§ Order for Second Reading read.
§ 3.48 p.m.
The Secretary of State for Social Services (Mr. David Enna1s)
I beg to move, That the Bill be now read a Second time.
The Bill fulfils the pledge given in the Queen's Speech that legislation to phase out pay beds would be introduced ill the course of this Session. The Bill, in Part III, also contains provisions relating to the regulation of the private sector, in respect of which there have been the consultations promised in the Queen's Speech.
I shall shortly deal clause by clause with the Bill, but before doing so I want to make a personal comment and then make some more general remarks to the House about the philosophy behind this Bill and the considerations which have led to its presentation today.
I want to say a word about my predecessor, my right hon. Friend the Member for Blackburn (Mrs. Castle). Some very hard and very unfair things have sometimes been said about her. When the dust has settled—and I am not denying that there has been some dust—she will be widely applauded as one who fought bravely and effectively to ensure that the NHS got its share of our national resources. She leaves behind many very good friends in the NHS as well as in the community and country at large who benefited from her commitment to all those who are needy and underprivileged in our society. It is an honour to follow my right hon. Friend, and no small challenge.
However much disagreement there may be in the House on the issues dealt with in this Bill, on one thing there can be no argument—namely, that pay beds in NHS hospitals are and have long been a matter of great controversy and division among those who work in the NHS, among patients, and in the country as a whole. That this controversy exists should cause no surprise, for the system of pay beds itself arose out of conflict. On the one hand, we have the principles 201 on which the National Health Service was founded—of a health care system free at the —point of use and available equally to all on the basis of medical priority alone—and, on the other, the principles strongly held by some of the right of the citizen to use his money to purchase medical treatment, and the corresponding right of the medical practitioner to offer his services through the private sector. Through the pay beds system facilities for the exercise of these rights of private practice are provided in an environment dedicated to a free and public service.
The marriage has not always been a happy one. Many staff who work in the NHS have often been offended by what they have seen as the operation of a system opposed to the principle of public service, and even more offended by what they have seen as the abuses of the NHS which have followed—of queue jumping, of greater attention to private patients than to NHS patients, of different qualities of food—and generally by the implication of dual standards—a first-class one for the private patient and a second class one for the NHS patient.
So great has been the feeling about this matter that it has led to four trade unions—NUPE, COHSE, NALGO and ASTMS, representing in all some 435,000 in the NHS, or over 55 per cent. of all staff—.passing policy resolutions against the existence of pay beds and, in some cases, the members of those unions taking industrial action.
If any proof were needed of the divisive nature of this issue, last week's events in the Oxford region should suffice. For there we had industrial action being taken by consultants in protest against our policy, causing inconvenience to some NHS patients, and that action being met by retaliation by ancillary workers who, I understand, decided to withdraw services from some doctors and from some private patients.
I want to make it clear that. as Secretary of State for Social Services, I deplore such action in the Health Service, from whichever quarter it comes and in pursuit of whatever objectives. The first casualties of industrial action are the patients. It is they who suffer, and suffer quite unfairly. Industrial action on the issue of pay beds—for or against them—is 202 totally unjustified, and I hope that the Opposition agree with me on this issue.
§ Mr. Patrick Jenkin (Wanstead and Woodford)
Would the right hon. Gentleman be prepared to address any of the four union conferences in the same forthright terms as I have just addressed 400 junior doctors and put forward the same argument in the Grand Committee Room?
§ Mr. Ennals
I shall have no doubt about doing so. I assure the right hon. Gentleman that I am prepared to make the same comments to my union colleagues, to the doctors, and to the House. These are matters on which we must be fair. This argument—I am sure that the right hon. Gentleman put it to the doctors, and others have put it—must be decided democratically in Parliament. This issue cannot be resolved through industrial action with patients as the pawns. There are, in my view, ethical issues involved when patients are affected by industrial action. I am glad that they are to be considered by a joint working party set up by the Royal Colleges and Faculties of Medicine and the BMA. Certainly the high standing of the doctors will be undermined by irresponsible unofficial industrial action.
The conflicts arising from pay beds may have nit the headlines only in the last two years, but they have been there, bubbling under the surface, for very much longer. It is five years since the Expenditure Committee, through its Employment and Social Services Sub-Committee chaired by my hon. Friend the Member for Wolverhampton, North-East (Mrs. Short)—I am glad that she is in the House today—began taking evidence on this matter. There, in the Committee's Report, we have page after page of charge and counter-charge—475 pages of evidence—one group of staff claiming that the system of pay beds worked to the detriment of the NHS with another group claiming the reverse. It is clear that these views were held strongly and with deep conviction. It is also clear that there were substantial differences of view between the professions themselves. I know this from my current postbag.
Of course, I accept that the British Medical Association's policy of opposition to the separation of pay beds has been arrived at after democratic debate, 203 that of the other three doctors' organisations only one—the Medical Practitioners Union—supports our policy and indeed would go much further, while the other two—the Hospital Consultants Specialist Association and the Junior Hospital Doctors Association—oppose it.
But let it not be forgotten that it was the Junior Hospital Doctors Association which in 1971 strongly criticised the pay beds system in evidence to the Expenditure Committee. The memorandum that it presented claimed that there were a number of abuses, including queue jumping and dual standards, arising from the system of private practice within the NHS. The JHDA made out a strong case in support of Government policy when, in the conclusion, it said:In view of the widespread staff shortages any significant increase in private practice must have an immediate adverse effect on service to NHS patients. Private health insurance is growing rapidly, following a widespread increase in real incomes, and any decline in standards of NHS care or any increase in waiting lists could lead to an acceleration of growth in private health insurance. This would lead to a diversion of scarce manpower to the private sector, inside or outside the NHS, with an inevitable further decline in NHS standards, thus accelerating still further the growth of private insurance. It would be difficult to arrest this vicious circle before the maximum number of people who can afford private health insurance had been driven into the private sector. This could amount to 40 per cent. of the population, and at this point there would be a two-tier medical service with a high standard private sector in competition with an impoverished low standard public sector.Of all the objections to pay beds, it is queue-jumping—seen as the purchase of privilege—which causes the greatest controversy, and understandably so, in my view. We all know that it is to "jump the queue" that is one of the main motives for patients choosing to go into pay beds.
I have been Secretary of State for Social Services for less than three weeks. But I served at the Department of Health for two years, from 1968 to 1970, and saw a great deal of the NHS during the time I was out of Parliament. Coming back to the NHS I have been struck forcibly by the intensity of feeling on this issue. I am convinced that the argument on pay beds will not just go away 204 because we wish it. It will remain a cankerous divide unless the Government act.
The separation of pay beds from the Service is the only solution which will end tension and conflict within the service. Moreover, I think that no purpose would be served either by referring the whole issue to the Royal Commission, as has been suggested by the Opposition, thus leaving it to fester for two years or so. This Bill has been prepared after a great deal of consideration and consultation. It seeks to meet many of the criticisms from the professions, as I shall show. It is better now to proceed with the measures and to deal with this ulcer by skilled surgery.
§ Mr. Raphael Tuck (Watford)
Does my right hon. Friend believe that the abolition of pay beds in NHS hospitals will abolish queue-jumping? There is queue-jumping in NHS hospitals today by local dignitaries, hospital staff, prominent members of society and perhaps MPs. [Interruption.] I should be grateful if I could put the question in my own way. Will queue-jumping be cured by the abolition of pay beds in NHS hospitals?
§ Mr. Ennals
I think that it will make a great contribution. I do not know to what extent my hon. Friend is right about the degree of queue-jumping in NHS hospitals. I should regret it. However, my hon. Friend appears to have some evidence and I will not question it now. This is not based on the ability to pay. Our task, as long as there are pay beds within the National Health Service, must be to seek to have a common waiting list. That is one of the tasks to which I shall be referring in the course of my speech.
On the day that the Bill was published the right hon. Member for Wanstead and Woodford (Mr. Jenkin) put forward his own suggestion for solving the problem —that staff "directly involved" in treat private patients should get an extra fee, just as the consultant at present does. This would, he claimed, remove one of the main sources of resentment from pay beds.
I cannot imagine any proposition more likely to intensify resentment in the service than this half-baked idea. What would the payment of an additional bonus to the staff who happened to be servicing the pay bed patients do for 205 industrial relations in the NHS? Would they get this bonus for extra work, or just because the patient happened to be a private one? And who would decide which staff had been "directly involved" in treating the private patient, and so would benefit from the bounty? Presumably the nurse and the porter in direct contact would get the bonus but not the boilerman responsible for keeping the private patient warm or the electrician responsible for ensuring vital supply of power to the operating theatres? The mind truly boggles at the disharmony that would break out if such a system were introduced.
Strangely the right hon. Gentleman's proposal is the absolute opposite of the conclusion reached by his Government in their White Paper, Command Paper No. 5270 in April 1973. Paragraph 26 said this:There was a reference in some of the evidence to dissatisfaction felt by staff whose work was concerned with private patients but who, unlike the consultants concerned, received no fee. In all such matters it must be remembered that the private patient pays to the hospital a daily charge which includes all except consultant services, and that this includes an appropriate share of the services of all other staff in the hospital. Thus it is within the functions of nursing, technical and junior medical staff to attend private patients as part of their normal duties and without a fee".The right hon. Gentleman now reaches exactly the opposite conclusion. It will be interesting to see whether he develops it in the course of his speech this after noon. If he thinks that the staff in the NHS hospitals can somehow be bought off on this issue, then I believe that he is absolutely wrong.
§ Mr. Michael Ward (Peterborough)
Does not the Minister accept that, among staff where, for example, nurses are taken off duty and put on to private wards, there is intense resentment because of the different work load carried by nurses in the private sector compared with those in the public sector? To give additional payments for this work would be a gratuitous insult to the rest of the nurses involved.
§ Mr. Ennals
I absolutely agree with my hon. Friend the Member for Peterborough (Mr. Ward). He adds weight to my own conclusions that it is a nonsensical approach. It would be very divisive 206 and it is quite contrary to the conclusions reached by the Government.
In my judgment the separation of pay beds from the NHS would have been inevitable within the next few years even if a Conservative Secretary of State had been in office. It would have been forced on him through the pressure of events and feelings which I have described. But I should make it clear that on this side of the House the separation of pay beds is seen not only as inevitable, but right because of the principles involved, and welcome for the benefits that the separation will bring to the service. I believe that the separation of pay beds will help restore that harmony and common sense of purpose to the service which is so necessary if all the other problems faced by the NHS are to be tackled.
There will also be more tangible benefits for the service which will arise from the release of staff and other resources previously used for pay bed patients. Because the phasing out of all but 1,000 of the pay beds will be in the hands of an independent board which will set its own timetable, I cannot say with precision when all these benefits will accrue. But over time the staff and resources released to the service will equal those needed to maintain 2,500 beds, the accommodation of three or four district general hospitals, which is a substantial benefit on anyone's reckoning.
I believe that the injection of the extra resources should have a beneficial effect, in the long term, on waiting times, though I am, of course, aware that other measures are needed if waiting times are to be reduced to an acceptable level.
I wholly reject the claims made by groups opposing our policy that the phasing out of pay beds will damage the NHS. One of the most vocal of these groups is the Campaign for Independence in Medicine. Let us look at its case, for it is not a very strong one.
First, it claims in its publicity thatthe fact that doctors have been able to combine public and private practice under the same roof has meant the saving of countless hours of travelling time—and countless hours in emergencies".The implication is that countless hours and lives will be lost once pay beds are phased out. That is not so. I accept that it is of value to have doctors working 207 in the same place the whole day, but for many consultants, whether they do private practice or not, the exigencies of their jobs are such as not to make this possible.
