsense approach to the problems involved has made their contribution to this massive exercise invaluable. Of course there have been disagreements. Disagreements are inevitable with such a large-scale and radical change of structure. But, while tenaciously protecting the interests of their members, and even when our differences seemed insoluble, the staff associations and the trade unions have never ceased to be allies in working towards a successful conclusion to our task. However, despite months of consultation and despite the constructive attitude of all concerned and the very hard work put into the matter, there are, I fear, still a number of complaints by staff of lack of knowledge. This is largely on matters—mostly conditions of service—which are still under consultation with the staff side at national level.

Proposals on compensation, early retirement and salary protection were first published as consultative documents, and the staff had to await the final arrangements. The early retirement scheme, in its final form, as published last month, and the aim is to publish compensation and salary protection arrangements in a few weeks' time. The early retirement terms contain specific improvements introduced as a result of consultation with the staff side. There have been detailed and fruitful discussions with the staff side on protection. Salaries are still being negotiated for a number of posts, particularly for second-line posts.

I must take this opportunity of saying that I am apologetic about the failure to be able to pay temporary allowances for a number of staff who put in extra work. The Governments' hopes and intentions were blocked by a Pay Board ruling which, in fairness, the Government had to accept for their staff, just as they required other interests to accept similar rules. I think that it is common ground with the staff side that the Government negotiated the temporary allowances with the best intentions and had every intention of honouring them, but they were blocked by the Pay Board ruling.

Mr. Cyril Smith

Did not the consultative document about early retirement to which the right hon. Gentleman has referred make special reference to the situation of chief administrative officers of health authorities in local government work, and do not the regulations as now issued specifically exclude them from the early retirement rules? Secondly, is the Minister aware of the fact that 27 trade unions were represented at a meeting in Manchester a week ago last Friday, a meeting which was attended by the hon. Member for Oldham, West (Mr. Meacher) and myself, and complained bitterly of the utter lack of consultation on the reorganisation of the health service that had occurred in the county?

Sir K. Joseph

I was not aware of the first point. I shall read what the hon. Gentleman has said and write to him. On the second point, I am sure that there is legitimate disappointment with the outcome of the consultation because in some cases the final documents have not yet been issued. But no one can charge us with not having had an enormous amount of consultation with the staff side and the trade unions.

In view of the time available I shall not go into great detail about the top management position. Out of 2,500–3,000 top management posts, some 600 are already filled, or interviews are now in progress or dates for interviews fixed. Short-listing is in progress or completed, and the posts are being advertised or are very shortly to be advertised for a further 1,200. Within a matter of weeks, very nearly all the top three-quarters of the main management echelons will have been completed.

My hon. Friend the Member for Ilford, North (Mr. Iremonger) has tabled an amendment on the Order Paper, which is not being called, about hospital secretaries. I appreciate that they, like other administrators, are anxious to have details as soon as possible of the range of new administrative posts. Negotiations for the second in line administrative salaries began in September. I understand that the Whitley Council expects to hold another meeting to discuss the management side's offer later this month.

I turn to districting, where about 90 per cent. of the 205 districts presented no great problems. The local joint liaison committees were able to reach agreement on their proposals, and I promulgated an agreed solution. But there were a number of cases, of which about a half a dozen were extremely difficult, where I would defy even Solomon to arrive at a solution agreeable to all interests. There was really a choice of unsatisfactory solutions. After considerable agonising and much listening to and reading of views, I had to come to a solution. I do not pretend that in the parts of London where our predecessors scattered hospitals in a manner unrelated to the present population the solutions are entirely satisfactory, but I maintain that they are marginally less unsatisfactory than the alternative would have been.

The hon. Member for Acton (Mr. Spearing) is doubtless about to ask why I have not been able to explain my decision in relation to his area. My hon. Friend the Under-Secretary met a deputation from the hon. Gentleman's area. He will be writing about the reasons for the decision, which he explained after the hon. Gentleman had, for perfectly legitimate reasons, left the meeting. My hon. Friend is meeting the area authority tomorrow.

Mr. Molloy

I remained for the entire meeting. We had some sympathy for the Under-Secretary, who informed us at the beginning of the meeting that the time taken up by the members of the deputation was being wasted, because his right hon. Friend had made the decision, from which the Under-Secretary could in no way depart.

Sir K. Joseph

These decisions have been made in what my colleagues and I regard as the public interest. They are made on a balance of the merits of the arguments. It will be open to the area health authorities, after some experience of the service—they will have to run the service for some time—to make proposals for the changing of districts. That is why these decisions can be altered later if they are shown to be less good than are the alternatives.

Mr. Spearing

No. It cannot happen in our case.

Sir K. Joseph

I must draw my speech to a close, but I shall ask my hon. Friend to take up the point if he catches your eye, Mr. Deputy Speaker.

I come now to my two final points. I have paid tribute to the trade unions and the staff association, and I should now like to pay tribute to my own staff. It has been an enormous job to translate the strategic decisions of Ministers into reality. I ask the House to accept that the critical path network for this reorganisation was of a huge size, with very large numbers of items, each infinitely complex and delicate, and I should like to say that my staff have spontaneously, enthusiastically and effectively carried out a really superhuman management task inside the Department. This reorganisation may be among the largest management enterprises ever undertaken, but this is a reorganisation which I believe the House should accept as necessary to go ahead, because it will strengthen the links between the professional skills, because it will bring better integrated and more effective care to the patient, and because it will increase public involvement in the National Health Service.

Most of the top jobs are now filled or are being filled. The whole massive remodelling of the National Health Service for the benefit of the patient is fast gathering momentum. There is no turning back, and we are moving in top gear towards the new service, which is only three and a half months away. I hope that my right hon. and hon. Friends will reject the plausible but ultimately negative and sterile motion on the Order Paper and will vote in favour of carrying on with the reorganisation on the appointed day.

4.42 p.m.

Mr. William Whitlock (Nottingham, North)

I am astonished at the complacency shown by the Secretary of State for Social Services, for the picture he portrayed of the smoothness with which this reorganisation is taking place is a totally different one from that which has been given to me in the Nottingham area. I want to refer later to the views of the staff there, but, first, I go back a little in time, as did my right hon. Friend the Member for Deptford (Mr. John Silkin).

When the National Health Service Reorganisation Bill was first presented it was quite apparent that it was much more concerned with management and administration than with people and accountability to the public. It will be recalled that a management study, in the setting of the Government's decisions on the reorganisation of the National Health Service, was conducted in 1972, and, as I pointed out in the debate on Second Reading, a study group came to Nottingham. That study group seemed to be largely in the hands of management consultants, who came to Nottingham with instructions about the kind of organisation that the Government wanted. They had preconceived ideas, which meant that their minds were closed to much of what people in the service in Nottingham had to say. They were concerned mainly with management and administration, and only remotely with people, with suffering humanity.

Since the emphasis of the whole exercise was on managerial efficiency, and since the approach of the Government was much more like that of a factory manager with a target of productivity in mind than of a body of people concerned with a system whose purpose is, after all, to prevent and treat disease, one would have thought that the Government would at least have ensured that the administrative arrangements for the reorganisation of the National Health Service would go ahead like clockwork. That has not happened; the reverse is the case. The mess which now exists suggests that for a long time ahead the service will be struggling with management arrangements to such an extent that the patient, the reason for the existence of the service, will suffer. In this field, as in so many others, the Government are like a conjuror with too many balls in the air at the same time, and the confusion created by this situation is causing bewilderment and immense uncertainty in the minds of staff.

The Government have arranged for the reorganisation of local government and health services to come into operation at the same time, for reasons which can be considered valid—and the right hon. Gentleman has argued that they are valid. But I have never known a time when there has existed so much worry, so much doubt and so much uncertainty in the minds of so many people in a variety of grades in both health services and local government. In both, large numbers of people are now being compelled to jostle with their colleagues in an endeavour to find posts in the reorganised systems. There is an unseemly scramble, forced upon these people by the manner in which the reorganisations have been dealt with by the Government, and this can only be to the detriment of local government and the health services.

The current position in regard to the reorganisation of the health services is that most senior officials have been appointed at regional and area levels, and similar appointments will be made by 31st March at district level. Thus, the new service will come into operation on 1st April 1974 with no other firm appointments made. The right hon. Gentleman's Department has virtually admitted that the state of reorganisation is hopelessly ill-prepared to commence the new services in April 1974, since it has issued National Health Service Reorganisation Circular, HRC (73)36, which states that the vast majority of existing departments, hospitals and other units will be "latched on" to those most senior officers who have been appointed by 1st April 1974. The term "latched on" is the Department's own expression.

Thus, there is an admission that there is no clear picture of the future for large numbers of staff. They are no more than unidentified numbers attached to senior officials, who are not likely in April 1974 suddenly and miraculously to produce a wonderfully cohesive structure in which everyone will have his appointed place and will know exactly how he can use his abilities in the interests of the health services. That is a terrible state of affairs after the Government have made their decision on the way in which the services will be reorganised, and after they have appointed "whizz-kid" managerial consultants to see that it is carried out.

I know of one fairly senior official who has given the whole of his working life to the hospital service but now, in his mid-fifties, finds himself cast on one side, having to punt around like so many others of his colleagues to find a new post. For him the future is very bleak because the reorganisation is taking place in such a way that he faces a very real possibility—I should have said almost a certainty—that he will have to spend the rest of his working life in a subordinate post, the great wealth of his experience lost to the service. This is just one example of what is happening. The same doubts about the future face large numbers of staff of all ages and in a variety of grades.

In spite of what the Secretary of State said, there is no effective consultation with these people, and to their doubts about their future is added the frustration caused by the unjustifiably narrow way in which the Pay Board views the proposed changes of the totally unrealistic salary scale, which cannot and does not attract staff in sufficient numbers. For some time Nottingham has been short of staff in many grades in the health services, and I fear that the present chaotic state reached in the run up to the reorganisation will cause many people to leave the service. I hope that that will not happen, but I fear the contrary.

In spite of all the frustrations inherent in all this, great efforts are being made by these dedicated people to keep up morale. But because of that no one should attempt to trade upon their loyalty. I believe they may well be reaching a breaking point in a number of cases, and the Government must not complacently brush aside their feelings and doubts in the hope that somehow on the appointed day all will be well. As we ask in the motion, the Government should postpone the date of the coming into operation of the reorganised service in the interests of the staff, in the interests of good management and not least in the interests of the community. They must give serious attention to the problems which their complacency and pig-headed-ness have created.

4.53 p.m.

Dr. Anthony Trafford (The Wrekin)

I hope that the hon. Member for Nottingham, North (Mr. Whitlock) will forgive me if I do not pursue the points he raised except over what he said about the necessity of the National Health Service being for the benefit of the patient. I hope that is something that every hon. Member will accept immediately.

I should like to direct my remarks to the speech by the right hon. Member for Deptford (Mr. John Silkin). He seemed to have one or two quite good darts but he must have been aiming at the board through bi-focals because he was missing the target. It seemed to me that someone had fed him the information, that it was second hand. That was how it seemed when he was referring to the immediate organisation of the health service as opposed to the broad managerial concept, which he obviously does not like. He used the term "democratic control". That is the sort of expression that we are ail supposed to pay lip service to, but what did he mean? Did he mean that each of the hundreds and thousands of decisions taken daily in an organisation like the health service must be taken in a democratic manner covered by a vote, or did he mean that the ultimate control of the service must be democratic? These seem to me two quite different concepts and the right hon. Gentleman did not spell out precisely what he meant.

The right hon. Gentleman went on to say that there is a 5 to 1 chance against women getting on one of the boards. There are two very good reasons for this. It is often forgotten that a large part of the function of operating something like the health service is concerned with such matters as building, engineering, capital works, finance and so on. These people, whether they are men or women—and, incidentally, this applies to the manual workers to whom the right hon. Gentleman referred as much as to women— need to be found in the first place so that they may be advanced to the area or regional boards. I cannot believe that my right hon. Friend has any prejudice against either of those groups of people.

I declare to those who do not already know it that I have a vested interest in this subject in that I am a doctor. Yet I do not believe that doctors are particularly well qualified to run the service any more than I think women are particularly well qualified to run it because they have babies. That was precisely what the right hon. Gentleman was arguing. I knew a distinguished doctor who felt he should have a much greater say in the running of the health service. I thought that as a doctor he was first-class but I thought that as a manager he was a fool. I had no say in whether he should assume this extra authority. It so happened that he obtained a part-time position which led him to the realisation that his particular specialty was not the only one on earth, that his particular minor vested interest—and in totality it was a minor interest—was not the only thing that mattered. Slowly over the course of four years that man became a first-class managerial talent who happened at the same time to be a doctor. I believe that his qualification to occupy his present position is that he knows what he is doing with regard to many other people's specialties and not because he happens to be a clever doctor.

Mr. John Silkin

The hon. Member for The Wrekin (Dr. Trafford) always speaks clearly and lucidly, yet he made one Freudian slip on this occasion on which I shall correct him I was surprised that the Secretary of State did not do so. These are authorities, not boards. He used the word "board" three times and that is because he is thinking of it as a hospital-based service. That is precisely one of the bases of my attacks on the reorganisation. That is why women are important. We are concerned not just with building hospitals but with developing community and family-based services.

Dr. Trafford

I am sorry that I gave way. If the right hon. Gentleman had only waited he would have seen that I had by no means overlooked the point. If I used the term "boards" and not "authorities", that is not a Freudian slip. A Freudian slip can be made only in connection with my mother or other women. It could not have been made in connection with a board. On a board, perhaps. With a board—well, the mind boggles.

The other point raised by the right hon. Gentleman was that too many "old lags" from the previous regional boards had been appointed to the new authorities. I will repeat the word twice—authorities, authorities. Now I have caught up with the number of times I misused the word "boards". One of the reasons why I am sure that my hon. Friend chose the old lags—I did not entirely agree with many of his choices—is connected with the very great problem of finding the right people. It is more important to find the right people than to find the right looking structure, because it is people who run the service and make it tick.

The right hon. Gentleman made a slightly unfair comment when he said that no area authority medical officers have been chosen. As I am sure he knows, to a large extent the functions of the people who will be applying for such jobs will be similar to many of the functions which they are now performing. If there is some weakness in definition the right hon. Gentleman should apply himself to how the job description should be defined. I dread to think how he might view such definition in view of his limited knowledge of psychiatric matters. Nevertheless, I feel that he should look carefully at the exact jobs which will be done by a district community physician. The position is still a little woolly. It will be found that many different areas will have different functions for their officers.

I agree with the right hon. Gentleman—and I am sure that my right hon. Friend would do so—that it is difficult to separate health and social services. I have always regretted that we were not able for various reasons to combine the reform of the social services and that of the National Health Service at the same time. This will be a far bigger weakness than delay, postponement and hasty appointments. Far more difficulties will arise because although there is a structural division between health and social services there is not always the same degree of actual or practical division between the two services.

One factor which the right hon. Gentleman overlooked is that inside the newly reorganised service there will be something known as the district medical team. It will have in it a community physician and various other people from the district. This will be the first time that the general practitioner services and the hospital services will be able to meet to take advice. I was going to say that there will be a statutory woman, but I would make an error. A nurse may be a man, and in that case my description would not be accurate. The people in the team should have their fingers right on the local pulse. I hope very much that the persons who serve on such a team will be able to keep closely in touch not only with the community councils and voluntary bodies but with the necessities of health in the area.

There are a number of unanswered questions. They are questions which I should like to see answered by the district team in any area. First, no one has ever answered the question: who runs a hospital, or how is a hospital run? Although it is said in theory that responsibility for the running of a hospital is with the hospital management committee, the regional board or finally with the Secretary of State, in fact, no one runs a hospital.

Hospitals tick over in a peculiarly disjointed fashion which often leads to gross inefficiency and gross misallocation of resources. Often it is the biggest, the strongest and the toughest of the doctors the consultants or the administrators who will be able to obtain his own way at the expense of others. A good district management team under the new reorganisation should be able to reallocate resources with greater efficiency. Of course, if they are useless people they will make useless decisions, but they now have an opportunity, when a hospital decision arises which involves the influence of those working in community medicine, in general practice or in district nursing, to bring their influence to bear on such a decision. That does not happen now.

I am probably the only hon. Member in the Chamber who has any experience of how, on the ground, the reorganisation of the National Health Service is going. Therefore, I claim a right to suggest to the right hon. Gentleman that his views on the reorganisation are second hand. It is not going as badly as the right hon. Gentleman or the hon. Member for Nottingham, North suggest. It is going very much better. The right hon. Gentleman referred to the patient. No doctor on 2nd April will act differently with regard to his patients. Nor will any district nurse, health visitor or social worker. The hospital casualty doors will be open as always. The hospital operating theatres will continue. The ambulances will work and the patients will arrive. The hospitals will proceed. I accept that there might be some administrative difficulties, but there is opportunity to concentrate towards patients the proper allocation of resources.

My right hon. Friend mentioned nothing about priorities in defending the reorganisation. It would be appropriate for hon. Members to ask themselves how the priorities will be decided. For example, which is the more serious, the elderly patient who lives alone and is threatened with cold in the winter, or the patient dying of a kidney disease, a heart attack or cancer? Who takes decisions on priorities, and how will the resources be allocated? At present no one takes such decisions. No one makes up a list of priorities. I should find it difficult to make such a list even if I were given dictatorial powers to do so.

The result is that in differing areas, and as a result of pressure groups, totally disproportionate resources can be allocated to something glamorous, something fresh or something new. It is even possible that resources can be granted to something which is phoney. With a leavening of common sense, which I trust will come from the community councils and from the lowest echelons of the newly reorganised service, management teams will be able to stop the misallocation of resources.

Furthermore, we badly need the collection of data upon which to act even at the most local level. There must be in the area to which I am referring as many patients suffering from severe arthritis as there are in any other area. The allocation of beds for care, and the amount of money spent on such people, is not great. At the same time, the area runs an expensive coronary care unit. An ambulance screams around the countryside, rather like the old carts during the 1665 plague, with its bell ringing and someone shouting "Bring out your injured." [HON. MEMBERS: "Bring out your dead"] No, the ambulance does not go round asking people to bring out their dead.

Somehow, a decision must be made as to how such demanding services are to be allocated resources. Is it right that such resources should be spent in one way rather than another? At the moment no one makes that sort of decision, and all sorts of differing pressures operate. My right hon. Friend will recognise immediately that only too often in the past, in matters of health, those who are able to produce from their pockets a pound for pound offer for a building project will frequently receive a wing to a hospital or an addition to a hospital which the far more deserving will not receive because they are unable to make such an offer. My example was in the context of building, but there is a necessity to allocate between a coronary care unit and the care of those suffering from arthritis.

I know that the arthritic will not die tomorrow and that the coronary might. We badly need data which will enable us to make the appropriate allocation of resources. Last year the ambulance to which I referred—an account was published in the British Medical Journal—made 1,082 calls, and only 750 which were referred to it were as a result of chest pains due to heart disease. Of that number, eight patients were resuscitated within the ambulance. Of those, four left hospital alive. In rough terms, of all the calls there was a 0.4 per cent. possible saving in terms of mortality. Perhaps there was a greater saving in terms of morbidity. That was achieved at enormous cost compared with that provided for people suffering from arthritis, old people's homes, the limbless and all the other interests that press upon us.

It is no good people coming forward and screaming at the top of their voice that we need more old people's homes, more money for the mentally disabled, more money for arthritics and more money for cancer relief. It happens that there are only three ways in which we can deal with the situation. The first is to say that by order and decision of Parliament, or of the Secretary of State through Parliament, this will happen. That is a purely arbitrary and dictatorial decision. The second is to say that we will cost it in some way, perhaps by a price mechanism. The first rations and the second costs. The third possible way is to hand it towards the locality with as much liberty as possible within the two ways I have mentioned to allocate the resources according to the necessities or the desired priorities of the locality. I prefer that third way.

I particularly wish to take up with the right hon. Gentleman the question of democratic or community control. At that level the members of the district team who are elected to the authority, with the exception of the administrators, who are appointed, are sensitive to local conditions, and they have an opportunity that no group has had in the National Health Service in 25 years to improve the lot of patients, to deliver the best possible health care within the allocated resources and to improve services in their own area in the direction that the particular necessities require or, if it is not a matter of necessity, in the choices that the residents dictate. That is a considerable advance and a worthwhile reorganisation. When I come to the areas and regions I am far less convinced that the change will make much difference to the way in which that part of the service operates.

However much good will and humanity is poured out by all those who speak on this subject, it is still necessary to have organised expertise brought to bear on the ultimate requirement of the health service, which is the best possible delivery of health care within a certain financial limit. That is the justification for a management reorganisation. For these major reasons I believe that there is an opportunity from which great advance and benefit to all can come.

5.12 p.m.

Mr. A. J. Beith (Berwick-upon-Tweed)

I am grateful to you, Mr. Deputy Speaker for enabling me to make my maiden speech on the subject of National Health Service reorganisation, which causes concern to rural areas because of the risk that centralisation of administration may lead to centralisation of the service.

I am privileged to represent Berwick-upon-Tweed, a constituency of great and diverse beauty. In an area of 800 square miles we have the grandeur of the Cheviot Hills, a magnificent coastline studded with castles, fishing villages, Holy Island, the Farne Islands, rivers known for their salmon-fishing, particularly the Tweed and the Coquet, and towns of great importance such as Berwick and Alnwick. Berwick is increasingly recognised as a walled town of international significance, although the cost of maintaining its great stock of listed buildings is beyond its means.

Ours is an area in which agriculture has traditionally been our major industry, but with vastly improved productivity it now employs a much smaller labour force than hitherto. Quarrying, forestry and fishing are important employers in the area, and one of the most important employers of all is the coal industry. Two pits, at Shilbottle and Whittle, provide house coal of high quality, but at the cost of extremely arduous working conditions in very low seams. In addition, we look to new developments in small industrial and administrative employment to stem the population decline.

The problems which face my constituency are not unknown to other hon. Members who represent rural areas, but they are made more difficult to solve because the Berwick-upon-Tweed constituency is further from London than any other in England, and this distance is not eased by any of the benefits of closer attention which the Scottish and Welsh Departments, even under the present limited decentralisation of power to those countries, are able to give to their areas. I think it can be shown that from the point of view of health reorganisation my area would have been more favourably treated had it not been in England.

I should perhaps correct a widespread misapprehension which may be less common in the House than in some Government offices. Although Berwick has changed hands between England and Scotland many times in earlier centuries and is reputed, incidentally, to have been left out of the peace treaty with Russia at the end of the Crimean War, leaving us still in a state of war with that country, it is not in Scotland. It contains no part of the Scottish county of Berwickshire, which is represented by another hon. Member. It consists entirely of the northern part of Northumberland. We prefer to take the best that Scotland can offer, be it Presbyterianism, whisky, Old Year's Night, or a position at the top of the Scottish Football League Division 2, while remaining resolutely English.

It should be unnecessary for me to describe my constituency and its problems at length to the Secretary of State. I am sorry that he is absent. He and other right hon. Members on the Government Front Bench were kind enough to visit my constituency, by coincidence, last month. I assure the right hon. Gentleman that my presence here in no way suggests that my constituents failed to appreciate the trouble he took, and I look forward to welcoming him back on any future occasion when he is able to fit a visit into his timetable.

I fear, however, that the Secretary of State's visit came too late and was too brief to affect his health service reorganisation. It is lamentably characteristic of schemes of reorganisation of all kinds—this one is no exception—that they are conceived with one part of the country in mind and then applied to another part to which they are totally unsuited.

I take the example of the district level of organisation in which the district general hospital is an essential component. There is no such thing as a district general hospital in the whole area of the new Northumberland Health Authority, and there is never likely to be, because Northumberland and Newcastle are interdependent for hospital services, and no one of the four general hospital centres within Northumberland could be developed to the extent that it could satisfactorily serve the whole area. As there is no district general hospital in the area, the logic of the district system breaks down and it becomes necessary to impose an arbitrary minimum population limit of 100,000 to prevent areas like my constituency from being treated as districts. I suggest that the right hon. Gentleman has a word with his right hon. and learned Friend the Secretary of State for Wales and considers the arrangements that that gentleman has approved for the county of Dyfed. That is an area, with a population identical to that of my own county, which has been treated much more favourably and divided into four health districts. That is why I said at the beginning that we would have been treated more favourably if we had been in Wales or Scotland.

It is to be hoped that if reorganisation proceeds on present lines both the Department and the area health authority will look favourably at the possibility of dividing Northumberland into at least three geographical sectors for the management of the health service with separate community health councils to match these sectors.