In London and other centres, for example, many consultants hold appointments in two or three hospitals and may already hold their private consultations outside their NHS hospital. Taking account of the hours they spend at home and on any non-clinical work, the hours during which they will be available on the spot in a particular hospital for emergencies are already a relatively small part of the 24 hours, and will be affected only marginally, if at all, by the phasing out of pay beds.
I accept that the consultant with an appointment to a single hospital might be more affected once the pay beds there are phased out, but here again the effect is likely to be far less than is made out, for one of the factors which the independent board will be taking into account in determining the phasing out of pay beds will by Clause 4(7) of the Bill be whether sufficient accommodationfor the private practice of medicineisreasonably available… to meet the reasonable demand…in the area …served by the hospital in question.Secondly, the Campaign for Independence in Medicine claims that the phasing out of pay bedswill increase the shortage of hospital doctors in the NHS—a shortage that could endanger your health and your family's".Not a word of justification for this scare-mongering claim is offered, and there is none. As I have said earlier, the phasing out of pay beds will ultimately lead to a release of staff resources to the NHS. And it is significant that this false claim was made only days before junior hospital doctors, at the BMA Junior Members Forum, were voicing fears not of a shortage of doctors but of a glut. Indeed, The Times of 29th March 1976 quoted a Dr. Olsen as speaking ofa spectre of mass medical unemploymentand Dr. David Wardle, Chairman of the HJSC, as speaking of the medical schools "churning out doctors ".
There has been much exaggerated talk of the cost of phasing out pay beds, and figures of £40 million loss of income have 208 been referred to. In fact, the loss of income in the foreseeable future will be far, far less than that. Because the pace of phasing out will be in the hands of the board, one cannot give precise figures, but my Department estimates that the cost will be about £3 or £4 million in the first full year, rising to about £20 million by 1980. My predecessor made clear that health authorities' allocations would be adjusted to make good these sums. It is certainly my view that the benefits will far outweigh the costs.
§ Mr. Patrick Jenkin
Perhaps the right hon. Gentleman will clear up one matter. He said that his Department estimated the cost of phasing out as being £3 million or £ million in the first full year. However, the Explanatory and Financial Memorandum says:The best estimate that can be made is that the reduction in income in 1976–77 will be of the order of £3–4 million.The Bill will not reach the statute book until later in the year, and clearly that estimate is for the remainder of the year. What is the figure for the first full 12-months period?
§ Mr. Ennals
I have given the best estimate I can. My hon. Friend the Minister of State will look at this, and if there is any further information which we can give, he will give it later in the debate.
§ Dr. Alan Glyn (Windsor and Maidenhead)
The former Minister said that the saving would be roughly £40 million. The right hon. Gentleman is now saying that the total saving will be £20 million. I cannot reconcile the two figures.
§ Mr. Ennals
The figure of £40 million was never given by my right hon. Friend the Member for Blackburn. Nor was it given by my Department. It was a false figure given by others. My Department's figure was always £20 million, and I have no doubt that my right hon. Friend will confirm that.
Lastly, the Campaign for Independence in Medicine makes its most sweeping and ill-founded allegations by claiming that this Bill representsa long step on the road to the eventual destruction of independent medicine".That is nonsense, and the medical profession knows it. This Government have said, time and time again—predecessor said so, too—is no part 209 of their policy to abolish private medicine. Our policy is for the separation of private medicine, not its abolition— is very different. Not only have we said this, but we have backed our words by safeguards written into this Bill which protect the rights of private practice both by hospital consultants and by general practitioners. Clause 2(2) provides this safeguard for consultants, and Clause 9 for general practitioners.
One other claim that I keep hearing from the doctors is that there has been insufficient time for consultation on this issue. On the contrary, it is difficult to recall an issue on which there has been more consultation or on which the consultation has been more effective in altering the manner in which a policy is to be carried out. The policy was first announced in our manifesto in February 1974, and it was repeated in October 1974. On 5th May last year my predecessor announced the Government's intention to implement the policies by legislation, and in August she issued a detailed consultative document on the subject. There followed much debate and controversy, publicly and between the organisations concerned, and then in very late November there began what Mr. Anthony Grabham, Chairman of the CCHMS, described in a letter of 5th January as aperiod of consultation with Government and with representatives of the professions (including those of the BMA, the British Dental Association, Hospital Consultants Specialist Association and of the Royal Colleges and Faculties),and involving Lord Goodman. That was a statement made back in January.
These discussions culminated in the proposals which were made by my predecessor, and announced to this House, on 15th December. They were backed by a letter from my right hon. Friend the Member for Huyton (Mr. Wilson), then Prime Minister, to the Chairman of the BMA in which he stated that if the proposals were accepted by the profession as a whole and normal working were resumed, the Government would embody those proposals in legislation.
I have taken note of the BMA's ballot result in which consultants voted by 4,438 to 2,048 in answer to the question whether they would accept the proposals provided they were embodied in the legislation, and of the resumption of 210 normal working. That was a very important vote, and we have now sought to inscribe in legislative form the proposals presented to the House on 15th December. I believe that it has been done fairly. So far as has been consistent with the requirements of parliamentary drafting, the Bill reproduces the actual wording of those proposals. The BMA recognises the extent to which the Bill reflects representations made by the profession, and Lord Goodman has accepted that the Bill fairly interprets the proposals presented to Parliament on 15th December.
§ Mr. Patrick Jenkin
In the interests of accuracy, may I correct what the right hon. Gentleman said about the CCHMS ballot? The question posed was not whether the Goodman proposals were acceptable. The question was whether those voting were prepared to accept Goodman or to hand in their resignations, as it were in escrow, to the BMA. The majority of those who voted said that they were not in favour of further industrial action. But I shall be giving the figures of the consultants' votes on the merits of what is in the Bill.
§ Mr. Ennals
There is no difference between us. The consultants were asked to ballot on the proposals which had been presented to the House by my right hon. Friend the Member for Blackburn—not on whether they agreed with them but on whether they would be acceptable it they were incorporated in legislation and normal working hours were resumed. I have indicated the result of the ballot. The right hon. Member for Wanstead and Woodford questioned its unanimity and spoke of the extent of the strong feeling amongst consultants. I might point out to him that half the consultants did not even trouble to vote in the ballot.
It is in this light that the Bill is presented. We have endeavoured faithfully to embody the 15th December proposals within the Bill, and I believe that we have succeeded. So far as has been consistent with the requirements of parliamentary drafting, the Bill reproduces the actual wording of those proposals.
§ Mr. Robert Kilroy-Silk (Ormskirk)
How can my right hon. Friend say at one stage that it is a matter of principle—and I agree—should phase out pay beds, and, at another stage, imply that this Bill is not the Government's Bill 211 but Lord Goodman's Bill and that we are simply phasing out those 1,000 pay beds which are surplus and which will go anyway?
§ Mr. Ennals
I did not make that implication. This Bill is the Bill prepared by my right hon. Friend the Member for Blackburn, and it is based on the proposals put to the House on 15th December by my right hon. Friend. I have made no changes in the Bill, but certainly it is true that Lord Goodman was involved in the discussions which led to the proposals made by my right hon. Friend which forunately ended a very damaging industrial dispute. It was recognised by many of those concerned that in the course of this long period of consultation many of the proposals in the consultative document were changed so that we could have a Bill which would be generally acceptable—
§ Mr. Ennals
I hope that it will be felt that the Bill which I am presenting today fully implements the manifesto policy of our party and in fact goes beyond it in terms of the regulation of the private sector.
Let me now turn to the clauses in the Bill. The "broad declaration" of paragraph 2 of the 15th December proposals that private pay beds and facilities should be separated from the NHS and the expression of the Government's commitment to maintain private medical practice is contained in Clause 2.
Clause 3 and Schedule 2 provide for the phasing out within six months of 1,000 pay beds, as provided under paragraph 3(b) of the 15th December proposals.
The make-up of this schedule, within the overall total of 1,000 beds, was one of the two items left over in the 15th December proposals for further consultation. There has been consultation with health authorities, area professional committees and other staff bodies and the Independent Hospital Group on the schedule, and we have endeavoured to accommodate all the points put to us. But I want to make it clear that consultation on this schedule can continue right up to and including the Committee stage on the Bill, and, in an effort to bring further flexibility to these consultations, 212 I have told health authorities that I am considering whether to use my powers to grant group authorisations in respect of those beds that remain after the 1,000 beds have been withdrawn.
I want to make it clear that on the particular division of the first 1,000 beds which is shown in Schedule 2, there has already been a considerable amount of consultation at area level and with the Independent Hospital Group. However, the profession have emphasised to me that the actual location of the beds that are to be withdrawn is to them very important. It could, they say, have significant effects on the viability of private practice. I accept that more time is needed. My predecessor had made it clear that local consultation would continue on the schedule. I should like, if possible, the list to be an agreed list. I am therefore inviting the profession and the Independent Hospitals Group to consult with me to see whether we can mutually agree which 1,000 beds are to be withdrawn. In doing this, we should of course want to take account of local representations.
I also intend to invite the Committee considering this Bill to accept a motion which will enable the Committee's discussion of the schedule to be taken towards the end of the Committee's deliberations. Then, if we manage to have an agreed schedule to bring forward, I shall be able to table it, in substitution of the one which is now in the Bill.
Part I and Schedule I establish the new Health Services Board, which will have two vital roles—that of determining the phasing out of all pay beds apart from the first 1,000 and that of regulating certain developments in the private sector. The board will be entirely independent of me as Secretary of State and of the Crown. It will have an independent chairman, two medical practitioners representing the professions, and two other members appointed after consultation with the NHS trade unions, other staff organisations and those representing the interests of patients. There are special committees of the board to operate in respect of its functions in Scotland and Wales. It is my intention to appoint a chairman of legal standing.
Clause 4 is the main operational clause for the board so far as its functions on phasing out are concerned. This requires the board to make proposals every six 213 months for the progressive revocation of pay beds, and requires the board, in deciding which pay beds should be phased out to have regard to four vital criteria set out at subsection (7). These almost word for word repeat the criteria in paragraph 3 (d) of the 15th December proposals, and, in short, provide for the pace of phasing out to be linked to the reasonable availability of alternative accommodation for the practice of private medicine, to the demand for private medicine and whether reasonable steps have been taken to provide those alternative facilities.
When the board makes its first report to the Secretary of State, it will have to include separate proposals dealing specifically with accommodation made available to consultants for private consulting rooms and authorised out-patient services for radiotherapy, diagnostic pathology and diagnostic radiology. At present the private sector relies heavily on the NHS for the provision of these services, and therefore careful consideration may be needed of the case for withdrawing authorisation for these services at individual hospitals.
As Secretary of State, I already have powers to make NHS supplies and services available other than for purposes of services under the NHS Acts. Clause 7 ensures that I can exercise these powers only if I am satisfied that doing so would not cause disadvantage to NHS patients. Clause 8 also requires me to use this power to allow a person access to accommodation and services at an NHS hospital as a private patient only if the services required are specialised and not privately available and accessible to the patient in Great Britain or if it is in the interests of the NHS for such services to be given at an NHS hospital.
These powers can be used only where I am satisfied that there will be no queue jumping—Clause 8(3)—and they cannot be used to reserve particular accommodation for private patients. These requirements will apply equally to patients from the United Kingdom and to those from overseas.