If that is not allowed there will be centralisation of management with a loss of efficiency, loss of an understanding of local problems, a loss of much-needed administrative and clerical employment to towns like Alnwick and Berwick and, perhaps more important, a loss of commitment to the decentralisation of medical services in the area.

At the moment far too many patients and relatives have to make long and difficult journeys to hospitals outside the constituency. It is common for relatives to have to spend four or five hours in travelling to Ashington or Newcastle for a brief visit to a patient. Cases have been reported of out-patients spending as long as seven hours in an ambulance travelling to and from a 15-minute consultation. There is great scope for the expansion of facilities at Alnwick and Berwick but little prospect of the expansion taking place if all the decisions rest with a larger area with a prior interest in building up Ashington.

The Secretary of State has often stressed the desirability of decentralising psychiatric beds out of large hospitals, but there is little sign of such a policy in Northumberland, where 2,000 beds are concentrated at Morpeth. Psychiatric day hospitals and small acute psychiatric units attached to the present infirmaries could all be developed at Alnwick and Berwick, where there are far better opportunities to recruit nursing and ancillary staff than in the more prosperous and congested areas. That, I think, was noted by the right hon. Gentleman on his recent visit.

Facilities for the young chronic sick and elderly patients with severe dementia could be provided in these centres. None of these things is likely to happen under a system in which decision making does not sufficiently involve local people with a real commitment to decentralisation.

This brings me to the two wider points which will lead me and my hon. Friends to support the motion. One is that of all the options which were open to the Government for reorganising the National Health Service they have chosen the least democratic and the least representative scheme possible. What were the possibilities for a united health service? There could have been local government control—an idea which was obliquely recommended by the Redcliffe-Maud report but was rejected by the Labour Government and by the present Conservative Government. There is a system based on ministerial appointments with no element of direct election, which is the option the Government have chosen. There is also the possibility of health authorities with directly elected members as well as representatives of the professions and occupations. We would have preferred such a system. The system eventually favoured by the Labour Government involved representation from the local authorities and supplied an element of democratic participation. This last possibility falls short of our ideals, but it was preferable to what we are now being offered. Indeed, in regard to lay involvement in running the health service the present system is preferable to the new one.

I am sure that there are many hon. Members on both sides of the House who regret the departure from health management of the thousands of men and women who gave valuable public service on hospital management committees and local authority health committees. In the new system the only place for lay participation on this scale is through the powerless community health councils, which, although no doubt they will find something useful to do, will be at the receiving end rather than at the making end of major decisions. At the level of the district team there is no lay participation at all, and at the area and regional level it is on an appointed basis. The public for whom the service is provided surely deserve a system to which they may have greater representative access than this. The right hon. Gentleman claimed that those of us who take this view are confused between management and the community's reaction to management. That confusion, if confusion it is, is at the heart of our whole system of government—local and central—and is embodied even in his own position as Secretary of State, and rightly so.

In this country we have long believed that elected representatives of the public should be involved in supervising the management of the services which are provided for the public. But there is another reason for concern which, in view of all the Government's references to the need for management ability in the new National Health Service, is surprising and even ironic. There is enormous and widespread feeling among those who operate the health service that the process of reorganisation has gone badly wrong.

I am involved as a councillor in local government reorganisation, and I know just how difficult the process is and the problems which are faced. But the trials and fears of local government reorganisation have been as nothing when compared to the present situation in the National Health Service. The list of grievances is very long. It ranges from the mysterious principles on which shortlisting for appointments is carried out to the lack of consultation cited by the unions representing hospital ancillary staffs, including usually moderate bodies like NALGO. Thousands of people are wondering whether they will have a job comparable to and in the same area as their present job. On top of a sense of insecurity, there is the sense of injustice that the additional payments for extra reorganisational work which have been granted to local government offices have been denied to the National Health Service staffs.

It would be hard to imagine a worse climate in which to establish a new National Health Service, and it is especially hard to imagine that by 1st April 1974 reorganisation can be completed in anything but a nominal sense.

5.25 p.m.

Mr. R. J. Maxwell-Hyslop (Tiverton)

It is a pleasure to follow the hon. Member for Berwick-upon-Tweed (Mr. Beith) and to have had the opportunity to be present in the House for his able maiden speech. I am sure that he will be an asset to his constituents and to the House to which we all welcome him.

The hon. Gentleman could not have made his maiden speech on a more important subject, for this is important not only to his constituents but to the country as a whole. We are dealing with one of the most important reforms of the last half century. It has involved the House of Commons in an enormous amount of work, and it has meant a great deal of work for those who are employed in the health service.

I wish to direct my comments more strictly to the motion than perhaps some speakers have done to date. The question of the composition of various bodies was settled one way or another during the Committee and Report stages of the legislation. The gravamen of this debate is whether the Secretary of State should in some unspecified way postpone the coming into being of the new National Health Service reorganisation.

I wish to cover two major aspects: first, why we need reorganisation at all; and, secondly, why it is thoroughly undesirable that that reorganisation should be delayed. We need reorganisation first to avoid the gaps and overlaps in the present system. An overlap is as bad as a gap, because if two authorities have the same responsibilities they are apt to leave the matter to each other, and neither does anything about it. This can also lead to duplication of effort.

The present management structure in many cases has fallen into a sad state of disarray. I know of large hospitals—and I regard a large hospital as one approaching 1,000 beds—where the hospital secretary does not always bother to attend meetings of the management committee. The management committee, despite its name, is not permitted to manage, and many of its alleged functions are usurped by the regional hospital board.

I know of cases where the disciplinary committee of a large hospital management committee receives unofficially from the regional hospital board information as to what decision it expects the disciplinary committee to make in cases which that committee is about to investigate, and also states what punishment it expects the disciplinary committee to inflict—and this occurs when the disciplinary committee has not even determined whether an offence has been committed. This is the sort of corruption into which the present system has fallen.

The regional hospital board is supposed to determine priorities, but so bad are its accounting systems that what often happens is nothing of the kind. Anybody who has been in this House for any length of time knows that the annual race to spend money is almost as acute as the annual struggle to get it. We know that large sums of money are spent on unnecessary decoration merely because there is money left in a particular account at the end of the year whereas desperately needed facilities are not provided because the cash cannot be found. We know about the sort of staffing structure in which a hospital secretary can be put on a higher pay grade if more gardeners are employed in the environs of a hospital. If the totality of the wage bill on non-medical personnel can be increased, the pay and status of the hospital secretary can also be increased.

If the present structure is supposed to be about anything at all it is supposed to be primarily about capital priorities, which are among the most contentious of all in that most laymen and specialists tend to have too restricted a focus to allocate priorities in a rational way. There can also be the situation where regional boards totally ignore the most pressing medical needs because they become fascinated by one project.

I quote an interesting example from the region in which I live. In Exeter there is the West of England Eye Infirmary, which serves the ophthalmic needs of the whole of Devon except for Plymouth and Torbay. It serves not merely regular needs but also casualty needs. This hospital is not a complete unit. It relies on a wide range of facilities from the large general hospital situated next door to it. I refer to the Royal Devon and Exeter Infirmary. Those facilities include testing for blood groups, X-ray, radiology, anaesthetics and facilities for feeding nurses and patients. For instance, when there is an unpleasant car crash and somebody's head is badly damaged the multi-disciplinary attentions of ophthalmic, orthopaedic and possibly dental surgeons are needed. At the moment these are all available with only a road between them.

The regional hospital board is about to demolish the Royal Devon and Exeter Hospital without making any arangements for the eye hospital except putatively the provision of a kitchen. Because a new hospital is being built about a mile away—incidentally, the road between it and the eye infirmary generally has static traffic upon it in the holiday season, so any question of moving personnel rapidly between the two does not arise—and that has been the focus of attention, the hospital board has literally forgotten the ophthalmic hospital and the needs of its patients and staff.

When complaints are made specifically by consultants at the ophthalmic hospital to the regional board they meet a blank wall. Occasionally there is the explanation that funds are not available. But no representations have been made by the regional board to local Members of Parliament that adequate funds are not available and asking that parliamentary channels be used to try to get extra funds.

There has been no effective consultation whatever between the regional hospital board and the consultants or other medical staff at this West of England Eye Infirmary, which will now be left isolated from the medical services on which it depends. Worse still, it is intended to put a complete traffic stream on both sides of it and to take away its garden so that the ring road runs immediately adjacent to it. The noise and vibration from that will come straight into the operating theatres where the most minute form of surgery in medical experience, with the possible exception of cerebral surgery, is supposed to take place.

I have no reason to believe that the South-West Regional Hospital Board is outstandingly incompetent compared with others throughout the United Kingdom, but I offer this as an example of the condition to which the present administration of hospital medicine in particular has disintegrated, and why we cannot go on postponing year after year organisational reforms which were already grossly overdue before they reached the statute book so recently.

It has been suggested that local authorities should have much greater control. Is not that exactly what the National Health Service was set up to get away from? We had local authority control over medical facilities until the inception of the National Health Service. [Interruption.] That is exactly what we had, and its shortcomings were widely recognised. The functions of local government are not primarily medical functions. Certainly there should be representatives of local authorities on the area health authorities, and there are.

The new structure, through the community health councils, associates the public more directly with the multi-disciplinary arrangements of the National Health Service than ever before. The fact that the public can be represented more directly than indirectly through local government appointments in no way means that they are cut off. Under the new local government structure of first and second tier authorities there will be more than enough work for councillors to do. I do not anticipate that their main problem, or even part of it, will be having too little with which to occupy themselves.

It has been glaringly obvious in many parts of Britain, including the South-West, that there have been wide areas of overlap and gap between the hospital services and the local authority health and welfare services, and that the position of the general practitioner has tended to go by default. He or she may have good personal relationships with consultants in the National Health Service, but to a large extent the efficiency of the liaison between the community doctor—I use that as an expression for the general practitioner—and his consultant colleagues in hospitals has worked because of good personal relationships rather than an adequate structural relationship between them.

In some cases where general practitioners, though excellent at their functions, either have not been in an area very long or have personality clashes with some of their consultant colleagues in the hospital service, I believe that patients have suffered because there have not been the structural relationships on which anything of that kind ought to depend rather more than on personal relationships.

I believe that in many parts of Britain where there is a rapidly changing pattern of population, not just numbers, the new structure set up by the Act will respond more quickly to those changing needs. I do not believe that doctors are necessarily the right people to determine priorities in medical expenditure, though certainly to advise on them, because under the present system dominance of personality has often had more to do with the allocation of funds than any objective criteria.

There is also a momentum of habit. If one lives in an area where the age balance is altering rapidly, where there is a greater proportion of elderly people each year, the needs of the psycho-geriatric and ophthalmic services and those to do with the degenerative diseases of the joints and bones have a greater social importance than some of the more fashionable and glamorous disciplines in medicine. The present hospital board structure has not been responsive to these changing needs.

The habit of mind that once geriatric patients can no longer spend the whole day in their own homes they must necessarily be incarcerated in a geriatric hospital dies hard. The obvious alternative is providing day out-patient facilities in geriatric hospitals for patients who are not bedridden, who can have the independence and self-respect of continuing to live in their own homes and attend out-patient sessions in geriatric hospitals by day. This can ease both the physical problems of providing the number of beds that would otherwise be required and the strain on the nursing staff who have to look after people who do not really need to be in geriatric beds but are allocated them because there is no alternative provision.

These are the flexibilities to which it is reasonable to believe the new structure will respond in a manner that the existing structure manifestly does not. That is why I hope that my right hon. Friend will not be deterred by the real and considerable difficulties that there are in this transitional stage. It has certainly been my experience that transitional difficulties are not generally eased by elongating the period of transition. Seen from beforehand, this often appears to be the case, but when the moment arrives it is not. Up to a year ago—and, for instance, for the last five—most farmers wanted the longest possible transition period while Britain was going into the EEC. Now the balance of opinion has turned completely. The appeals that we get are to telescope the transition period. There is value in this analogy for the reorganisation of the National Health Service.

I can think of few things that would be less advantageous to the patient than to alter the time scale of the reorganisation when it is already in full flood, and not to synchronise that reorganisation with the reorganisation of local government, when the major purpose of both, in relation to each other, is that of inter-dependability. I hope that we do not lose sight of this interdependence. It is of immense importance. I hope that we manage through it to avoid the jealousies and the empire building which have so often gone on in the past, to the waste of resources and to the harm of the patient when there are gaps and overlaps.

The sooner that we have a reorganised National Health Service structure with its colleagues in a reorganised local government service aiming at the same goals the better.