§ Mr. Peter Hardy (Rother Valley)
My right hon. Friend may be aware that there could be difficulty over the definition of the word "specialised" and that access to the NHS could continue for treatment of a specialised character. 214 There may well be a difference in the interpretation of the word "specialised" in relation to the word "specialist". I hope that my right hon. Friend will look at that in order that the Committee and the House in due course can be satisfied as to the definition.
§ Mr. Ennals
I will readily look at that point in the course of the Committee stage of the Bill.
Clause 8 sets out the method by which charges for these services should be drawn up.
Clause 9 enables the Secretary of State to give permission to practitioners offering family practitioner services at health centres, and to NHS chiropodists, to use the facilities for the treatment of their private patients. It confirms the existing entitlement. The Secretary of State for England, Wales and Scotland will have to submit to Parliament annual reports describing the facilities still authorised for private in-patients and out-patients and also the use they have made of their powers to allow the use on particular occasions of NHS services or accommodation.
The second area that was left over for further consultation under paragraph 3(f) of the 15th December proposals concerned the need for some system for regulating the developments in the private sector. The possibility of a wholly voluntary scheme was left open by those proposals, but the professions in subsequent discussions told my predecessor's Department that they had no proposals for a wholly voluntary scheme. For their part the Government have concluded that it is necessary to take powers in the Bill to control certain developments in the private sector. It is possible that some private sector developments could seriously damage the NHS, particularly by drawing off skilled and scarce staff in a particular area.
Last November in answer to a Question from my hon. Friend the Member for Leicester, South (Mr. Marshall) my predecessor gave details of some 38 private hospital developments, with provision for some 2,500 beds, of which my Department had notice. Some of these developments were small and are unlikely to damage the NHS wherever they are sited. But some are large—over 100 beds—and 215 some are very large–300 beds in Cromwell Road, and 500 beds in Bristol.
It must be obvious that hospitals of this size, in the wrong places could drain off resources from the NHS rather seriously. It is perhaps not realised just how large, in terms of staff, a 75 or 100-bedded hospital is. A 75-bedded hospital providing acute medical and surgical treatment would need about ten full-time doctors, 70 nurses, and 40 other staff. For a 100-bedded hospital 16 doctors, 90 nurses, and 65 other staff would be required.
In judging the potential harm which might be caused to the NHS it should not be considered that such development will be "competing" only with the larger district general hospitals of 500 beds or so. In fact, of the 2,280 non-psychiatric hospitals in Great Britain 877, or 38 per cent., have fewer than 50 beds and a further 1,034, or 45 per cent., have between 50 and 250 beds. Fewer than one-sixth of NHS non-psychiatric hospitals have over 250 beds.
After reviewing this evidence the Government have concluded that it would he right to take powers to control developments in the acute sector leading to hospitals over 100 beds in the GLC area, and 75 beds outside that area.
§ Mr. David Mitchell (Basingstoke)
Has it occurred to the Secretary of State that, instead of taking resources from the National Health Service, the provision of this private sector might reduce the flood of consultants and others who are emigrating from this country?
§ Mr. Ennals
Not at all. First, there is not a flood of doctors and consultants emigrating. Although there are more than I would like, one of the encouraging things is that an increasing number are actually returning to this country. The percentage increase of those returning is higher than the increase in those departing. I do not accept that argument at all.
We consulted the Independent Hospital Group about these size limits, but I regret to say that we could not accept its proposals for 250 beds for hospitals in the London area, 150 beds for those in the metropolitan counties and 1,000 beds elsewhere. To have done so would 216 have placed some parts of the NHS potentially at risk and would have rendered the controls virtually otiose.
§ Mr. Ennals
If I said 1,000 beds, I meant 100 beds in hospitals elsewhere.
If we had not imposed these controls but had accepted the proposals put to us, the control would have been negligible. It is interesting that that was recognised in an editorial in this week's Lancet. But I am pleased to tell the House that, in a number of other important respects, the Government have accepted the scheme of scrutiny which the Independent Hospital Group proposed in a letter to my Department of 5th April. The board, and not the Secretary of State is to be the determining authority, under Clause 13. The board will be assisted by assessors. There will be a right of appeal on points of law, and the criterion by which the board will judge proposals, in Clause 13—namely, whether the development would significantly operate to the disadvantage of NHS patients—is broadly similar to, though a little wider than, that proposed by the IHG.
In the light of the group's further comments, I intend to propose a change in the scheme so far as the smaller developments are concerned. It is only necessary for the independent board to have information to assist it in its general task of phasing out pay beds and facilities, and to underline that this is not a form of licensing for those under the figures I have given, I intend to substitute a simpler notification procedure for what the Bill describes as certification. The developer will be required to notify the board of a private hospital development before he seeks planning permission from the local authority. He will receive an acknowledgement of this notification, which he will need to show to the local planning authority. There will be no charge to the developer for this simple procedure. But I want to emphasise that these regulatory matters have one purpose only—that of preventing damage to the NHS.
I said at the beginning of my speech that queue-jumping has long been one 217 source of the friction and conflict that has developed on this issue. Under para. 3(a) of the 15th December proposals, now written into Clause 6 of the Bill, the board will be required within six months to make recommendations for the operation of common waiting lists, to ensure that private and NHS patients, whether in-patients or out-patients, are admitted to NHS hospitals so far as practicable on the basis of medical priority alone. On this side of the House we shall look forward to the board's recommendations with great interest.
Since my offer to the professions to consider carefully any suggestion for improvements in the Bill, they have sent me details of a considerable number of points which I am examining. I think some of them go to the heart of matters which we shall want to discuss in Committee. Others are matters of clarification and assurances on which I shall be ready to help them. My Department will be meeting the professions' representatives shortly to discuss these points.
In conclusion I want to make a direct appeal to the medical profession and to some of their spokesmen in the House. This Bill is very different from the proposals contained in the consultative document. It is the result of frank and sometimes acrimonious exchanges between the profession and the Department. Major changes have been conceded, although the principles of the Bill have been left absolutely unchanged. We now have a framework in which the phasing out of pay beds will take place, but at a pace which gives the medical profession time to make adjustments in the private sector, and which safeguards the right of private practice. There is no point in doctors and others tilting at windmills as some of those who are threatening industrial action are doing. It is time to recognise that a fair compromise has been struck which should provide an enduring basis for a settlement of this divisive issue. Let us stop the politicking and get back to the primary task of patient care.
§ 4.35 p.m.
§ Mr. Patrick Jenkin (Wanstead and Woodford)
I think that the whole House will endorse the last six words of the Secretary of State—that we should once 218 again start to try to put patients before politics. That is just what this Bill does not do.
We oppose this Bill for many reasons, but the core of the case which I shall seek to advance is that, inevitably, it will damage the National Health Service and harm the National Health Service patient. Ministers have in the past—I concede, not the right hon. Gentleman today—tried to represent those who oppose their policy as somehow diehard defenders of outdated privilege. If one's own motive is primarily envy, naturally that is the sort of reaction that one adopts towards those who resist one's proposals.
However, the new Secretary of State has recognised, I think, as regrettably his predecessor did not always recognise, that the doctors, whose main organisations have united—that in itself is pretty unprecedented—to fight the Bill, are primarily concerned for the future of health care in Britain, which must mean primarily the 98 per cent. of patients in NHS hospitals who are not private patients. It is they who will be the losers when doctors have to spend their time travelling between NHS hospitals and private clinics. It is they who will be the losers when the NHS loses—[Interruption.] I will justify these figures in a moment.
This absurd policy will cost £40 million to £50 million. It is the NHS patients who will lose when hospitals cease to be the object of private benefaction and when some of the best doctors withdraw from the NHS altogether, either to emigrate or to confine themselves to independent practice outside the NHS.
§ Mr. Jenkin
The hon. Lady wants to know where they should go. Perhaps she should ask them herself. Why are they all learning French and German? What will be the opportunities in the rest of the Community when, in December, there is free movement of professional personnel? The hon. Lady should ask herself that.
I shall have more to say about these points later, but they are some of the hard practical consequences which will inexorably flow from the Bill; it is NHS patients who will suffer.
219 These are some of the reasons which have driven some doctors to resort to the strike weapon. I have just addressed about 400 junior doctors in the Grand Committee Room and what I shall say to the House now I said to them then. I said that I should make my position quite clear. I totally condemn any form of industrial action which has as its intention the coercion of Parliament or Government. That is the negation of parliamentary democracy. But the corollary is that Government and Parliament must listen to reasonable arguments and respond to them.
When I tell the leaders of the doctors' organisations that I cannot support or condone their industrial action, I am told in terms that it was the only way that they made this Government listen to their case. Sadly, that was true of the right hon. Gentleman's predecessor, but it need not be true now of the right hon. Gentleman.
The leader in last Sunday's Sunday Times made the point admirably:Further concessions are being asked from the professional side: senior doctors will have to travel between hospitals more than they do now. Those concessions will only be cheer-fully made if the suspicion of bad faith, the feeling that the Government is vowed to its own schemes whatever counter-recommendations it hears, is banished for good.That is the challenge to the right hon. Gentleman. I believe that the policy in this Bill is misconceived and damaging. It is largely irrelevant to the real problems confronting the National Health Service and I hope that it will be defeated tonight. But if it is not defeated—and that depends on the view taken by the minority parties—and perhaps the minority party on the Government Front Bench below the Gangway will be of some assistance—the Government must at all stages conduct the debate in a spirit of magnanimity, compromise and reconciliation. Lord Goodman, in a very long apologia pro vita sua in The Times this morning, said that the new Secretary of State had a
grave and even terrifying responsibility to restore tranquility to a profession which traditionally wants to get on with its job.It is sad and regrettable but true that the right hon. Member for Blackburn (Mrs. Castle) left a poisonous legacy of bad blood which history will never for- 220 give. But the right hon. Gentleman—and he alone can do it—must now undertake what I might call the process of parliamentary dialysis.
§ Mr. Ennals
Will the right hon. Gentleman agree that it is not only a matter of trying to bring tranquillity to the National Health Service by means of concessions to the doctors. This is an issue on which principles are deeply held and views strongly felt by many other people in the service, and I have the task of not giving in to one side under the mistaken impression that this would buy peace. Peace can be bought only when the views of all are properly considered.
§ Mr. Jenkin
I accept that; but one has to examine the validity of the arguments put up by the different contenders. I am already listening to the arguments of those who perhaps share the Minister's views.
The Minister emphasises that changes have been made from the August consultative document. Perhaps about the only good thing about the Bill is that it is not now the total disaster foreshadowed in that paper. I pay unstinting tribute to the work of Lord Goodman, but I cannot go as far as he has gone in The Times today and at the weekend when he speaks ofmassive concessions and immense victoriesto the doctors in the negotiations. It is true that some of the worst features which disfigured that paper have been removed, but the central themes remain—the phased abolition of pay beds and the introduction of quantity licensing of hospital care out-side the National Health Service.
I appeal to the right hon. Gentleman to recognise, even at this late hour, that these two sensitive and contentious matters must be part of the wider consideration of National Health Service problems which the Government have refered to the Royal Commission. Why cannot he recognise that the right way to resolve the conflicts tormenting the National Health Service is to let the Royal Commission examine them and include them in its report?