5.42 p.m.

Mr. Christopher Mayhew (Woolwich, East)

I begin by adding my congratulations to the hon. Member for Berwick-upon-Tweed (Mr. Beith) on his well-informed and witty speech, which has the advantage that it will read well not only in HANSARD but in his local paper, a circumstance he will come to value more and more as election time draws nearer.

I intervene to ask only two questions, one of my right hon. Friend and the hon. Member opposite, about the community health councils. In the absence of my right hon. Friend, perhaps my hon. Friend the Member for Halifax (Dr. Summerskill) will answer when she winds up. What is meant by the composition of the community health councils as my right hon. Friend described it? If I heard him aright, he said that all members of community health councils should be members of local authorities. I hope that he did not say that. [HON. MEMBERS: "What did he say?"] I do not remember that we argued that on Second Reading. I do not know why we now have this concept. I do not see any advantages in it. I recall that the Opposition were alert to the danger that when one appoints a watchdog one should not have too many members of that watchdog overlapping with the membership of the bodies they are supposed to be watching over. It is a good principle.

I remember moving an amendment which the Secretary of State was gracious enough to accept on condition that I did not speak to it. It was an amendment to say that no one should be both a member of the community health council and a member of the area health authority. I would have thought that the same principle applied as did the objection to my right hon. Friend's suggestion that all members of community health councils should be members appointed by or of the local authority when, as we all agree, local authorities have substantial representation on the area health authorities. It must be wrong. That is my question to my right hon. Friend, and I hope that my right hon. Friend the Member for Halifax will reassure me.

To the Minister I ask: what is the time scale for setting up the community health councils? I recall raising this point on Second Reading and being assured in the most specific manner by the Secretary of State that there would be no question of any substantive decision being taken about the regional or area health authority until the watchdogs were in operation. This is right, and we must insist on it. But I should like to be reassured, because the Secretary of State has not even yet asked for nominations to the community health councils. What worries me is that substantive decisions may be taken by the authorities before the community health councils are established. That would be unacceptable.

5.47 p.m.

Mr. Laurie Pavitt (Willesden, West)

This reorganisation is the greatest series of botched-up operations since the days when barbers took blood from patients suffering from anaemia. I hope that my right hon. Friend and the hon. Member for Tiverton (Mr. Maxwell-Hyslop) will forgive me for not taking up their remarks, because I wish to press most of my attack against the right hon. Gentleman, whose speech failed to deal with these crises. It was mainly a Second Reading speech. It was not what we normally expect of him.

I accuse the right hon. Gentleman of doing precisely what we accused him of doing in Standing Committee. It is not the Act itself that we are criticising in the motion—we are criticising the way in which he has administered it.

The right hon. Gentleman is guilty of dictatorial decisions and of riding roughshod over genuine consultations, and, although he said in his opening speech today that he was satisfied with the consultations with the trades unions he will know that the National Association of Local Government Officers has pointed out to every hon. Member that there are 80,000 NALGO members suffering from a bewildering lack of consultation, a clear mess-up of the way senior appointments have been advertised and handled, a Government veto on extra payments for those senior officers carrying out extensive extra work, and for the great majority of them still massive uncertainty as to what is to happen to them on April 1. That is the charge I level and I hope that when the Under-Secretary replies he will be able to give us more satisfaction than did the Secretary of State in his opening comments.

One of the gross injustices of the re organisation is, as usual, its effect on all the nursing professions. The right hon. Gentleman knows very well that I have asked him question after question about pay and conditions, but when it comes to the nursing professions I always get the same answer—that it has nothing to do with him; it is the Whitley Council's decision. But what has happened in the reorganisation and the appointment of nursing officers is that because the Whitley Council has been unable to reach agreement the right hon. Gentleman has again used it as a puppet. He has gone over the top and made decisions about which the nurses are totally dissatisfied.

Why is it that when the Whitley Council machinery is overridden it is always the health service sectors into which the Government step and take charge? The right hon. Gentleman will recall that the very first time that procedure occurred in the history of all Whitley Councils was in 1957, and again it was the National Health Service workers who suffered. Once again the right hon. Gentleman has issued a diktat because the Nursing and Midwives Whitley Council has reached deadlock. When it comes to the appointment of regional authority or area health authority nursing officers there is to be no arbitration, despite the fact that in every case previously when nurses have been unable to get justice from the Whitley Council it has gone to arbitration, not once, but dozens of times. The right hon. Gentleman says that he has not time to arbitrate and do these things before April 1st, and because of that the motion is worded as it is, to enable him to find enough time to do the right thing.

I find a considerable amount of interest in the right hon. Gentleman, who is one of the most formidable members of the Government Front Bench, but he always presents himself as a "Jekyll and Hyde" in health matters. As Dr. Jekyll, he shows considerable compassion for the disabled and for those in long-stay hospitals, and his record is one that no one would be ashamed of. But he seems to revel in his Mr. Hyde rôle, in bashing the nurses. He does it more in sorrow than in anger, but he does not desist. His policies are already having effect on the Central Middlesex Hospital. Nurses are not eating mid-day meals because of economic difficulties. What has happened is that in two years the price of the main mid-day meal at the Central Middlesex Hospital has risen by 75 per cent. In the meantime, the pay of the nurses has been restrained by phase 1, phase 2 and phase 3 of this Government's policy.

When it comes to making appointments of regional and area health nursing officers, it must be remembered that nursing salaries start at the top and that until we have the top right we shall have a job to do anything at the bottom and with all intermediate grades. I quote the example of the University Hospital Group in Cardiff. The nursing officer there has a budget of £5.5 million a year, and a staff of 6,000. There are another 600 nurses in training. The nursing officer now gets less than £5,000 a year. Is there anywhere in industry or commerce where a person with that kind of responsibility gets so low a reward?

I ask the right hon. Gentleman to do something about the Whitley Council breakdown. In the reorganised National Health Service nurses are supposed to be equal members of the team. We find in the North-West Thames Regional Health Authority, for example, that there is a difference of £2,400 between the pay of the nurse in the team and that of the administrative officer. That cannot be fair. It cannot give the right kind of background.

Sir K. Joseph

Perhaps I may say to the hon. Gentleman as mildly as possible that his right hon. Friend the Member for Deptford (Mr. John Silkin) did not choose to raise any of these matters when he opened this debate. Discussions with the nurses are still in progress. There is an offer to them on the table, as no doubt the hon. Gentleman will know.

Mr. Pavitt

I am grateful for that intervention. However, the right hon. Gentleman will appreciate that in a short debate of this kind we try to cover as much ground as possible but that we cannot cover all the subjects.

The right hon. Gentleman has asked the Pay Board to look into this case. The nurses' pay claim is with the Pay Board, and the right hon. Gentleman has little jurisdiction over the board.

Sir K. Joseph

The hon. Member carries a great deal of authority. However, on this occasion he is wrong. He is talking about nurses. In fact, his argument about the salaries of nurses and the Whitley Council is connected with the new nursing management posts. The offer to them has not gone to the Pay Board. It is on the table and under discussion with the nurses.

Mr. Pavitt

I am again grateful for that intervention. I was speaking only this morning to representatives of the Royal College of Nurses, and they were concerned about the effect of the rest of the reorganisation proposals upon nurses' pay. I was told that the Pay Board has the matter under consideration.

In Committee I accused the Secretary of State—and I do so again—of being hospital-oriented. In drawing the boundaries of the districts of area health authorities, my accusation has been proved right. I can give the right hon. Gentleman the example of my own area. My hon. Friends the Members for Ealing, North (Mr. Molloy) and Acton (Mr. Spearing) have made representations on the same point. Brent and Harrow is the area that I represent. In this case the joint liaison committee has been no more than a piece of window dressing. Any attempt to make representations has been overridden once again by the Secretary of State.

I have a letter from the secretary of the joint liaison committee. He writes: The Department state in their letter indicating the decision of the Secretary on this matter that 'there has been the fullest possible consultation at local level between Joint Liaison Committees and other interested parties including the Department.' This is not so in the case of the Harrow and Brent Health Authorities. The JLC of that area tried to get in contact with and consult the JHC of the regional health authority, only to be turned down.

There are four districts in the hospital catchment areas of Brent, Central Middlesex, St. Mary's, Northwick Park and Edgware General. The hon. and qualified Member for the Wrekin (Dr. Trafford) recently made a plea for closer liaison between the social services and the local health and welfare services. It is this that makes a nonsense of the way that the reorganisation has gone. In my area not only district management teams but community health councils will be drawn up on areas of hospital catchment which cut across the boundaries of the welfare and social services activities, and there will be a completely unnatural community basis.

In the London borough of Brent a 33 per cent. overlap will mean that 90,000 residents will find themselves outwith the areas which will fit in with the community responsibilities that they have. It means that there has been a complete breakdown of confidence on the joint liaison committee, with the powers that it has to change any decisions made arbitrarily by the Secretary of State.

The Secretary of State answered a question of mine by saying that the area health authorities could alter this later on. I have gathered since, from further points that he has made, that this is very unlikely and that present boundaries will not be altered after 1st April.

The staff chaos, which is becoming even more confused, is at its worst in the local health authority sector. The uncertainty means that everyone is looking for a way out of the new service since the local authority departments will pay more than the area health authorities pay for similar responsibilities. Already in my own borough a quarter of the staff attached to the health authority have moved over to posts in the local authority.

We have an even greater nonsense in the case of dentists. The Government's proposals are supposed to come into being on 1st April, yet area dental officers are not to be appointed until well past the end of April, although district officers are to be appointed in March. In other words, the area officers will be appointed well after the district officers have been appointed to their posts. The confusion resulting from that decision will make the whole situation confoundedly difficult.

The Secretary of State will have had many representations about administrative staff. I have not time to go into them all because I know that other hon. Members wish to speak. But the administrative situation is in such a state that the new system cannot possibly begin on 1st April. It is clear that the Secretary of State will not be able to get half of it going until about six months after 1st April.

My hon. Friend the Member for Nottingham, North (Mr. Whitlock) quoted a case of dissatisfaction. I quote a similar case. It concerns Mr. X, a treasurer with 25 years' service with a hospital management committee, for most of the time with responsibility for nine hospitals. The new district will contain precisely the same nine hospitals. The finance department will have the same responsibilities with only a 20 per cent. payroll increase. But Mr. X is not even short-listed—and he has not even been short-listed for four comparable posts. Having done 25 years' service, he naturally feels very bitter. His situation is repeated time and time again. As the right hon. Gentleman knows, his staff commission is not consulting sufficiently. When short lists are being drawn up and when suggestions are being made, in the final analysis the persons concerned do not feel that they are getting justice. In fact, justice is not being seen to be done.

The same gentleman has been working a six-day week since September 1972, with no additional pay. The Secretary of State explains that away by quoting the Government's policy on phase 3. But when a local government officer is paid and a health officer is not paid, the Government ought to find some way round the problem even if it means bending the rules a little. Mr. X has done 60 days unpaid work.

The Secretary of State knows that although the scheduled starting date is 1st April we shall no doubt still be muddling through in May, June and July. Already in circulars he is indicating that it will be nine months in many cases before the new system gets going. The great benefit to the patient is that in spite of administrative muddle those with clinical responsibilities will not alter very much. They will still be doing the same job in the same places, despite the inevitable administrative chaos. But 800,000 workers are experiencing this upheaval, and all of them are in a tremendous confusion, including consultants and general practitioners, dentists, opticians, and even those affected by the order which the right hon. Gentleman laid this week concerning family practitioner committees.

On Second Reading and in Committee the Secretary of State argued that the reorganisation of the health service was necessary because of the managerial inefficiency in the present set-up. If his case has any validity, he should give himself and his Department time to do the job properly. I take only the argument about consultation. Anyone visiting the headquarters of the BMA at Tavistock House sees shoals and shoals of circulars about which there is supposed to be consultation, but there has not yet been time for consultation. The Department is scattering information, and information is not consultation. The right hon. Gentleman should give himself more time. He should hold a thorough inquiry into what is going on, not on the Act but on the arrangements stemming from it, so that he is able to put things right, thus avoiding later adjustments in the reorganised health service because of the bad way in which the reorganisation has been carried out, which may take years to put right.

6 p.m.

Mr. Nicholas Edwards (Pembroke)

I agree with the hon. Member for Willesden, West (Mr. Pavitt) that there is anxiety among those employed in the National Health Service. It would be surprising if that were not so, confronted as we are by such a massive reorganisation. We must ask whether it is likely that the anxiety would be diminished by postponing and extending the whole mas- sive arrangement. It seems that that would add a lot more to the anxieties.

It is surprising that during the whole course of the debate, except for one period of 20 minutes, there has not been one Welsh Member present. I say this because I think back with feeling to the long debates we held in the House and in the Welsh Grand Committee on this subject. We were told then that this was a matter of immense importance to the people of Wales, as it is. It was so important, so it was said, that there should be a separate Welsh Bill. Opposition Members said that there was inadequate time on the Floor of the House to debate these significant matters. Yet today the Opposition are launching this attack without any one present to press the Welsh point of view.

Mr. Molloy

Is the hon. Gentleman suggesting that if we did have contributions from Welsh Members there is a possibility that he and his hon. Friends would support them in the Lobby tonight or that his right hon. Friend would change his mind?

Mr. Edwards

We will always judge contributions by individual Members on their merits. I am simply pointing out that the Minister of State, Welsh Office is present, and was present at the start of the debate, no doubt to listen to the contributions and criticisms made by Welsh Members. They have been non-existent, as have the hon. Members who might have made them. I can only assume from that that there is broad satisfaction among Welsh Labour Members with what is taking place.

I listened with great interest to the speech of the right hon. Member for Deptford (Mr. John Silkin). He always makes a formidable contribution. We know that he is capable on occasions of bowling very fast balls, as he did the other night. I thought today's was one of the least convincing speeches I have ever heard him make. He seemed to be getting close to a dangerous obsession with numbers. It is a terribly easy game to play. It has become increasingly common to say that on any committee or group or in any party organisation or any representative body there must be a given percentage of people matching their proportion in the population. This was clearly the inference behind the right hon. Gentleman's remarks when he criticised the inadequate representation of women.

We are on a slippery path if we carry the argument too far. I draw the right hon. Gentleman's attention to the salutary tale of the Democratic Party in the United States. At the last Presidential election it got itself into the position that it was less concerned with the individual contributions that might be made and more concerned with proportions. The result was devastating for that party. We should be more concerned with the contribution that can be made to these area health authorities instead of looking for strictly numerical proportions.

I have argued that in some parts of the country it might be appropriate to have rather larger authorities with a greater degree of local authority representation. I have argued that because it seems that in a tightly-knit urban community it may well be that three or four local authority representatives will be familiar with the area they represent, while in a far-flung part of the country, such as Dyfed in West Wales, individual local authority representatives may not be familiar with areas that may be 50, 60 or even 80 miles away.

It therefore seemed important that we should have flexibility in approaching this problem. It seems that the criterion on which we should judge the whole scheme is whether the people who have been selected represent a wide variety of skills and talents so that they can bring the proper critical faculties to bear on the decisions and the administrative work that will be undertaken by the administrators within the health service.

Mr. John Silkin

The hon. Gentleman is on a fair point, and I would not like to dispute the logic of his remark. But I would not want it to be thought that I was trying to do a strict numerical Gallup Poll. What I wanted to get across was the fact that every single regional health authority chairman in England and 82 out of the 90 chairmen of area health authorities in England—I do not know the position in Wales—come from the hospital service. That cannot be a proper balance, which is what the White Paper said there ought to be.

Mr. Edwards

As my right hon. Friend pointed out, there are a variety of other talents and experiences. The right hon. Gentleman produced a lot of other figures in which he seemed to be pressing this argument to a dangerous degree. I am glad that he is now perhaps drawing back.

Mr. Silkin

No.

Mr. Edwards

The right hon. Gentleman said that there should be a substantial majority of local authority and trade union representatives on the authorities. I note the point, but it does not seem to be necessarily the best qualification for effective membership of area health authorities. I entirely concede that these groups of people should be represented and that we should like to see able trade unionists and local authority representatives where this is possible. It does not seem to be the prime criterion when selecting people to fulfil this function.

I turn to the argument that the whole thing should be postponed. My right hon. Friend has said that this was probably the largest management enterprise ever undertaken. He pointed out the importance of making it coincide with the equally massive reorganisation of local government. It would be totally catastrophic if we postponed at this point. Not only would we find ourselves in the extraordinary position of having done away with a whole group of authorities which have responsibility while putting nothing in their place, but the chaos that would be created would have to be seen to be believed. Anyone who has ever been involved in reorganising anything knows that it is always tempting to put it off. That is almost always a mistake.

We have been debating and thrashing out this issue for almost as long as some of us remember. Government after Government have turned their attention to these problems. If we are successfully to implement the new structure, we have to get on with it within a given timetable. That is the only discipline which remains to ensure that the new system comes into effect smoothly and efficiently.

It was an extraordinary and deplorable suggestion by the right hon. Member for Deptford that the community councils should be filled only with members of local authorities. I was glad it was attacked by his right hon. Friend the Member for Woolwich, East (Mr. May-hew), who, like me, could hardly believe his ears. As he said, it was not previously a Labour Party proposal. I have only to look to my own area and the contribution in knowledge and experience made by the voluntary bodies to see what a disastrous proposal it would be.

For example, the local society which takes an interest in the mentally handicapped is immensely knowledgeable, does an enormous amount of good work in the area and is to be represented on the new community councils in the area. That is absolutely right: it will make an immense contribution. There are other voluntary bodies of a similar kind. It would be deplorable if, because of some rigid Front Bench theory, groups like this were to be removed and the community councils which are supposed to represent the interests of local people in the broadest sense were to be restricted to local authority membership—membership of people who may have no particular knowledge in this sphere. That suggestion would have disastrous results.

6.12 p.m.

Mr. Harry Lamborn (Southwark)

Much reference has been made to a democratic health service, and Conservative Members have asked what the phrase meant. The greatest defect in the present health service—the hon. Member for Tiverton (Mr. Maxwell-Hyslop) gave vivid examples of this—is lack of public accountability. The new Act perpetuates that lack of accountability to exactly the same extent as the present health service.

The hospital service, with which I have been closely associated, has, to my mind and obviously to that of the hon. Member for Tiverton, worked largely in a vacuum; certainly the executive councils have. But the executive councils within the general medical committees will still work in that same vacuum. The present proposals are so hospital-orientated that exactly the same defects in the present organisation will be carried over to the new.

It is not enough for the Government to say that the Secretary of State is answerable to Parliament. We all know the difficulty of getting answers to important and fundamental local problems if the only channel for processing complaints is the few opportunities that one has here. So my first concern is lack of public accountability, which goes together with lack of public control.

My right hon. Friend the Member for Deptford (Mr. John Silkin) referred to the formation of certain district councils. All of us in the Greater London area were concerned at the suggestion that London should be treated differently from the regions, in that the area health authorities would not coincide with the London borough boundaries. Having fought and lost that battle in the House and in Committee, we then had the ridiculous position of which my right hon. Friend has quoted an example—Southwark, Lambeth and Lewisham are three boroughs but in that same area there will be four districts based not on borough boundaries but on hospital catchment areas.

There could be some justification for that if the catchment areas were so closely associated with those districts that this was the predominant function that the hospital was performing. But in the four districts concerned, despite the fiercest opposition by the local authorities and one of the teaching hospitals, one finds little evidence of this. Only 30 per cent. of St. Thomas's patients come from the district in which it is placed, and only 39 per cent. of Guy's Hospital's patients. I hope that the Secretary of State will consider this matter further. It is causing great concern in my area and greatly affects the effective functioning of the community councils.

The hon. Member for Pembroke (Mr. Nicholas Edwards) made great play with the part that voluntary organisations have to play within the community councils. But the voluntary organisations—the local councils of social service, the mental health organisations, the associations dealing with the handicapped and the elderly—are based, both financially and geographically, on the borough boundaries. The same boundaries are obviously the natural basis for the districts.

This glaring anomaly was very much resented by the three borough councils I have mentioned, and they were joined in their objection by one of the hospitals concerned. I urge, along the lines of the motion, that all these matters show the need for taking more time to consider the operation of the service rather than steamrollering it through in order to meet a timetable which will mean a lack of time for discussions and the making of appointments, and will thus ensure that a service which should stand for a considerable time will need reorganisation again before it comes into being.

6.20 p.m.

Dame Joan Vickers (Plymouth, Devonport)

I hope that my right hon. Friend knows how grateful we are in Plymouth, because, 30 years after the scheme was first suggested, the first sod was cut by the Lord Mayor, last Friday, for our new district hospital. This scheme is coming to fruition on a lovely site, and it will benefit many people.

We should give more consideration to management committees. Hon. Members have been running them down. Management committees have held the fort for many years and our thanks are due for all their work in the past. I deplore the motion's suggestion that we should postpone reorganisation of the health service. Postponement would mean more uncertainty, and there is already enough of that. It is also suggested that there should be a full-scale inquiry. I doubt whether we could find anyone willing to undertake such an inquiry, because he would feel that his work would be wasted. There is now a Parliamentary Commissioner to look into matters relating to the health service. Anyone can get in touch with him and put forward their views or complaints.

I wish to raise a point about health visitors. The community health services are worried about the future of the service because it is felt that there is a new gap between the community health service and the community social services. I refer to home nursing, midwifery, chiropody and family planning, all of which have been local services. There is real anxiety among the health visitors employed in these services, as they consider that it may be very difficult for them to maintain their work because a vital part of it has been co-operation with the social services and the education service. It would therefore be helpful to have an assurance on this point.

I am pleased that patients now spend less and less time in hospital and receive more nursing at home. The community service staff fear that they will have to fight for recognition and for resources which will now be under the control of members and officers, who, perhaps, will have no understanding of anything outside hospital work.

Administrators, treasurers, doctors and nurses in the new service will have equal authority and status, but the salary scales imposed on nursing appointments, after rejection by the Staff Side of the Nurses' and Midwives' Whitley Council, fall short of those offered to administrators by nearly £3,000 at the top and £1,200 in the lower scales.

It is interesting to note that even in the smallest districts administrators are to be paid almost the same as nursing officers in the large regions. I hope that my right hon. Friend will look into this matter. It seems that in making appointments there have been rather unfortunate decisions by the Staff Commission, which, I am told, because of these decisions has begun to lose the confidence of those who have been appointed.

Under Section 19 of the Act, car allowances will not be protected for health visitors, who also do not yet know what superannuation they will be offered, what will be the compensation arrangements, and how the appeal system will work. Health visitors are still worried about the disappearance of their profession from the statute book by the repeal of Section 24 of the National Health Service Act 1946.

The reply I received to a Question on this matter was not very satisfactory because it referred only to the inclusion of nursing in Section 2(2)(c) of the reorganisation Act. The activities of the health visitors under Section 24 of the 1946 Act were reinstated in Section 2 of the new Act. For the record, health visitors are not nurses. They do not do nursing; they do health visiting, as their name proclaims. They are very worried about their future status. I wish to emphasise that point.

I again pay tribute to those who have worked on management committee of hospitals. I served for nine years on the hospital management committee of the London County Council. Members of hospital management committees have done magnificent work and have given up their time fully and freely to the service of their fellow citizens. This should not be forgotten.

6.25 p.m.

Mr. William Molloy (Ealing, North)

I am conscious that time is running out. This is one of the ridiculous ways in which the House of Commons behaves. When we have a massive issue like the health of the nation, and a service which I believe to be the greatest service we have created we must, because of rules and regulations, cramp our views in as quickly and tightly as possible. However, after listening to the Secretary of State, I feel that even if we had a week to discuss this matter he would remain implacable. He is not prepared to give one inch. He is enshrined in his philosophy—which is remarkable for a Tory—that Whitehall knows best and that no one else must contribute.

On many past occasions in Opposition, Conservative Members unjustifiably accused Labour Governments of being unwilling to discuss and debate proposals, but in this debate speaker after speaker on the Government side has demonstrated that the Government will do what suits their purpose. They have shown that they accept the philosophy that Whitehall knows best and that no one else may contribute to the proposals. It does not even matter to the Government what the political views are of those outside the House who wish to contribute to discussion of these proposals. If there are to be changes in which people are involved, it would be far better to spend another six months debating the issue and listening to submissions from those who feel strongly about it, rather than say that the date is fixed and that then the new arrangements will begin.

The right hon. Gentleman, like all Tory Members, has forgotten that reorganisation of the health service is not about committees, consultants, or specialists; it is about ordinary folk. This point has been missed by the Conservatives.