When Ministers are pressed they are inclined to mutter something about manifesto commitments. Quite apart from the fact that there was nothing in the manifesto about licensing, the decision to 221 appoint a Royal Commission has changed the whole context in which the question falls to be considered. There was nothing in either the February or October 1974 manifestos about a Royal Commission to examine the whole financing and man-power of the Health Service; yet by October last year the mounting problems and the collapsing morale of the service, to which this politically inspired vendetta made a major contribution, led the Government to decide that a Royal Commission was the only answer. From then it became at once, and remains today, utterly senseless to proceed with this legislation in advance of the Royal Commission's report.
§ Mr. Ennals
It would be absurd now to postpone, for as much as two years before the Royal Commission reports, a decision on this issue which has been under discussion. We want to get this settled as there are many much more important issues to be taken up by the Royal Commission.
§ Mr. Jenkin
I accept the right hon. Gentleman's figure of two years and I will come back to that. What I said about the Royal Commission is the view of the Liberal Party. On 20th October the Leader of the Liberal Party asked the then Prime Minister if he would consider referring the pay beds issue to the Royal Commission,thereby obtaining the widest degree of consultation and avoiding a possible confrontation".—[Official Report, 20th October 1975; Vol. 898, c. 39.]I do not know what view the Liberal Party will take in the Division tonight, but it would be wholly consistent with the view of its Leader that the Bill should be rejected so that the issues can be referred, as they should be, to the Royal Commission.
If the policy is rejected by the Royal Commission the country will have been saved the damage of this disastrous legislation. If, however, the policy is confirmed by the Royal Commission, what has been lost? The Secretary of State says two years. But pay beds have been in the Health Service for 30 years, and I shall refer later to what Aneurin Bevan said about them in the beginning.
§ Mr. Jenkin
It may be news to the hon. Member. I do not suppose that he has read Mr. Bevan's speeches.
222 Between 1964 and 1970 there was no pressure to end the system of pay beds. There was the Health Services and Public Health Act in 1968 which expressly confirmed the principle with only minor modifications. The minority Report of the Select Committee in 1971–72 to which the hon. Member for Wolverhampton, North-East (Mrs. Short)—who was Chairman of the Committee—was a principal signatory shrank from recommending out-right abolition of pay beds. It suggested a series of detailed administrative changes to deal with the abuses which were referred to in evidence by some witnesses, but it did not recommend that pay beds should be abolished.
§ Mr. Jenkin
I shall come to them. Perhaps the hon. Member will contain himself. He has been sitting there shouting comments, and he must now show a little patience. Neither the minority Report nor the hon. Member for Wolverhampton, North-East recommended abolition.
The House should and could properly reject the Bill tonight, not necessarily in final judgment of the substantive issues, but because the appointment of the Royal Commission has supervened. Whatever else is said about the Bill, it cannot be wise for the Government to pre-empt the report of the Royal Commission by legislating hastily in advance of its doing its work.
The new Secretary of State has thrown away one chance by instructing his officials to put the Bill down for First Reading before he had read it. The House has another chance tonight. I believe that we should take it.
The Secretary of State says that the Bill represents the Goodman proposals. That is not wholly true. I want to make a general point about Goodman. Whatever may have been agreed between the professions and the Government, legislation is for this House to decide. Changes to the Bill will be urged on the Government by both sides and I ask that they be considered on their merits and not rejected as deviating from Goodman. Legislation is for Parliament, and Parliament cannot be bound by any under-standing reached by the Government out-side Parliament. Understandings rarely 223 comprehend the full detail that is in the Bill, and it is the Bill when it becomes law which will govern the conduct of affairs, not the proposals foreshadowing it.
Second, it is clear that the professions never agreed with the Goodman proposals. Those who took part in the talks had no power to bind their colleagues. The consultants who took part in the CCHMS ballot to which the right hon. Gentleman referred voted three to one to reject pay bed separation, and seven to one to reject licensing. I shall not remind the right hon. Gentleman of the actual question to which he referred, but they were given a choice whether to accept or resign. That is a very different matter from accepting outright.
§ Mr. John Ovenden (Gravesend)
The right hon. Gentleman is becoming very erratic in his arguments. He has said twice within the past two or three minutes that legislation is a matter for Parliament, yet only five minutes ago he was saying that Parliament should not concern itself with this legislation and that we should await the Royal Commission. Perhaps the right hon. Gentleman will make up his mind.
§ Mr. Jenkin
With respect, that is a sophistical argument. It is complete sophistry. I am saying that the Bill should not be before Parliament at all. The issue should be referred to the Royal Commission. However, as it is here, it must be a matter for Parliament. The hon. Gentleman is demeaning himself by trying to pretend that I am illogical.
§ Mrs. Barbara Castle (Blackburn)
The right hon. Gentleman has tried to imply that the consultants, in the ballot chosen by their own organisation as the correct way of consulting them, voted to reject the proposal. Is that what he said? I[...] that were so, the Government would have proceeded not with this Bill but with the original Bill.
§ Mr. Jenkin
The right hon. Lady is drawing a wrong conclusion. The profession was invited by the Government to withdraw its industrial action. The consultants were asked,please indicate which of the two propositions outlined below is nearer to your view as to the 224 desirable course of action for the professions now to adopt. Please tick one box only. EITHER I believe that the Goodman proposals should be accepted, on the understanding that they will be incorporated in any legislation OR I do not believe that the Goodman proposals provide adequate protection for the independence of the professions and I am therefore prepared to submit my undated resignation from my NHS" —
§ Mr. Jenkin
No, let me continue. It is perhaps indicative that, given that unpalatable choice, nearly half the consultants felt unable to tick either box. On the substantive question,Do you object to the proposed separation…?there were 5,165 consultants who said "Yes" and 1,834 who said "No"—namely, a three to one majority. On the question of independent licensing, 5,995 said that they were against it and 866 said that they were in favour of it.
§ Mrs. Castle
Incidentally, nearly 2,000 voted for the separation of pay beds. It would have been interesting if the right hon. Gentleman had quoted that. Is he not still running away from my major point? Is he saying that the professions do not accept the Goodman proposals? As the former Prime Minister's letter of 15th December to the BMA made clear, the Government were prepared to embody these proposals in legislation only if they were accepted by the medical profession as a whole. Is the right hon. Gentleman suggesting that we should withdraw the Bill and return to the original proposal?
§ Mr. Jenkin
The Secretary of State knows that I am saying that we should withdraw the Bill and refer the matter to the Royal Commission. That would be the sensible course to take. The right hon. Lady has referred to the Prime Minister's letter. In fact, the Prime Minister recognised that the profession would remain rootedly opposed to the proposal. On 15th December the then Prime Minister wrote to the chairman of the BMA in the following terms:I fully appreciate that your willingness to submit these proposals does not mean that you and your colleagues have in any way withdrawn your opposition to the phasing out of private practice and that you will reserve your right to try to influence Parliament's decision on the principle of phasing out.What is wrong with that? In fact, they withdrew their industrial action. That 225 put the Government in the position in which they cannot now resile from the Goodman proposals to the detriment of the medical profession. No doubt we shall discuss these matters in Committee.
The Secretary of State has said that the Bill fully embodies the Goodman proposals. It does not. There are several important departures, but at this stage I shall refer only to two. The first departure involves the issue of the 1,000 beds. The schedule does not cover Northern Ireland. It was always the clear understanding of the BMA representatives that the total of 1,000 referred to the United Kingdom, not merely to Great Britain. I recognise that the Northern Ireland Health Service is not part of the NHS, but when representatives of the professions met the former Prime Minister and other Ministers on 21st October 1975, the Secretary of State for Northern Ireland was present. He took part in the dialogue on phasing out pay beds in the Province. If phasing out were not to cover Northern Ireland, why was he there and why did he take part?
Alternatively, if subsequent discussions did not include Northern Ireland, why was that not made clear to the professions at the time. Whichever it is, as Northern Ireland is not included in the Bill the figure of 1,000 must be reduced to about 800 if the 13111 is to reflect the Goodman discussions. Some part of the 1,000 was clearly understood to refer to Northern Ireland.
The second departure concerns consultation. I recognise that the right hon. Gentleman felt a bit uneasy about the consultation he has managed to have so far on the list of beds to go. I shall remind him of what the Goodman document provided about the schedule of 1,000 beds. The document reads,In determining this Schedule the Government will wish to consult fully with the medical and dental professions".At a later stage the document reads,The Government will also wish to consult at the level of the individual hospital.There can be no dispute between the two sides of the House that they have not even begun to do that.
On 27th February a letter was sent to area administrators. It was sent to area health authorities. It said that such authorities were not required to comment on the location of the pay beds from which 226 authorisations would be withdrawn or the distribution or location of those that will remain. It continued:These are matters which the Secretary of of State recognises should be the subject of fuller consultation during the passage of the BillThe matter does not stop there. The letter continues:and, if necessary, in the period immediately following Royal Assent.That is what was written. But there is no power in the Bill to change the schedule. There is no power in the Bill as it stands to make that change.
I believe that the right hon. Gentleman recognises the inconsistency of the situation in which he finds himself, but it is worse than that. A Written Answer to my hon. Friend the Member for Woking (Mr. Onslow) disclosed that the community health councils have not been approached either. It is impudent nonsense for the Government to try to pretend that they have consulted in accordance with the Goodman proposals.
I do not suppose that the right hon. Gentleman react it, but the Press notice put out by his Department under the heading "Note to Editors" reads:Proposals for the initial reduction of pay beds in each area health authority made after wide consultations, are contained in a schedule to the Bill.That is impudent nonsense and the right hon. Gentleman should be ashamed of it.
This is an important matter of principle because phasing out is not merely a matter of numbers. It must take account of the kind of beds to go and the location of beds to go. It must take account of the availability of alternative beds. If it does not refer to individual hospitals and refers only to areas, it is impossible to decide whether the numbers are right in the first place.
Indeed, The Sunday Times made the following point:These are pre-eminently decisions where there should be careful, and if necessary prolonged, local consultation. Otherwise charges of dogmatism and high-handedness will persist.I believe that it is the right hon. Gentleman's intention not to have that label hung around his neck. Clearly we have had enough of it over the past two years. If he wants to live up to that intention he must be prepared to spell out exactly how he proposes to handle the consultation and in the meantime to take the 227 schedule away so that the list can be properly dealt with. The nub of the Bill is the question of separation. The Government are abandoning one of the key compromises on which the NHS came into existence and has existed for the past 28 years. I should like at this point to refer to the wise remarks of the late Aneurin Bevan speaking in Committee on the National Health Service Bill. He said:I admit at once that specialists are being given very favourable treatment, but I believe that by this means we shall eventually obtain a far higher standard of service for the patient…What we are endeavouring to do and what we must try to secure, is that the specialist is induced, as far as possible, to spend all his time at the hospital, both for his own sake and for the sake of the patients in the hospital, and—in the case of the teaching hospitals—for the sake of the students, and indeed, the whole atmosphere of the hospital. The more he spends his time in the hospital, the better for everyone concerned. I would encourage the specialist to have as much consultation in the hospital as possible. I do not want him to go to his surgery; I want him to be there on the spot and to see the people in the hospital."—[Official Report, Standing Committee C, 21st May 1946; c. 1155.]I suggest that that argument is every bit as valid today as it was in 1946. That is the concept which has become known as geographical whole-time practice.
I want to try to remove the misconceptions on which some accusations of abuse are based. A consultant who takes maximum part-time service with the NHS undertakes to give to the NHS and his NHS patients the equivalent of the care given by his whole-time colleagues—that is his contract—but he forgoes two-elevenths of his salary and two-elevenths of any distinction award he may receive. In return for giving up that part of his salary—and, remember, he accepts the full obligation of the whole-time man he has the right to do private practice and to arrange his NHS commitment flexibly enough to combine both. I stress these two points because they are not always recognised even by those who work in the NHS. He has a reduced salary but he has the same obligation as the full-time consultant. In that, he is different from all other employees in the hospital who get their full pay and 228 whose normal duties may cover either NHS patients or private beds.
Nearly half–47 per cent.—of the consultants in the NHS are maximum part-timers. Thus, their services are retained for the benefit of NHS patients, or they are working for NHS hospitals virtually full-time and overwhelmingly for NHS patients.
I have no doubt, and the Secretary of State should have no doubt, that if pay beds go and the consultants who wish to continue to take advantage of the private practice undertaking are forced to divide their time between two locations, some of the most distinguished will leave the NHS altogether and cease to be available for NHS patients. Others will continue to serve the NHS but this division is bound to be to the detriment of the NHS patient. If the consultant has to look after his private patients outside the hospital, in an emergency someone else will have to look after his patient in the NHS hospital. Instead of being on the premises he will be elsewhere or, even worse, commuting between hospitals. If all consultants opt to do that, one expert has estimated that the equivalent of 500 full-time consultants will be lost to the NHS. It is impossible to see how that will benefit the NHS patient.
As Mr. Bevan pointed out, not only patients but medical education will be affected. In 1968 the Todd Commission proposed the opposite of what the Bill proposes for private practice. Paragraph 515 of the Todd Report reads as follows:A number of Consultant teachers will probably wish to continue some private practice. The problems which this raises …have given rise to proposals that Consultant teachers' service should be geographically full-time', i.e. that they should be enabled to see and treat private patients at the teaching hospital.…We think that facilities for 'geographically full-time' service on these lines would offer great advantages to medical education.… we think that all university hospital authorities should do their best to provide accommodation suitable for this purpose and should expect that any private practice by their medical staff would be undertaken there".What a sensible view compared with the nonsense in the Bill, which goes in exactly the opposite direction! I have been told that in Canada the problem is dealt with in exactly the opposite way to the way which the Bill proposes. Consultants who wish to combine both functions have to 229 do so under one roof, whereas here the Government are forcing them to go separate and to perform their functions in different locations. I believe that Aneurin Bevan was absolutely right on this issue.
§ Mrs. Castle
Does the right hon. Gentleman also think that Nye Bevan was absolutely right when in "In place of Fear" he referred to his concession on pay beds as a defect in the scheme which was seen as such from the start?
§ Mr. Jenkin
I said that it was a compromise. It is a compromise which has produced inestimable benefits for the National Health Service.
Then there is the question of finance. I hoped that it would not be disputed that the policy will cost a great deal of money. At a time when NHS resources are under great pressure, that is money needlessly thrown away. The Secretary of State challenged the figures given to him by my hon. Friend the Member for Windsor and Maidenhead (Dr. Glyn) in an intervention. But his predecessor made perfectly clear what would be the cost. The right hon. Member for Blackburn said:Income from pay bed charges in England in 1973–74 was £14.3 million. On the basis of a similar use of pay beds, the estimate for 1975–76 is £26 million"—[Official Report, 4th November 1975; Vol. 191, c. 201.]Since then there has been a 30 per cent. increase in the charge for pay beds, so that the £26 million should perhaps be about £33 million or £34 million in 1976–77 for England, and for Great Britain as a whole perhaps £36 million. £37 million or £38 million.
In addition, some consultants will give up part-time status and take full-time consultancy, and they will have to be paid the extra two-elevenths. So I believe that we are talking about £40 million plus as the full-term cost of this policy. That is a loss to the NHS.
§ Mr. Jenkin
My hon. Friend is very knowledgeable in these matters. I have adequately justified the figure on the basis 230 of the figures given by the former Secretary of State. We know that the NHS is running out of money. There is no shortage of other resources but there is a shortage of money, and the public expenditure White Paper made clear that this money which is being lost because of the loss of pay bed revenue has to be made up by the Government at the expense of other things.
What will £40 million buy? It is the full cost of implementing the proposals in the White Paper "Better Services for the Mentally Ill" which we debated a few weeks ago. It is what the Government hope to save by repealing last year's decision by the House on the pensioners earnings rule. A sum of £40 million would go a long way to meet the objectives of the Central Council for the Disabled on mobility for the disabled. There is a whole raft of important medical priorities which are being shoved aside by the Bill. Is it the case that the Government put a higher priority on separating pay beds from the National Health Service than those matters that I have mentioned?
§ Mr. Jenkin
Even the administrative costs of £200,000 represent the annual cost of treating 200 dialysis patients. The Bill talks of medical priorities. What sort of priority is that?
The matter does not stop there. The Sun newspaper today bears the headline:Healey poised to slash spending. Massive Government spending cuts may be on the way.It should not be thought that the Health Service will be exempt. On page 2 the Sun says:The health service would also get a battering.Having been in a Government Department myself, I recognise that that has the smell of truth about it. I believe that the Government are considering further major cuts in spending. Is it the case that the Bill, which is the product of Socialist dogma, will have a higher priority than the care of patients in hospitals even though the matter could be referred with complete honour and integrity on all sides to a Royal Commission?
231 That then is the formidable case against the Bill. What of the case for? In 1971 a Select Committee examined the abuses of the system. In any large organisation, perhaps even within the Labour Party itself, there are abuses. Every profession has its few black sheep, and one must maintain constant vigilance. But one does not amputate the leg because of a few bunions on the toes. That is what is happening here. It is a major criticism that the Government have made no attempt to examine with the professions or anyone else how absurd might be eliminated.
The Select Committee considered abuses under six headings four of which were specific. The first was that consultants neglected National Health Service work; secondly, that the consultants altered hospital operating lists; thirdly, that they borrowed or stole drugs and equipment; fourthly, that hospitals sometimes used unauthorised pay beds.
Everyone agreed that it was impossible to quantify the extent or the effect of such abuses and that there was no evidence that they were widespread. Tighter administration, better controls and more vigilance would cure the trouble and certainly all that would be left would be a tiny pinprick compared with the damage done by separation.
One disadvantage which was referred to is the distortion of career structure—an argument primarily put forward by the Junior Hospital Doctors Association. Having been faced with the consequences of separation, that organisation is now entirely against the Government proposals. The Association's change of view is one of the most significant features of the argument.
The Government have made it cleat that their primary goal was the elimination of queue jumping, and I want to deal with that subject fully. The argument could be relevant for two reasons—first, the perceived effect—what people think is the effect and think is happening—and, second, the real effect—what actually happens. It is important to distinguish between the two because what people think happens affects attitudes. The only relevance of the queue jumping argument would be if it had any material effect on the waiting lists of National Health Service patients or if it lengthened the 232 time they have to wait for consultation or operation.
Let us look first at the substantive effect of so-called queue jumping on the waiting lists. It is doubtful whether there is any substantive effect at all. Paragraph 20 of Command Paper 5270, the White Paper published in reply to the Select Committee's Report, shows that the average number of private patients is less than half of 1 per cent. of NHS patients waiting for treatment. We are therefore dealing with a tiny corner of the service. There is no correlation between the level of waiting lists and the number of pay beds. Paragraph 20 states:Between 1966 and 1969 when the number of pay beds was reduced by over 22 per cent. waiting lists actually increased—by a little more than 4 per cent. From the end of 1969 to the end of 1971 when there was a small increase in pay beds (from 4,766 to 4,883) waiting lists for the first time for many years showed a reduction of about 6 per cent. There are acute general hospitals with long waiting lists and few or no pay beds, and some with shorter waiting lists and a large number of pay beds.
§ Mr. Kilroy-Silk
If pay beds do not provide the ability to queue jump, why do consultants refuse to agree to common waiting lists?
§ Mr. Jenkin
The question is, what will be the effect on the NHS patient? The attitude of some hon. Members is one of pure, undiluted envy. At least that is clear. The supporters of the Bill are not interested in whether it will confer any benefit on the patient.
It is hardly surprising that the question put to the DHSS by the chairman of the Hospital Consultants and Specialists Association, Mr. Nigel Harris, on what effect the phasing out would have on waiting lists received this reply:I am afraid it is not possible to confirm that the waiting time for a consultation will be reduced and the waiting time for admission for treatment will shorten when pay beds are phased out of National Health Service hospitals, but it is certainly hoped that this will improve the situation
§ The Minister of State, Department of Health and Social Security (Dr. David Owen)
Since that letter has been misquoted on many occasions, will the hon. Gentleman read the next paragraph?
§ Mr. Jenkin
People do not always quote the whole sentence as I did. I was going to refer to the reply by the right hon. Member for Blackburn, but I will 233 spare her blushes. The next paragraph reads:'The basic waiting list problem is one of very long standing. The Department have made a small start in tackling it by allocating, for the first time ever, £5 million in 1975/76 especially to deal with those aspects of waiting time that can be improved by capital expenditure.—there will be less for that, because pay bed money will be lost—We recognise that this can only have a small impact on a nationwide problem, and that much more is needed to eliminate otherwise intractable difficulties in all areas.The letter shows that the waiting lists have nothing to do with pay beds. That is confirmed recently in the priorities document which in paragraph 4.21 lays stress on the need to close under-used NHS beds in acute hospitals which are surplus to requirements in many areas. Most of the pay beds to be phased out will be in the same areas and it is becoming clear, as The Times said on March 25,the likelihood that they will be emancipated in large numbers only to be closed is increased.The substantive effect is minimal, negligible or non-existent and does not justify turning the whole basis of geographical full-time practice upside down or shattering medical morale as the Government have done.
But what of the perceived effect? Ever since I learnt that every right-minded Welshman believes that Churchill sent the troops against the miners at Tonypandy I have realised that in politics what matters is what people think happens, not what actually happens. That is what is wrong with pay beds. We need to offset the misconceptions by ensuring that the real advantages of pay beds are equally perceived by all those concerned with the NHS.
That is why I recently suggested three minor changes which could have that effect. First, and most important, I suggested that part of the money paid to the NHS for pay beds, which now goes direct into the Treasury, where it is lost in the common pool, should be used for the benefit of the hospital where it is earned.
Secondly, I suggested that the money should go into an earmarked fund, most of which should be used for identifiable projects or equipment which everyone 234 would know had been funded by private patients' fees.
Thirdly, I suggested that it might be right to examine the possibility of the payment of a modest honorarium to those hospital staff who work directly with the consultant for his private patients. I did not place on that suggestion the emphasis that the right hon. Gentleman placed on it, and I was interested in his reaction. I have told the union leaders whom I am meeting that I am prepared to discuss the proposal with them. It might be possible to establish a "tronc" similar to that in the hotel industry, as a result of which all those who do the work can benefit from the payments made.
I place much more importance on the first two suggestions, which would be sensible reforms, the main purpose of which would be to demonstrate to staff and others that there are undoubted advantages to NHS patients in retaining the system of pay beds.
I shall deal briefly with the other part of the Bill, which is primarily a matter for Committee. The licensing provisions, even in their modified form, arouse the gravest suspicions. The suspicion is that controls will be used effectively to throttle any developments in the independent health sector. We know that the Labour Party conference has voted twice to abolish independent medicine and to nationalise all independent nursing homes and hospitals. We know also that the right hon. Lady's consultative document contained the express intention to limit the size to the level of beds in 1974.
This is a fundamental issue of freedom of choice. If people choose to spend their money on providing for their own families' health, who the hell are the Government to say that they should not? If, with rising standards of prosperity, more people choose to exercise that right, why should any Government deny it to them?