The hon. Member for Tiverton (Mr. Maxwell-Hyslop) complimented the right hon. Gentleman on the fact that the objective is to have a new organisation coterminous with the local authority boundaries. If this is so, and if it is right for perhaps four-fifths of the nation, why should it not also be right for the Greater London area? Under the proposals the new organisation does not fit in with the local authority boundaries in the Greater London area. What has the right hon. Gentleman got against the Greater London area?

In my constituency it is not a political issue per se. A deputation from my constituency went to see the Under-Secretary of State. The men and women in the deputation had given up their time and taken a day from work to meet the Minister with officers from the local council. The meeting began with the terms of reference being read. The deputation was then told—and this confirmed their apprehensions—"There is nothing I can do. The Secretary of State will not let me." This is neither democratic nor sensible. Under the Local Authority Social Services Act 1970 local authority social services should have close links with social and health functions. People believed that that would take place with the reorganisation of the health service in the Greater London area.

There are many absurdities. For example, the London borough of Ealing, with a population of 300,000, is being chopped up for the purposes of reorganisation, whereas Hillingdon, larger in area but with a population of 250,000, is not. No wonder people are desperately concerned.

Again, why is it that the London boroughs within the Inner London Education Authority's area are to have two representatives on the family practitioner committees, whereas boroughs outside the ILEA area, which are themselves local education authorities, are allowed to have only one?

Neither the Conservatives nor the Labour supporters in Ealing understand the situation. The Conservative and Labour parties in Ealing are at one on this, as are the Conservative and Labour councillors. I ask the Under-Secretary of State not to assume the arrogance of the Secretary of State in his reply. I ask him to say that he is prepared to examine the problem so that when the new service is launched in Ealing it will be with some endeavour to see that it is a good service, without the bitterness and enmity towards the Secretary of State which, regrettably, exists at the moment.

6.31 p.m.

Dr. Shirley Summerskill (Halifax)

First, I congratulate the hon. Member for Berwick-upon-Tweed (Mr. Beith) on his maiden speech, particularly as I agreed with everything he said. We look forward to many more equally fluent, witty and informed speeches from him.

Secondly, I want to reply to a point raised by my hon. Friend the Member for Woolwich, East (Mr. Mayhew). My right hon. Friend the Member for Dept-ford (Mr. John Silkin) was suggesting three possible matters for discussion by the inquiry we would like to see set up, but he has authorised me to say that it was his own particular view that he was expressing.

When the Secretary of State moved the Second Reading of the National Health Service Reorganisation Bill, he said that its whole purpose was to provide an improved service for the patients, and he repeated it today. But, for this to happen, the service must reflect and be responsive both to the needs of the people it serves, as has been pointed out by my hon. Friends the Members for Southwark (Mr. Lamborn) and Ealing, North (Mr. Molloy), and to the needs of the people who work in it. I think our debate has shown that on both these counts the newly-reorganised service is not succeeding.

The voices of people served by the service are to be suppressed, with the emphasis upon selection and ministerial appointment instead of upon election. A similar arrogance of attitude is shown in the lack of consultation with those who work in and for the service, and taken together these are a recipe not so much for reorganisation as for disorganisation. They cannot provide, as the right hon. Gentleman intended, an improved service for the patients.

We warned the Government during the passage of the Bill that they could treat the National Health Service as if it were a biscuit factory with the Secretary of State's appointees as the board of directors. It is about the care of the sick, not the management of the sick. We stressed the need for continuous concentration on the administrative staff, who are the keystone of the service, and particularly during this critical transitional period.

As the right hon. Gentleman reminded us, the reorganisation will involve the work of nearly 1 million people in a service costing the taxpayers over £2,500 million a year. This Act has created an intricate, complex piece of machinery, and, like one of the early flying machines, it crashed as soon as it left the ground. The pilot and the designers should have given it greater thought.

My right hon. Friend has illustrated the basic similarity between the new regional health authorities and area health authorities and the old oligarchic, undemocratic, self-perpetuating hospital boards and hospital management committees. The Secretary of State reminds me of one of those apothecaries who practised in the Middle Ages—limited in vision but obstinate in purpose. After prolonged stirring and mixing, he finally produced with a great flourish a potion for treating the National Health Service, but it is no better than the one the patient has taken for years, except that it has a different name, and, in fact, the patient becomes a great deal worse.

Where are the promised new brooms to sweep the service clean? We find that the identikit chairman of a new regional health authority appointed by the Secretary of State will be a middle-aged male, a holder of the British Empire Medal, and he will have no qualifications at all to work in any branch of the service. The Secretary of State's appointees as chairmen of the area health authorities include less than one-third local democratically-elected representatives, and some token trade union representatives of the people who actually work in the service. Presumably this is because they have not the drive, humanity, judgment and diplomacy which the Secretary of State said he was looking for. So, how can the Government's new management be more efficient than the old when it will simply be the mixture as before?

My right hon. Friend mentioned the dearth of women amongst the Secretary of State's appointees. The figures are extremely revealing. Of the regional health authority chairmen, there will only be two women out of 14. Of the area health authority chairmen, there are only 11 women out of the 88 appointees so far. Out of a total of 217 appointees to the regional health authorities, only 47 are women. I am not advocating a specific quota for women, but I cannot believe that, in a population the majority of which is female, a larger number of women with suitable qualifications was not available for this important work, especially as at least half, if not more than half, of the people who work in the service are women.

I now come to the serious effect of the reorganisation on the senior administrative staff, whose traditional dedication and loyalty we take for granted. Their morale is desperately low, and the right hon. Gentleman must accept the fact, unpleasant though it is, that there is a crisis of confidence within the service today, as has been well illustrated by my hon. Friend the Member for Willesden, West (Mr. Pavitt) and my hon. Friend the Member for Nottingham, North (Mr. Whitlock). Because of the deplorable lack of consultation and information, there is widespread anxiety and uncertainty about future posts and new salary scales. The National and Local Government Officers' Association representing key administrative, professional and technical staffs, will be lobbying Parliament next week. It has written to every Member already. It wants to ensure a cohesive management and staffing structure. The right hon. Gentleman started off on the wrong foot when he arbitrarily fixed the salaries of the chief officers, and it was only after NALGO protested and saw the Prime Minister that an adjustment was made.

The right hon. Gentleman is also aware of the widespread dissatisfaction about the selection procedures and the method of short-listing for the appointment of senior hospital management staff and senior nursing staff to new posts in the new service. Several hundred top posts are involved, some with salaries of £8,000, yet the right hon. Gentleman claimed on Second Reading that the purpose of the Staff Commission was to safeguard the interests of the staff.

As a result of all this, last week the right hon. Gentleman admitted to the House, in what must be the understatement of the Session that: Some officers in local authority health departments are not showing keen enthusiasm to join the new health service."—[OFFICIAL REPORT, 4th December 1973; Vol. 865, c. 1067.] The fact is that a great many are taking jobs in local government because there is no guarantee as to their future conditions of employment in the new service or of the protection of their present pay and conditions of service.

Perhaps I can bring this serious situation nearer home to the right hon. Gentleman, right on to his political doorstep. The Leeds area health authority is to lose no fewer than four of its top community health service administrators, including the chief administrative officer. They are going to work in other local government departments. One of them, Mr. John Maury, has said: I do not know what my prospects would have been had I remained here. So when the local government structures were announced I had to make up my mind whether to opt for something I coupld see or for some thing I could not see. Security was doubtful. Another chief health service administrative officer from the West Riding, who is leaving, with his deputy, for local government, has said: If we had stayed here we would have had no idea, either on April 1st or in the future, where we would work, what we would have done, how much we would have been paid in the National Health Service. I could give many more examples. It is tragic that the valuable experience and expertise of so many senior administrative staff is being lost to the National Health Service at this very critical time. As for the rest of the staff, too many of them are afraid of being trampled underfoot by the mighty, all-powerful elephant under the Secretary of State's remote control. If one talks to nurses, dentists, medical officers of health, general practitioners, social workers and nonprofessional health service workers, one finds confusion, bewilderment and anxiety about their future rôle in the National Health Service, to helping which they have dedicated their lives. They are concerned about their inadequate representation on the health authorities.

It is 25 years since the Labour Government proudly created the National Health Service. Under the present Government we have witnessed increasing and unprecedented unrest among people who staff the service, culminating in the present industrial action of the ambulance men. Today we are trying to save the service, the patients and the staff from bureaucratic management and all that goes with it. The Government should postpone the introduction of the new service on April Fool's Day. We want a full-scale inquiry into this reorganisation, a reorganisation which is based on a regressive and undemocratic Act which will do irreparable harm to the National Health Service.

6.43 p.m.

The Under-Secretary of State for Health and Social Security (Mr. Michael Alison)

Like the hon. Member for Halifax (Dr. Summerskill), I start by congratulating the hon. Member for Berwick-upon-Tweed (Mr. Beith). I hope he is enjoying the congratulations raining upon him. They are not quite so liable to be repeated. Nevertheless, we are quite genuine in our congratulations. For one delicious moment I thought we were about to be led into a real tourist visit to his marvellous constituency, but then the hon. Gentleman brought us back to the nitty-gritty of the National Health Service reorganisation, and he proved himself to be extremely well informed about that.

I should like to deal quickly with one of the hon. Gentleman's main points. I cannot hold out much hope of sectors in his area each having a community health council. But, although sectorisation will be necessary in his part of the world, community health councils will nevertheless have a valuable rôle in preventing the sort of polarisation which tends to happen in fairly large areas and in giving a genuine community service.

In addressing ourselves to the Opposition motion, as we must, the House is facing one particular difficulty. There are two quite different aspects of the motion. The first is the grave concern that it expresses about the way that reorganisation is taking place—in other words, the implementation of policy—and subordinate to that, but very much part of the motion, is a broad regret about the composition of the authorities, the method of their appointment, the fact that they are not elected, and so on.

The aspect about the composition raises again the whole philosophical policy argument which has been going on for a very long time. We have debated it at length. We debated it on Second Reading of the Bill, as it then was, and extensively on Report and, as the right hon. Member for Deptford (Mr. John Silkin) knows, in Committee. But this matter goes back very much further than that. I remind the House of the time scale which has been involved on precisely this philosophical point, which the right hon. Gentleman wants us to look at again, to debate and to take up time upon. I think that the House will agree that it is quite out of proportion and unreasonable to ask us to spend more time on this matter.

This matter started probably two or three years before 1968, when the Department first began its internal thoughts under the right hon. Gentleman's Government. They had extensive discussions with interested groups on this subject, leading to their first Green Paper in 1968, which took a tentative view, certainly, that the National Health Service should be unified as to its three parts. They then tended to think that it should be outside local government, although because the Royal Commission had not reported and various other matters were being debated, such as the reorganisation of the social services, they were somewhat tentative in their view that reorganisation should take place outside local government.

However, two years later we come to the second Green Paper, of 1970. The right hon. Gentleman's Government, and the right hon. Member for Coventry, East (Mr. Crossman), took a clear and explicit position that the service should be unified as to its three parts outside local government. They gave a list of London boroughs which should be incorporated in the new area health authorities. They are very similar to the proposals which the right hon. Gentleman was criticising my right hon. Friend for postulating this afternoon. We have all been over that ground previously.

We then come to the present Government's entry to office and our consultative document. That very much took up the position which the right hon. Member for Coventry, East had postulated in his Green Paper about a year previously, and confirmed that we thought that the best thing to do was to reorganise the National Health Service outside local government, which the Act embodies. It was at this point—previously one might have expected it—that the right hon. Member for Coventry, East reneged on the Green Paper of which he was the author and switched everything. What took place in 1968, the two Green Papers and previous consultations was completely wrong, and the Opposition wanted a system in which the health services were to be entirely reorganised within local government.

That was typically perverse of the right hon. Member for Coventry, East; but I am glad to see that the right hon. Member for Deptford, in his studied and commendable moderation, has taken a slightly more balanced view. He saw the difficulties of going wholesale against the original position of his predecessor. In Committee he took a very reasonable position, which was that in an ideal world there ought to be close links between the health service and local authority and there was the argument about democracy as well. But he was content to acknowledge that the ideal was far into the future, and to say that the first tenative steps in that direction should perhaps be a slightly larger number of local government appointees to the area health authorities. But further than that he did not go.

But now we come to December 1973, and a most radical departure, even from the two variations of the Labour Party's philosophical vision, was introduced today. It takes one's breath away to see what the right hon. Gentleman is now proposing: that most area health authorities and regional health authority members should be appointed from the ranks of local government and the trade unions. Furthermore, as the hon. Member for Woolwich, East (Mr. Mayhew) pointed out, this is associated with community health councils entirely to be appointed by local government, and local government exercising surveillance and control over these partly nominated area health authorities.