Part III, whose intention must be construed in the light of the known prejudices of the Labour Party, is yet another manifestation of the ugly and unacceptable face of Socialism, the desire to spread the tentacles of State control and State monopoly ever wider over the lives of our people.
This is a nasty, misbegotten piece of Socialist legislation. It is wholly irrelevant to the real problems of the Health 235 Service. It will damage the itnerests of NHS patients. It will cost the NHS tens of millions of pounds per year. It will make no contribution to restoring the morale of the medical profession. Its professed objectives are either illusory or trivial compared with the damage it will cause. The so-called abuses that the Bill aims to correct could and should have been dealt with by tighter administration.
It is nothing less than a tragedy that so much time, effort and passion should have had to be expended on what is, in the last resort, a peripheral issue. I hope that all right hon. and hon. Members who do not share the prejudices, the envy and spite of the party opposite and also those who believe that at any rate the issue should be referred to the Royal Commission will join me and my right hon. and hon. Friends in voting against the Bill tonight.
§ 5.24 p.m.
§ Mrs. Barbara Castle (Blackburn)
I congratulate my right hon. Friend the Secretary of State on his new job and thank him for the kind things he said about me. I also congratulate him on keeping to the deadline for the introduction of the Bill, which was essential if it was to become law this Session, in fulfilment of our commitment in the Queen's Speech.
I am sure that my right hon. Friend is no more surprised than I am to discover that the Conservative Opposition will vote against the Bill. As I listened to the speech of the right hon. Member for Wanstead and Woodford (Mr. Jenkin), opening for the Opposition, I was interested in the remarkable echoes from the passage of Mr. Aneurin Bevan's Bill. It was the right hon. Gentleman's party which, in the period of 1946 to 1948, voted against the original NHS Bill. Now, Conservative Members are saying that they are in business to defend the very NHS they opposed. The fact that Aneurin Bevan had made his concession on pay beds did not alter the fact that on Second Reading they voted against the NHS.
§ Mrs. Castle
And on Third Reading they voted against the Bill complete with 236 the very compromise which they now say made it perfect. They used exactly the same kind of argument as we have heard today—that it was the thin end of the wedge of State tyranny and bureaucracy.
When my right hon. Friend referred to the fascinating brochure issued by the Campaign for Independence in Medicine I hoped that he would send that body a copy of the article by our old friend, Dr. Charles Hill, published in February 1946, when he was Secretary to the British Medical Association. It appealed to the patients of Britain to reject the NHS as a whole. It was for the same reason as has been advanced today that it was the result of "pride and envy" and that the patient would suffer. The actual words that dear Dr. Charles Hill used, addressing the patients of Britain through the Sunday Dispatch, were:You will suffer. You may tend to become a unit, an entry on a card.Therefore, what we have heard so far today was remarkably familiar, and it was equally irrelevant.
We on the Labour Benches know that we must force through the great social changes always in the teeth of bitter attack from the Opposition, only to have them say 27 years later that the thing we now think should advance a little further should not change one iota from the state it was in when they voted against it. That is the position we are in this afternoon.
I know the pressures that will have been put on my right hon. Friend from the medical profession as soon as he walked into the Elephant and Castle, just as they were on me. He will find that his honeymoon period is remarkably short. [Interruption.] I gather that it has not even started. I have seen no signs of it. My right hon. Friend is accused in the British Medical Journal of continuing what that journal calls my "breathless timetable" to get this legislation through. That is utter nonsense.
In addition to all the recent detailed consultations of which my right hon. Friend has spoken, my hon. Friend the Member for Plymouth, Devonport (Dr. Owen) and I raised the whole question of our election manifesto commitment the first time the BMA came to see us at the beginning of 1974. My hon. Friend the Minister of State, presiding over the 237 Owen Working Party, had two meetings with the BMA way back in October and November 1974 on the private practice panel of that working party, when we told the medical profession that that was our commitment and we intended to honour it.
The medical profession's policy all along has been to play for time, in the hope that, if it could be delayed, this terrible new improvement in the NHS would just go away. That is all that is behind the demand for the Royal Commission to look at the proposition. Procrastination is politics for the medical profession. It is its right to try to get the proposal postponed, or ditched, if it can, but it is our duty to go ahead without further delay, as two years have elapsed since we fought and won an election on this commitment. This Government were elected twice on their campaign to take the profit motive out of public medicine. That was our campaign. It is an honourable one.
It is a more honourable one than the campaign for independence in medicine, because the argument over pay beds is fundamentally about money and nothing else. It is the money that is to be made out of queue jumping. That is the point of principle that the medical profession is concerned to preserve. That is exactly why it has always refused to discuss the possibility of our moving more gradually towards phasing out through the introduction of common waiting lists. If the medical profession has the interests of the patient at heart, one would have thought that every consultant concerned about patient care would have hurried forward to say "Yes, let us keep our pay beds in NHS hospitals, but we will accept with you and work out with you and help you to apply and police a common waiting list for patients who come in free on the NHS, so that they may get exactly the same medical priority as those who pay us a fee."
If that had ever been their argument we could listen to it, but, of course, when my hon. Friend the Minister of State raised this with the private practice panel of the Owen Working Party he was told categorically "We cannot agree to this because some of our people would lose money" This is the point. I have no objection to the medical profession being concerned about the rate of remunera- 238 tion just as much as anybody else, but please spare us the hypocrisy of pretending that anything else is involved. The Government can stand with their head high over their treatment of the medical profession in regard to pay.
§ Mrs. Castle
Oh, yes. I remember the situation very clearly. There were many in the medical profession, whether consultants, general practitioners or junior doctors, who, because they were at the end of the pay queue, their review being due in April, really believed that they would lose out on pay policy, and that the Government would be introducing some incomes policy before they had had their chance to catch up. I said to them "No, your turn will come. It would be dishonourable not to allow you freely to catch up, as other groups have been allowed to do."
The Government therefore, fully honoured the review settlement by the DDRB in April 1975, because, of course, doctors must be properly rewarded, and they have the right to be concerned about their remuneration. I will be the first to defend that right, but do not let us pretend, I repeat, that any other principle is involved. If it is a high moral principle that we are concerned about we should be concerned with the foundation principle of the NHS.
This is how Aneurin Bevan described it in introducing it in those earlier days. He said:No society can legitimately call itself civilised if a sick person is denied medical aid for lack of means.What we are now adding to this is the principle that our society cannot legitimately call itself civilised if a sick person has to go lower down in the queue for medical treatment because of his lack of means.
§ Mrs. Castle
I know that my hon. Friend will try very hard to get into the debate later, and perhaps he will allow me to carry on.
This is a principle that hon. Members opposite have never understood, and that is why they voted against the National Health Service in the first place.
239 Intrinsically, the National Health Service is a church. It is the nearest thing to the embodiment of the Good Samaritan that we have in any aspect of our public policy. What would we say of a person who argued that he could only serve God properly if he had pay pews in his church? That is the difference between us.
When the right hon. Gentleman says that it is pure, undiluted envy on our part, he does not begin to understand that what motivates the other workers in the National Health Service—the nurses, the ancillary workers, the radiographers and the therapists—is not envy. It is not that they are cross because they do not share the swag. It is their deep medical pride in the principle that when a patient comes into a hospital he should be treated and considered on medical grounds alone. Anybody who wants to strengthen that in this difficult time ought to thank God that we have, uniquely in the world, a health service which embodies that principle—the "cohesion of our society" was the term that Nye often used—and should want to strengthen it by removing that defect in the scheme which was clear in it from the start, as Nye Bevan said in "In Place of Fear".
The argument about the independence of medicine being threatened is nonsense. Apart from anything else, nearly half the consultants work whole-time anyway, and no one can tell me that they are in shackles and chains. They do not think they are. There are specialties after specialties, such as the less glamorous ones in the country where the whole-timer is practically the only consultant there, because there are no extra pickings to be had.
No one can tell me that those who deal with geriatrics and the mentally handicapped are medical slaves. Of course they are not. People who use that kind of argument are insulting half the profession.
We have only to look at a great hospital such as St. Bartholemew's, one of the outstanding hospitals in the world. It is part of its charter that it does not take paying patients from the United Kingdom and cannot do so. Nobody can tell me that the people who work there are not free.
§ Mr. Patrick Jenkin
Does the right hon. Lady not accept that a very large number of the consultants, and an even larger number of the junior hospital doctors, will say absolutely outright not only that they do not have any expectation of having a private practice but that they would not wish to have one, and yet they stand resolutely with their brethren in opposition to the Bill?
§ Mrs. Castle
I am well aware of that, but it is a fact that Nye Bevan had to take the medical profession by the hand and lead it gently into the modern world, and 27 years later the profession thanks him for it. It did not at the time. The profession then said exactly the same things as the right hon. Gentleman has been saying about me, when he spoke of my having left behind poisoned relationships, and the rest of it. The profession in those days called Nye Bevan a medical Fuhrer, and said that he was introducing a Hitler regime. [Interruption.] Oh, yes. Let hon. Members opposite read Michael Foot's book on Nye Bevan. Indeed, I suggest that no Tories ought to take part in this debate till they have read Michael Foot's book on Nye Bevan. [Interruption.] They were saying these things, incidentally, about the National Health Service even after Nye had made his concession over the pay beds.
Something even remotely like peace was only restored by Nye by a last-minute concession that it should be written into the legislation that doctors were not to be obliged to serve whole time. We have rewritten that provision into this Bill. It is there in Clause 2(2) and has been from the very beginning of the discussions. I said to the medical profession "We are not compelling you to go whole-time. We will rewrite that guarantee into the legislation."
I know that a number of my hon. Friends want a whole-time salaried service, but we are not giving them it in the Bill. Some of them have attacked me for it. I cannot be attacked from both sides on that same point without one of them being wrong, and it happens to be the hon. Members opposite who are wrong—not for the first time.
I ask my right hon. Friend the Secretary of State for Social Services to resist the siren voices of Lord Goodman and 241 the Sunday Times who seek to pressurise him to water down the Bill still more.
§ Mr. Dennis Skinner (Bolsover)
What we are trying to say in our interjections is that already Lord Goodman has watered down this Bill.
§ Mrs. Castle
No. He has not watered down the Bill. I shall come to Lord Goodman's role in a moment. This Bill is the product of a compromise, but my right hon. Friend the Secretary of State is now being told in terms, by the Sunday Times and Lord Goodman, that his fitness to govern will be proved by the extent to which he is prepared to make still more concessions.
This Bill represents the ultimate in compromise. I know that for a number of my hon. Friends it goes far too far. I believe that it represents a reasonable compromise. I believe that as trade unionists we should not suddenly and arbitarily cut off a source of income from anybody.
§ Mrs. Castle
No: it is practiced by trade unionists.
Some consultants operate in what may be called geographically unattractive areas, of which there are a few in my constituency. In those areas there are only a few pay beds and there are not the fat pickings that are to be found in the South. In the southern part of England consultants can easily transfer into private institutions, but that process is much more difficult in the remote and less attractive areas.
When I considered this matter originally I envisaged a Bill that would lay down a reasonable period of phasing out, not the abolition of all pay beds from the date of Royal Assent. I believe that phasing out would be a good Socialist and trade union principle. It would give people a fair chance to adjust their lives. I have always believed in phasing out, and, indeed, it is a phrase that we have used in all our manifestos. The difference now is that these matters will be 242 controlled not by the Secretary of State for Social Services but by an independent body. The constitution of that body has been carefully argued and agreed in our negotiations with the medical profession conducted through Lord Goodman.
It is clear that the profession does not trust me, but not just me. Indeed, as Nye Bevan said, the medical profession has never trusted any Minister of Health. In two minutes flat it will be found that they will not trust my right hon. Friend the Secretary of State for Social Services. The profession feared that the approach I have outlined would not be applied. Therefore, the idea of an independent board was thought to give it security. I must admit that it gives me a sense of security, too.
We all know that Secretaries of State change. Powers that might be operated by me in a certain way could be operated in a different manner by somebody else —and I am not referring to my right hon. Friend the Secretary of State for Social Services. I know that he and I are of the same kidney in this respect, but there are other future Secretaries of State to be considered. There is even the horribly remote contingency that we shall have another Tory Government, and the wicked successor syndrome is very much in my mind.
We are to have an independent board on which trade unionists as well as members of the medical profession will sit, working under an independent chairman. That will be a guarantee that no Secretary of State in future can come along and administratively wreck the whole programme of phasing out because that power is within his or her discretion. In this situation there is something to be said for limiting the administrative discretion. I should love to have that discretion personally, but I should not be so happy if it were to be in the hands of some other people. I shall not name names, but I am certainly referring to Members of the Opposition.
There is in this legislation the essence of a reasonable compromise. However, I believe that Lord Goodman is now pushing his luck by making the sort of statement he made last weekend. Now that I have been removed from office he is trying unilaterally to reinterpret the agreement, an agreement which I and my 243 hon. Friend the Minister of State, Department of Health and Social Security worked out with the medical profession, through the intermediary of Lord Goodman.
Let us make no mistake about the fact that detailed discussions took place on these matters, although the medical profession now refuses to call them negotiations. The profession is terrified of commiting itself to anything. If they were not negotiations, all I can say is that they certainly resulted in an agreement containing proposals that were argued line by line and word by word.
It is important for the debate that lies ahead for us to understand the nature of that compromise. It was set out in my statement to the House on 15th December. Incidentally, every word of my statement had been seen and approved by Dr. Derek Stevenson of the BMA as a fair interpretation on the outcome of these arms-length talks. I said in my statement:It is proposed that the legislation would embody two principles: first that private beds and facilities should be separated from the NHS"—a crucial part of the package compromise. Secondly, I expressed the Government's commitment to themaintenance of private practice in this country through the renewal of the provision in the National Health Service (Amendment) Act 1949, which maintains the right to private practice by entitling doctors to work both privately and in NHS establishments.' —[Official Report, 15th Dec., 1975; Vol. 902, c. 972.]Both those principles are embodied in this package and are crucial to it.
I wish to draw attention to a letter from my right hon. Friend the then Prime Minister which was sent to the profession on the same day as I made the statement. The former Prime Minister referred to the fact that discussions had been going on and said that he understood that detailed proposals had "evolved" and were to be placed before the profession and its committees and councils for urgent consideration. The Prime Minister wrote as follows:I am writing to inform you that if the proposals are accepted by the professions as a whole and normal working is resumed, the Government would embody the proposals in the legislation.244 He went on:I fully appreciate that your willingness to submit these proposals does not mean that you and your colleagues have in any way withdrawn your opposition to the passing out of private practice and that you will reserve your right to try to influence Parliament's decision on the principle of phasing outI stress the word "principle". One important thing to remember is that it was always accepted that the profession should have the right to try to stop the Second Reading of the Bill. Put the profession also accepted the following which is in paragraph 3 of the Goodman proposals:Despite their continuing opposition the medical and dental professions acknowledge that the phasing out of pay beds in NHS hospitals may, through legislation, become the will of Parliament. In that event the phasing out should be subject to the safe-guards outlined below.That is a very clear deal which has been struck, and the Prime Minister acknowledged the profession's right to try to defeat the Bill, but if any Bill goes forward, the deal is that it is to be a Bill along these lines. Of course, I accept absolutely that it is for Parliament to decide the contents of any legislation, and the right hon. Member for Wanstead and Woodford was right to make that point.
However, as far as the Government are concerned, what the Government are committed to and what they are obliged to ask their supporters to vote for is this compromise package and nothing else. If it is weakened, and if attempts are now made to say" We have to look now at the schedule because 1,000 beds is too many and we must cut them to 750"—I have even read that—I would point out that the commitment to phase out 1,000 beds within the schedule within six months is in the proposals the acceptance of which by the profession led to the Government embodying them in the legislation. If we are told that the profession is now going back on that then, by heavens, there are some things that some of the rest of us would want to go back on. I say to my comrades and to the House that what the Government of which I was a member tried to do was to bring peace to the NHS by striking a balance between their commitment to separate private practice from NHS hospitals and the fears of the medical profession that this would be a step towards 245 the total abolition of private medicine, which was never our policy.
§ Mr. Ronald Bell (Beaconsfield)
The right hon. Lady seemed to say—I am sure that it must have been inadvertently —that the Government were committed by their agreement with the medical and dental professions to pay no regard to debates in Parliament and not to be persuaded by them.
§ Mrs. Castle
No. I said absolutely the opposite. Of course it is for Parliament to decide the contents of any legislation. However, as far as the Government are concerned, I accepted on their behalf the obligation, in accepting that compromise, at least to try to persuade the House to adopt its contents. But if the profession fights not merely against the principle on Second Reading but fights to change the contents in the remaining stages of the Bill's passage through the House, an entirely new situation arises.
Therefore, I say to my hon. Friends that what we tried to do was to embody in this legislation a fair programme of phasing out which would give private interests a reasonable time to develop alternative facilities. It is not the Labour Party's policy, and has not been in our manifestos or anywhere else, to abolish private medicine.
However, when Lord Goodman says, as he did this weekend—I quote from the Daily Telegraph of 24th April—This is not a Bill to phase out pay bedsI tell him that he is dangerously inciting key workers in the NHS, who have been very patient through all these discussions, and, I believe, would continue to be patient, and would realise the decency of phasing out pay beds in a proper way if we were standing firm by our principle.
I remind the House of the key sentence in the whole of the Goodman proposals and which, I repeat, I said in my statement to the House, with full acceptance by the BMA. It is in paragraph 2 of the Goodman proposals:The legislation would contain first a broad declaration that private beds and facilities should be separated from the NHSI would never have agreed to any compromise which did not contain that governing principle.
§ Mrs. Castle
No. I must get on.
When Lord Goodman says that pay beds will not be phased out in his lifetime, andin some places, not at all",I wonder how imminent he expects his demise to be. However, it is not for him to interpret the criteria merely in order to win over his medical audience. The criteria are laid down in this legislation, laid down in detail in Clause 8.
I ask my colleagues to look at these criteria very carefully, because they provide reasonable time for alternative facilities to be provided. They also say specifically that if after a reasonable time opportunity is not being taken to provide alternative private facilities, that in itself would be reason enough for the board to decide that pay beds in that area should go. I repeat that I consider that to be a vital part. There may not be a final date in the Bill, but there is finality.
As for licensing, which the medical profession is now saying was in our manifesto, I reply that it is in the proposals that I put to the House on 15th December, the acceptance of which, by ballot of the consultants, has led to their embodiment in the Bill. I personally believe that a major flaw in the Bill is that the figures that we have allowed for unlicensed beds are too high, but that is a point on which we cannot have perfection.
Therefore, while sincerely wishing my right hon. Friend well in the stormy voyage that lies ahead I must say that he has here a very delicately balanced package. He said that he would not be unbending. I say to him that if he is tempted to bend to pressures from the professions he will face some very vigorous pressures from his own side of the House.
§ 5.56 p.m.
§ Sir George Young (Ealing, Acton)
The longer I listened to the speech of the right hon. Member for Blackburn (Mrs. Castle), the clearer it became to me that her removal from office was a prerequisite for better relations in the National Health Service. If she harangued the medical profession as she has just harangued the House, it is no 247 wonder that the profession felt embittered, threatened and insulted, and no wonder that the atmosphere between them became tense.
No one can have failed to notice the contrast in the two speeches that we have heard from the Government side of the House. The right hon. Lady said that the Bill represents the ultimate of compromise and that there could be no watering down. On the other hand, the new Secretary of State made it absolutely clear that he is open to persuasion on the content of the Bill and that he will not have a closed mind on the various representations that may be made to him. Whatever one's reservations about the principle of the Bill, the fact that we have a Secretary of State who is more moderate and reasoned in his approach to it is something on which the House can congratulate itself.
However, those are the only kind words that I have for the new Secretary of State. I listened very closely to his speech.
§ Mr. Ennals
Before the hon. Gentleman goes on and makes me feel uncomfortable, I want to state that I have presented the Bill that was prepared by my right hon. Friend, and any Secretary of State who does not say that in the course of debate he will listen to representations from both sides is very unwise. I listen to representations from all sides. That is why at one stage I intervened during the speech of the right hon. Member for Wanstead and Woodford (Mr. Jenkin) to make quite clear that I would listen to the views of all sides, and not only of those of the medical profession.
§ Sir G. Young
The right hon. Gentleman should not perhaps be addressing me so much as his colleagues. He has made it absolutely clear that he is prepared to amend the Bill in the light of representations made, and his right hon. Friend has already said—she was applauded by some of her colleagues—that the Bill represents the ultimate of compromise. The right hon. Gentleman's argument is not with me but with his right hon. Friend.
I listened very closely to the right hon. Gentleman's speech and for the answer to two very basic questions that are 248 puzzling my constituents and myself. First, who will actually benefit if the Bill is passed? Secondly, why has an arrangement which four previous Labour Administrations have allowed to continue and which has served the country well for 30 years suddenly be removed? The Secretary of State shed no light whatsoever on either of those basic questions. He expressed vague hope that the Bill would promote harmony and common sense. He was unable to describe any tangible benefit which would accrue to anyone in the NHS, and provided no rational explanation for suddenly wishing to separate pay beds from the NHS after so long a period, if not of marriage, of peaceful cohabitation. The Bill represents a triumph of dogma over reality.
Looking at the very wide range of problems confronting the NHS today, it is quite impossible to conclude that the overriding priority is to separate pay beds from the NHS. If hon. Members talk to their constituents about the problems facing the NHS, they will find that their constituents will not tell them that they find it mortally offensive that pay beds should co-exist with NHS. Constituents complain about a wide range of other subjects—about the difficulties of getting a home visit from a general practiitoner, shortages of experienced doctors in some hospitals, the threatened closure of cottage hospitals, and the need for modernisation of some of our older premises. Those are the issues which the House should be debating. We should be concerned about increasing the resources available to health care in this country.
If hon. Members opposite believe that the elimination of pay beds is an urgent measure to help the National Health Service or that their constituents want it, that shows how little they know about the NHS and how remote they are from the constituents they seek to represent.
The Bill introduces itself with a sentence which should be referred to the Director General of Fair Trading. It is described as a BillTo make further provision with respect to the use or acquisition by private patients and others of facilities and supplies available under the National Health Service Acts …".If there is one thing the Bill does not do, it is to make further provision for 249 anyone. There is less provision for both NHS and private patients.
What will happen to the private beds which are to be phased out within the first six months? I understand that 18 of the 46 beds to be withdrawn from the Kensington, Chelsea and Westminster area health authority will be withdrawn from the Woolavendon wing of the Middlesex Hospital. But they will not be made available to the NHS. They will simply be locked up. The district administrator has made clear that the funds are not available to the hospital to keep them going. This basic resource of the Health Service will not be used at all and the hospital will have less money because it will not receive the income from the beds. This shows how ridiculous these proposals are. It is not only a question of fewer beds, but of fewer hours from our medical practitioners.