Incidentally, where does democracy come into trade union appointments? Is appointment of the trade union representatives to be made by the block vote? Is this the democratic element which we are to have introduced into the appointment of area health authorities? Under these radical proposals, are the community health councils to exercise authority over the appointee area health authorities? If so, what happens if community health council members fall out with the trade union appointee members of an area health authority? What sort of nonsense will emerge from this arrangement?

But then the right hon. Gentleman assured us that he has not introduced any very radical changes; he has merely suggested that a special inquiry should be set up to examine his proposals, which would sit for a long time. If the inquiry found, as it well might, in favour of the Green Paper No. 1, Labour 1968 version, we should be right back to where we started and all this time would have been wasted. The philosophical argument goes backwards and forwards, and everybody is kept waiting.

Mr. John Silkin

I enjoy the Under-Secretary's fun as much as anybody, but I want to correct his facts. He said that I suggested—he ought to look at HANSARD tomorrow and he will then no doubt withdraw what he said—that the community health councils should be superior to the area health authorities. I did not suggest that at all. I suggested that they should manage the district management teams.

Mr. Alison

I certainly accept that variation. But, in a sense, the right hon. Gentleman has made the picture even more gloomy, because one of the great advantages of the new scheme, as my hon. Friend the Member for The Wrekin (Dr. Trafford) pointed out with such insight and eloquence, is that the district management team, which is closest to the ground and involves doctors in management, will be the crucible in which key policies affecting a patient's life are formulated. This team will now be managed by the community health council appointed by local government. But what is the point of having a district management team, deliberately made up of a cross-representation of professional folk who are involved with the key issues of health care, if it is managed by appointees of local government? If a court of inquiry were considering this aspect—it might not have to spend very long thinking about it—I am pretty certain that it would come up once again with the sort of solution which rational men, shouldered with responsibility—such as the right hon. Gentleman's predecessors in office, and ourselves, once in office—have all agreed about; namely, that unification should take place with intercommunicating links with local government, but firmly outside it for reasons to do both with the budget and with the scale of operations of health care, and starting at the level of the region, which at present is much bigger than any existing local government unit, although it may not be bigger in the future. To link the two together at this stage would be entirely impractical.

Mr. Robert C. Brown (Newcastle-upon-Tyne, West)

Will the hon. Gentleman agree that, whether trade unionists working within the service are nominated at a branch meeting, at a regional council meeting or by the democratically-elected national executive of a union, such appointments are a damn sight more democratic than his right hon. Friend appointing a village squire or a local industrialist?

Mr. Alison

The hon. Gentleman is no doubt an expert in the way people are democratically appointed in the trade union movement. But democracy must be seen to be working, and what the public understands by democracy in the trade union movement is what happens in the Trades Union Congress every year with the block vote. That creates the same impression as we get when it is suggested that some of the area health authority members should be appointed by the trade unions. I agree with the hon. Member for Ealing, North (Mr. Molloy), who said that it is a pity we have so little time. Hon. and right hon. Gentlemen have raised a number of queries, and I must, therefore, leave this rather philosophical theme and turn to specific points.

My hon. Friend the Member for Tiverton (Mr. Maxwell-Hyslop) talked about the West of England Eye Infirmary. I am glad to be able to confirm to him that after reorganisation the infirmary will be part of the Exeter and Mid-Devon district, and as such will share the multi-disciplinary management provided for all hospitals in the district.

The hon. Member for Woolwich, East raised an important point about community health councils. I think he will recall my right hon. Friend's reply to him on this subject on 17th July, but I confirm that our aim is still to establish community health councils by 1st April, when the new authorities will take over operational responsibility for the reorganised services. At the worst, this will happen in the month of April, if not by 1st April. I think that the fears which he reasonably pinpointed—namely, that authorities might be taking crucial decisions on issues affecting the consumer—will not be realised, if the time scale which we anticipate and for which we are planning is met.

Mr. Mayhew

The hon. Gentleman now says that there will be a further month in which decisions can be taken by the area health authority and the regional health authority, with no watchdog appointed.

Mr. Alison

I again use the form of words which my right hon. Friend used in his reply; that it is our aim to have them appointed by 1st April. The only qualification is the necessity to be cautious about the use of the future tense. We cannot be completely and categorically certain in advance whether we shall succeed, particularly if the motion which is now being debated is repeated and if there are delays, but our aim is to get these people in post by 1st April. We think that we shall succeed. That is not an absolute and irrevocable commitment, but we will do our best.

There was a good deal of talk about consultation. I must again remind the House that there has been very extensive consultation, not only by the Staff Commission in relation to the relatively small number of senior appointments before 1st April 1974, but also about all the staff who will be transferred. The importance of consultation about transfers has been stressed throughout, and that is taking place in preparation for the transfer schemes. Under a circular which we have issued very recently, authorities have to consult, first, with the staff as a whole or in groups having similar geographical or functional interests; secondly, with appropriate trade unions, professional organisations or staff associations; and, thirdly, in some cases, as necessary, with individual officers. I am confident that extensive consultation is taking place.

Mr. W. R. Rees-Davies (Isle of Thanet) rose——

Mr. Alison

My hon. Friend will see that I have only two minutes left, so I must ask him to write to me about what is causing him anxiety. I believe that we have as clean a record as it is possible to achieve on the matter of consultation, not only with the professional organisations but by the Staff Commission.

In view of the time which has already elapsed in considering the Bill and the very considerable thought which has been given to these philosophical and policy matters, upon which the right hon. Member for Deptford laid such stress this afternoon, in view of the fact that far greater uncertainty would arise for staff if we sought once again to postpone the implementation of an agreed Act, in view of the fact that morale is crucially affected by the period of uncertainty and we want to end this as soon as possible, and in view

Division No. 21.]	AYES	[6.59 p.m.
Abse, Leo	Dempsey, James	Janner, Greville
Albu, Austen	Doig, Peter	Jay, Rt. Hn. Douglas
Allaun, Frank (Salford, E.)	Douglas, Dick (Stirlingshire, E.)	Jeger, Mrs. Lena
Archer, Peter (Rowley Regis)	Douglas-Mann, Bruce	Jenkins, Hugh (Putney)
Armstrong, Ernest	Driberg, Tom	Jenkins, Rt. Hn. Roy (Stechford)
Ashton, Joe	Duffy, A. E. P.	John, Brynmor
Atkinson, Norman	Dunn, James A.	Johnson, Carol (Lewisham, S.)
Austick, David	Dunnett, Jack	Johnson, James (K'ston-on-Hull, W.)
Bagier, Gordon A. T.	Edelman, Maurice	Johnson, Walter (Derby, S.)
Barnes, Michael	Edwards, Robert (Bilston)	Jones, Barry (Flint, E.)
Barnett, Guy (Greenwich)	Edwards, William (Merioneth)	Jones, Dan (Burnley)
Barnett, Joel (Heywood and Royton)	Ellis, Tom	Jones, Rt. Hn. Sir Elwyn (W. Ham, S.)
Baxter, William	English, Michael	Jones, Gwynoro (Carmarthen)
Beith, A. J.	Evans, Fred	Jones, T. Alec (Rhondda, W.)
Benn, Rt. Hn. Anthony Wedgwood	Ewing, Harry	Judd, Frank
Bennett, James (Glasgow, Bridgeton)	Faulds, Andrew	Kaufman, Gerald
Bidwell, Sydney	Fernyhough, Rt. Hn. E.	Kelley, Richard
Bishop, E. S.	Fisher, Mrs. Doris (B'ham, Ladywood)	Kerr, Russell
Blenkinsop, Arthur	Fitch, Alan (Wigan)	Kinnock, Neil
Boardman, H. (Leigh)	Fletcher, Ted (Darlington)	Lambie, David
Boothroyd, Miss Betty	Foot, Michael	Lamborn, Harry
Bottomley, Rt. Hn. Arthur	Ford, Ben	Lamond, James
Boyden, James (Bishop Auckland)	Forrester, John	Latham, Arthur
Bradley, Tom	Fraser, John (Norwood)	Lawson, George
Brown, Robert C. (N'c'tle-u-Tyne, W.)	Freeson, Reginald	Leadbitter, Ted
Buchanan, Richard (G'gow, Sp'burn)	Galpern, Sir Myer	Lee, Rt. Hn. Frederick
Butler, Mrs. Joyce (Wood Green)	Garrett, W. E.	Leonard, Dick
Callaghan, Rt. Hn. James	Gilbert, Dr. John	Lestor, Miss Joan
Campbell, I. (Dunbartonshire, W.)	Ginsburg, David (Dewsbury)	Lever, Rt. Hn. Harold
Cant, R. B.	Golding, John	Lomas, Kenneth
Carmichael, Neil	Gordon Walker, Rt. Hn. P. C.	Lyons, Edward (Bradford, E.)
Carter, Ray (Birmingh'm, Northfield)	Gourlay, Harry	Mabon, Dr. J. Dickson
Carter-Jones, Lewis (Eccles)	Grant, George (Morpeth)	McBride, Neil
Castle, Rt. Hn. Barbara	Grant, John D. (Islington, E.)	McCartney, Hugh
Clark, David (Colne Valley)	Griffiths, Eddie (Brightside)	McElhone, Frank
Cocks, Michael (Bristol, S.)	Grimond, Rt. Hn. J.	McGuire, Michael
Cohen, Stanley	Hamilton, William (Fife, W.)	Machin, George
Concannon, J. D.	Hamling, William	Mackenzie, Gregor
Conlan, Bernard	Hannan, William (G'gow, Maryhill)	Mackie, John
Corbet, Mrs. Freda	Hardy, Peter	Mackintosh, John P.
Cox, Thomas (Wandsworth, C.)	Harper, Joseph	Maclennan, Robert
Crawshaw, Richard	Harrison, Walter (Wakefield)	McMillan, Tom (Glasgow, C.)
Cronin, John	Hart, Rt. Hn. Judith	McNamara, J. Kevin
Crosland, Rt. Hn. Anthony	Hattersley, Roy	Mallalieu. J. P. W. (Huddersfield, E.)
Cunningham, C. (Islington, S.W.)	Hatton, F.	Marks, Kenneth
Dalyell, Tam	Healey, Rt. Hn. Denis	Marquand, David
Darling, Rt. Hn. George	Heffer, Eric S.	Marsden, F.
Davidson, Arthur	Hilton, W. S.	Marshall, Dr. Edmund
Davies, Denzil (Llanelly)	Hooson, Emlyn	Mayhew, Christopher
Davies, G. Elfed (Rhondda, E.)	Horam, John	Meacher, Michael
Davies, lfor (Gower)	Houghton, Rt. Hn. Douglas	Mellish, Rt. Hn. Robert
Davis, Clinton (Hackney, C.)	Howell, Denis (Small Heath)	Mikardo, Ian
Davis, Terry (Bromsgrove)	Huckfield, Leslie	Millan, Bruce
Deakins, Eric	Hughes, Rt. Hn. Cledwyn (Anglesey)	Miller, Dr. M. S.
de Freitas, Rt. Hn. Sir Geoffrey	Hughes, Mark (Durham)	Milne, Edward
Delargy, Hugh	Hughes, Robert (Aberdeen, N.)	Mitchell, R. C. (S'hampton, Itchen)
Dell, Rt. Hn. Edmund	Hughes, Roy (Newport)	Molloy, William
	Hunter, Adam	Morgan, Elystan (Cardiganshire)

of the fact that we have made a good start, I must ask my right hon. and hon. Friends to reject the call for further delays in the implementation of the National Health Service Reorganisation Act, and to sweep away this irrelevant motion.

Question put, That this House expresses its grave concern at the way in which the reorganisation of the National Health Service is currently taking place; regrets that the composition of the authorities is primarily appointed rather than elected; and calls upon Her Majesty's Government to postpone the coming into operation of the new service pending a full-scale inquiry

The House divided: Ayes 266, Notes 285.

Morris, Alfred (Wythenshawe)	Richard, Ivor	Taverne, Dick
Morris, Charles R. (Openshaw)	Roberts, Albert (Normanton)	Thomas, Rt. Hn. George (Cardiff, W.)
Morris, Rt. Hn. John (Aberavon)	Roberts, Rt. Hn. Goronwy (Caernarvon)	Thomas, Jeffrey (Abertillery)
Moyle, Roland	Robertson, John (Paisley)	Tinn, James
Mulley, Rt. Hn. Frederick	Roderick, Caerwyn E. (Brc'n&R'dnor)	Tope, Graham
Murray, Ronald King	Rodgers, William (Stockton-on-Tees)	Torney, Tom
Oakes, Gordon	Rose, Paul B.	Tuck, Raphael
Ogden, Eric	Ross, Rt. Hn. William (Kilmarnock)	Urwin, T. W.
O'Halloran, Michael	Rowlands, Ted	Varley, Eric G.
O'Malley, Brian	Sandelson, Neville	Wainwright, Edwin
Oram, Bert	Sheldon, Robert (Ashton-under-Lyne)	Walden, Brian (B'm'ham, All Saints)
Orbach, Maurice	Short, Rt. Hn. Edward (N'c'tle-u-Tyne)	Walker, Harold (Doncaster)
Orme, Stanley	Short, Mrs. Renée (W'hampton.N.E.)	Wallace, George
Oswald, Thomas	Silkin, Rt. Hn. John (Deptford)	Watkins, David
Owen, Dr. David (Plymouth, Sutton)	Silkin, Hn. S. C. (Dulwich)	Weitzman, David
Padley, Walter	Sillars, James	Wellbeloved, James
Paget, R. T.	Silverman, Julius	Wells, William (Walsall, N.)
Palmer, Arthur	Skinner, Dennis	White, James (Glasgow, Pollok)
Pannell, Rt. Hn. Charles	Smith, Cyril (Rochdale)	Whitehead, Phillip
Pardoe, John	Smith, John (Lanarkshire, N.)	Whitlock, William
Parker, John (Dagenham)	Spearing, Nigel	Willey, Rt. Hn. Frederick
Parry, Robert (Liverpool, Exchange)	Spriggs, Leslie	Williams, Alan (Swansea, W.)
Pavitt, Laurie	Stallard, A. W.	Williams, Mrs. Shirley (Hitchin)
Peart, Rt. Hn. Fred	Steel, David	Williams, W. T. (Warrington)
Perry, Ernest G.	Stewart, Donald (Western Isles)	Wilson, Alexander (Hamilton)
Prentice, Rt. Hn. Reg.	Stewart, Rt. Hn. Michael (Fulham)	Wilson, Rt. Hn. Harold (Huyton)
Prescott, John	Stoddart, David (Swindon)	Wilson, William (Coventry, S.)
Price, William (Rugby)	Stonehouse, Rt. Hn. John	Woof, Robert
Probert, Arthur	Stott, Roger
Radice, Giles	Strang, Gavin	TELLERS FOR THE AYES:
Reed, D. (Sedgefield)	Strauss, Rt. Hn. G. R.	Mr. James Hamilton and
Rees, Merlyn (Leeds, S.)	Summerskill, Hn. Dr. Shirley	Mr. J. D. Dormand.
Rhodes, Geoffrey

NOES
Adley, Robert	Cooke, Robert	Gray, Hamish
Alison, Michael (Barkston Ash)	Coombs, Derek	Green, Alan
Allason, James (Hemel Hempstead)	Cooper, A. E.	Grieve, Percy
Archer, Jeffrey (Louth)	Cordle, John	Griffiths, Eldon (Bury St. Edmunds)
Astor, John	Corfield, Rt. Hn. Sir Frederick	Grylls, Michael
Atkins, Humphrey	Cormack, Patrick	Gummer, J. Selwyn
Awdry, Daniel	Costain, A. P.	Gurden, Harold
Baker, Kenneth (St. Marylebone)	Crouch, David	Hall, Miss Joan (Keighley)
Baker, W. H. K. (Banff)	Crowder, F. P.	Hall, Sir John (Wycombe)
Balniel, Rt. Hn. Lord	Davies, Rt. Hn. John (Knutsford)	Hall-Davis, A. G. F.
Barber, Rt. Hn. Anthony	d'Avigdor-Goldsmid, Sir Henry	Hamilton, Michael (Salisbury)
Batsford, Brian	d'Avigdor-Goldsmid. Maj.-Gen. Jack	Hannam, John (Exeter)
Beamish, Col. Sir Tufton	Dean, Paul	Harrison, Brian (Maldon)
Bell, Ronald	Deedes, Rt. Hn. W. F.	Harrison, Col. Sir Harwood (Eye)
Bennett, Sir Frederic (Torquay)	Dixon, Piers	Haselhurst, Alan
Bennett, Dr. Reginald (Gosport)	Dodds-Parker, Sir Douglas	Hastings, Stephen
Benyon, W.	Drayson, Burnaby	Havers, Sir Michael
Berry, Hn. Anthony	du Cann, Rt. Hn. Edward	Hay, John
Biffen, John	Dykes, Hugh	Hayhoe, Barney
Biggs-Davison, John	Eden, Rt. Hn. Sir John	Heath, Rt. Hn. Edward
Blaker, Peter	Edwards, Nicholas (Pembroke)	Heseltine, Michael
Boardman, Tom (Leicester, S.W.)	Elliot, Capt. Walter (Carshalton)	Hicks, Robert
Body, Richard	Elliott, R. W. (N'c'le-upon-Tyne, N.)	Higgins, Terence L.
Boscawen, Hn. Robert	Emery, Peter	Hill, John E. B. (Norfolk, S.)
Bossom, Sir Clive	Eyre, Reginald	Holland, Philip
Bowden, Andrew	Farr, John	Holt, Miss Mary
Braine, Sir Bernard	Fenner, Mrs. Peggy	Hordern, Peter
Bray, Ronald	Fidler, Michael	Hornby, Richard
Brewis, John	Finsberg, Geoffrey (Hampstead)	Hornsby-Smith, Rt. Hn. Dame Patricia
Brinton, Sir Tatton	Fisher, Nigel (Surbiton)	Howe, Rt. Hn. Sir Geoffrey (Reigate)
Brocklebank-Fowler, Christopher	Fletcher, Alexander (Edinburgh, N.)	Howell, David (Guildford)
Brown, Sir Edward (Bath)	Fletcher-Cooke, Charles	Howell, Ralph (Norfolk, N.)
Bruce-Gardyne, J.	Fookes, Miss Janet	Hunt, John
Bryan, Sir Paul	Fortescue, Tim	Hutchison, Michael Clark
Buchanan-Smith, Alick (Angus, N&M)	Foster, Sir John	Iremonger, T. L.
Buck, Antony	Fowler, Norman	Irvine, Bryant Godman (Rye)
Bullus, Sir Eric	Fox, Marcus	James, David
Burden, F. A.	Fraser, Rt. Hn. Hugh (St'fford & Stone)	Jenkin, Rt. Hn. Patrick (Woodford)
Butler, Adam (Bosworth)	Fry, Peter	Jennings, J. C. (Burton)
Campbell, Rt. Hn. G. (Moray & Nairn)	Galbraith, Hn. T. G. D.	Jessel, Toby
Carlisle, Mark	Gardner, Edward	Johnson Smith, G. (E. Grinstead)
Carr, Rt. Hn. Robert	Gibson-Watt, David	Jones, Arthur (Northants, S.)
Channon, Paul	Gilmour, Ian (Norfolk, C.)	Jopling, Michael
Chapman, Sydney	Gilmour, Sir John (Fife, E.)	Joseph, Rt. Hn. Sir Keith
Chataway, Rt. Hn. Christopher	Glyn, Dr. Alan	Kellett-Bowman, Mrs. Elaine
Churchill, W. S.	Goodhew, Victor	Kershaw, Anthony
Clark, William (Surrey, E.)	Gorst, John	Kimball, Marcus
Clarke, Kenneth (Rushcliffe)	Gower, Raymond	King, Evelyn (Dorset, S.)
Cockeram, Eric	Grant, Anthony (Harrow, C.)	King, Tom (Bridgwater)
		Kinsey, J. R.

Kitson, Timothy	Noble, Rt. Hn. Michael	Sproat, lain
Knox, David	Normanton, Tom	Stainton, Keith
Lamont, Norman	Nott, John	Stanbrook, Ivor
Lane, David	Onslow, Cranley	Stewart-Smith, Geoffrey (Belper)
Langford-Holt, Sir John	Oppenheim, Mrs. Sally	Stodart, Anthony (Edinburgh, W.)
Le Marchant, Spencer	Orr, Capt. L. P. S.	Stokes, John
Lewis, Kenneth (Rutland)	Owen, Idris (Stockport, N.)	Sutcliffe, John
Lloyd, Rt. Hn. Geoffrey (Sut'n C'field)	Page, Rt. Hn. Graham (Crosby)	Tapsell, Peter
Lloyd, Ian (P'tsm'th, Langstone)	Parkinson, Cecil	Taylor, Sir Charles (Eastbourne)
Longden, Sir Gilbert	Percival, Ian	Taylor, Edward M. (G'gow, Cathcart)
Loveridge, John	Peyton, Rt. Hn. John	Taylor, Frank (Moss Side)
Luce, R. N.	Pike, Miss Mervyn	Taylor, Robert (Croydon, N.W.)
McAdden, Sir Stephen	Pink, R. Bonner	Tebbit, Norman
MacArthur, Ian	Powell, Rt. Hn. J. Enoch	Temple, John M.
McCrindle, R. A.	Price, David (Eastleigh)	Thatcher, Rt. Hn. Mrs. Margaret
McLaren, Martin	Prior, Rt. Hn. J. M. L.	Thomas, John Stradling (Monmouth)
McMaster, Stanley	Proudfoot, Wilfred	Thompson, Sir Richard (Croydon, S.)
Macmillan, Rt. Hn. Maurice (Farnham)	Quennell, Miss J. M.	Tilney, Sir John
McNair-Wilson Michael	Raison, Timothy	Trafford, Dr. Anthony
McNair-Wilson, Patrick (New Forest)	Ramsden, Rt. Hn. James	Trew, Peter
Madel, David	Redmond, Robert	Tugendhat, Christopher
Maginnis, John E.	Reed, Laurance (Bolton, E.)	Turton, Rt. Hn. Sir Robin
Marples, Rt. Hn. Ernest	Rees, Peter (Dover)	Vaughan, Dr. Gerard
Marten, Neil	Rees-Davies, W. R.	Vickers, Dame Joan
Mather, Carol	Rhys Williams, Sir Brandon	Waddington, David
Maude, Angus	Ridley, Hn. Nicholas	Walder, David (Clitheroe)
Maudling, Rt. Kn. Reginald	Ridsdale, Julian	Walker, Rt. Hn. Peter (Worcester)
Mawby, Ray	Rippon, Rt. Hn. Geoffrey	Walters, Dennis
Maxwell-Hyslop, R. J.	Roberts, Wyn (Conway)	Ward, Dame Irene
Meyer, Sir Anthony	Rossi, Hugh (Hornsey)	Warren, Kenneth
Mills, Peter (Torrington)	Rost, Peter	Weatherill, Bernard
Miscampbell, Norman	Royle, Anthony	Wells, John (Maidstone)
Mitchell, Lt.- Col. C. (Aberdeenshire, W)	Russell, Sir Ronald	White, Roger (Gravesend)
Mitchell, David (Basingstoke)	St. John-Stevas, Norman	Whitelaw, Rt. Hn. William
Moate, Roger	Sainsbury, Tim	Wiggin, Jerry
Molyneaux, James	Scott, Nicholas	Wilkinson, John
Money, Ernle	Scott-Hopkins, James	Winterton, Nicholas
Monks, Mrs. Connie	Shaw, Michael (Sc'b'gh & Whitby)	Wolrige-Gordon, Patrick
Monro, Hector	Shelton, William (Clapham)	Wood, Rt. Hn. Richard
Montgomery, Fergus	Shersby, Michael	Woodhouse, Hn. Christopher
More, Jasper	Simeons, Charles	Woodnutt, Mark
Morgan, Geraint (Denbigh)	Sinclair, Sir George	Worsley, Marcus
Morgan-Giles, Rear-Adm.	Skeet, T. H. H.	Younger, Hn. George
Morrison, Charles	Smith, Dudley (W'wick & L'mington)
Mudd, David	Soref, Harold	TELLERS FOR THE NOES:
Neave, Airey	Speed, Keith	Mr. Walter Clegg and
Nicholls, Sir Harmar	Spence, John	Mr. Paul Hawkins.

Question accordingly negatived.

1. PRIVATE BUSINESS