A consultant neuro-surgeon who lives in Ealing does nine sessions a week with the NHS—six at the Middlesex Hospital and three in East London. He also has a private practice based on the Middlesex Hospital. As a result of the Bill, he has offered to go whole time, provided he can work from the Middlesex Hospital. However, he has been told that there is not sufficient money available to the NHS to enable him to go whole time. Consequently, in order to maintain his in-come he must run a private practice, though not at the Middlesex Hospital because pay beds are to be withdrawn. The result will be that, instead of giving 60 hours a week to the NHS as he does at present, he will have time to give only the 31 hours for which he is contracted. He says;The only alternative is to take myself and my skills to another country, but this would involve a great personal sacrifice and, I dare to add, a further loss to the NHS.May I also quote from a letter written by a member of the department of obstetrics of St. Mary's Hospital in London. He writes:I do not undertake private practice for my own reward, but occasionally manage private inpatients who pay their fees into a departmental fund. This is used by the professor and myself to finance research and other activities for which our university grant is inadequate. If private beds are phased out of this teaching hospital, I foresee the following results:
For some consultants, the option of going whole-time is not available because the NHS does not have the resources to pay them.
- 1) Departmental research, the visits of junior doctors for scientific meetings and
250 the purchase of medical journals would be restricted by the absence of our departmental private fees fund.
- 2) Part-time colleagues, who at present do their private operating here, will do this work elsewhere and will be less available to deal with emergencies involving Health Service patients. They will also be less able to be involved in the teaching of medical students.
- 3) St. Mary's Hospital will be less able to offer its special skills to people from overseas."
May I now say a word or two about the North Hammersmith District which serves part of my constituency. Hammersmith Hospital has no private wing, but it has 20 private beds. Between 90 per cent. and 98 per cent. of its private patients come from overseas. This is partly because the hospital has a post-graduate course for overseas doctors, who recommend it on their return to their countries of origin, and partly because it has built up an international reputation in the treatment of certain illnesses. The revenue from these private patients does not go to individual members of staff but to a research fund, and last year the revenue totalled £90,000.
Not only is this a useful source of foreign exchange, which the country badly needs, but it also represents resources for medical research which would not be available if this private practice were phased out. The revenue is threatened by the Bill, and I see no recognition of this valuable contribution in any of the clauses.
Patients from overseas often have illnesses which are uncommon in this country and their presence is of particular advantage in the training of doctors. Many other teaching hospitals, including Charing Cross, are in a similar position and stand to lose. Yet I can see no exemption for hospitals in this position.
I turn finally to the notion embodied in Clause 13 that the NHS needs protection against the private sector. This is straight from "Alice Through the Looking Glass". Does the Minister expect us to believe that the NHS, backed by the resources of the Government and the taxpayer and controlling 99 per cent. of hospital beds, is threatened by the 251 minuscule private sector, supported by post-tax income and with only 1 per cent. of the beds? Given the disparity and the size of the sectors, I suggest that the private sector may need protection from the public sector.
If we suppose that the viability of the NHS is threatened by the private sector, the Government do not seem alive to a much wider problem, which is that the private sector in this country may not tempt doctors away—they may be tempted away by other countries. It seems singularly short-sighted of the Government to say that they must protect the NHS from the private sector in this country when there may be an accelerated emigration of doctors from this country resulting in their loss from both the private and public sectors.
This clause raises an important point of principle in a mixed economy. Goods and services are provided by both the public and the private sector and the existence of two sources of supply give the consumer choice and, by offering competition, improves quality.
If we are to accept that goods and services provided by the public sector are to be protected from competition from the private sector, that is no longer the language of the mixed economy but rather of the State monopoly. There are various other goods and services to which the principle could be extended. Education is a clear example, but the State is in competition with the private sector in the production of motor cars and aeroplanes and, if this principle were established, it would be rapidly extended. It concerns me greatly.
We should be increasing the resources available to health care and not trying to hold up one sector in the hope that the other will grow a little faster. We should be encouraging both to grow. Hon. Members opposite will say that private patients' schemes can continue, but many would like to move to the elimination of private health care in its entirety and the attraction of private patients schemes is diminished by some of the proposals in the Bill.
We must stop looking at this rather narrow problem facing the National Health Service and concentrate on increasing its efficiency, creating additional resources and redistributing resources 252 from one sector to another. The House should be doing that rather than having to debate this peripheral and irrelevant Bill.
The Bill is not a cure for the long-term problems of health care in Great Britain. It is a short-term "fix" to raise the sagging spirits of the Parliamentary Labour Party.
§ 6.10 p.m.
§ Mr. George Thompson (Galloway)
Plainly, this is largely an English debate. So far as I can see, unless I need a new pair of NHS spectacles, there is not one Scottish Tory Member present who is prepared to mount the barricades with his English colleagues to defend the bastions of privilege. I congratulate the right hon. Member for Blackburn (Mrs. Castle) on enticing a couple of them into the House momentarily to listen to her speech. I hope that they benefited from what they heard. Perhaps they would be ashamed to tell their constituents that they had supported these bastions of privilege. We shall watch to see how they vote on the Bill.
It is not surprising that this is largely an English occasion. The vast majority of pay beds are in England. On the rare occasions when I say anything about England, it is usually the Health Service which drives me to it. The position in England is incredible. I think that members of the English medical profession should make educational visits to Scotland. Indeed, that also applies to English Tory Members of Parliament. They would see that things are done in Scotland in a much less socially divisive way than in England. When Scotland eventually attains self-Government, it will no doubt become an interesting country for people to see what we do, in the same way as at present they seem to go to France and Germany.
Frankly, if I were a member of the common folk of England—I am a member of the common folk of Scotland—I should be on the rampage. I should be up in arms against the socially divisive effects of the English medical system, and, indeed, of the English educational system. The people of England need to develop a greater sense of themselves as a single community where teachers, doctors, and all the rest would be devoted to the service of that community.
253 When I hear of the pickings which are available in the South-East of England, I have a wry smile at the thought of the patron saints, if they still are, of the medical profession—Cosmas and Damian —because Greek and Russian Christians call these patron saints of the medical profesion the holy moneyless ones. I commend the patron saints of the medical profesion to Harley Street and other such places.
The Bill, so far as it affects Scotland, is creating a sledge hammer to crack an ever diminishing nut. I understand why that should be so. The Bill has to tackle the situation in England. That is of first importance. But it is not unreasonable that it should contain provisions dealing with Scotland as well.
Pay beds in the Scottish Health Service have been falling steadily in numbers over the years. That is why this is a diminishing nut. Reference to Schedule 2 will show that. I am satisfied that, given time, pay beds in NHS hospitals in Scotland will disappear altogether. However, it does not seem unreasonable to help them on their way out, which is what the Bill will do.
There is a certain amount of confusion in the minds of some people in Scotland about the effects of the Bill. I had a letter passed to me this morning from someone who appeared to think that the Bill would abolish private practice. As the Secretary of State said, that is not so. The Bill seeks to separate private practice from the National Health Service. I am proud to say that the Scottish National Party supports that aim and the Bill.
We envisage a separate private sector in Scotland for those who feel that they want to pay twice for their health care. That is, in effect, what they are doing. If they want to spend their money in that way—only a small proportion of Scottish people would want to pay twice for a particular service—that is fair enough. Let them do so, but outside the National Health Service.
The Health Service in Scotland is very good. I agree with the right hon. Member for Blackburn that the NHS is an excellent service and that it has been of great benefit to ordinary people in this country. By that, I mean all parts of the United Kingdom. I hope that the Scottish Health Service will continue to be very 254 good and will so improve that no one will feel the necessity to spend money on private health care.
I should like to point out, as I have pointed out in the House on other occasions, the strong sense of commitment to the people of Scotland, irrespective of social class, by the vast majority of workers in the Health Service. I particularly commend that aspect to English Members.
The Bill continues the principle of allowing consultants to practise partly in the NHS and partly in the private sector. Clearly, if there is to be a private sector in Scotland—I repeat, if people want it, let them have it—it will be essential for consultants to be able to practise in both the private sector and the NHS. There would not be enough work for consultants to practise full time in the private sector as there would not be enough custom for them.
I happily commend Clause 6 and the aim of bringing in common waiting lists and preventing queue jumping, if indeed that disgraceful custom obtains. As we have had ample evidence of its existence. clearly it must be stopped.
My hon. Friends and I welcome the Bill in its application to Scotland. We hope that it will help to create in England a Health Service and medical profession as a whole committed to the service of the whole community of England.
§ 6.17 p.m.
§ Mr. Raphael Tuck (Watford)
I should be less than honest if I did not voice my grave concern about the probable effects of phasing out pay beds, which is what the Government seek to do. I know that my views will not be echoed by many of my right hon. and hon. Friends, although some have told me privately that they agree with me. [HON. MEMBERS:" "Name them"] I cannot name them, because they told me privately. How-ever, I ask my hon. Friends to realise that I hold my views with the same sincerity as they hold theirs. Therefore, I ask them to hear me out so that they can consider what I have to say.
Politics has been defined as the art of the possible. I wonder whether what we are about to do is possible. As a rule, doctors will generally perform only on 255 their own terms. We have heard of tremendous opposition to this measure by the medical profession. There have been strikes in the Oxford area. Consultants and doctors have told me that if this measure goes through, they will leave the NHS and emigrate. To where will they emigrate? They will emigrate to EEC countries where there is free movement of medical consultants and doctors. They will emigrate to the United States, Canada and Australia. They have decided that their sons, who are training to be qualified doctors, will also emigrate. We shall lose them from our medical service. That will inevitably result in a lowering of morale in the medical service in this country. There has also been opposition by NALGO in Kent, Wigan. Broxtowe, Havant and Warwickshire.
Is this idea possible? Politics, I repeat, is the art of the possible. The House will recall that in the 1930s the United States tried to enforce prohibition. Politics was the art of the possible, but that proved impossible. Years later, with their tails between their legs, the United States Government had to withdraw prohibition.
I am wondering whether the phasing out of pay beds will be possible in view of the enormous opposition which has been mounted by the medical profession.
I should like to refer to the tragic example of Sweden which had socialised medicine of a kind for 200 years. In 1955 the Swedish Government put through a Bill on compulsory health insurance which worked well for both patients and doctors. But in 1960 private rooms within general hospitals were discontinued and patients lost their freedom to choose their hospital or their surgeon.
From then on things went from bad to worse. I would refer my hon. friends to an article in the Bulletin, the journal of the American College of Surgeons, by Philip Sandblom, M.D. "The Tragic Development of Socialised Medicine in Sweden". My right hon. Friends on the Front Bench have already read it. My hon. Friends are concerned about waiting lists. The abolition of pay beds will not do away with waiting lists. As the right hon. Member for Wanstead and Woodford (Mr. Jenkin) pointed out, in the years 1966 to 1969 pay beds were reduced 256 by 25 per cent., but waiting lists grew by 4 per cent. There is, furthermore, no shortage of beds at the present time in the National Health Service hospitals. Waiting lists result from something quite different—they result from a shortage of staff.
So what do we do? We shall cut off our nose to spite our face by driving many of the already small number of doctors in the NHS hospitals out of those hospitals into private hospitals of their own. This will make waiting lists longer because of the time it takes doctors to travel to and from the private hospitals. If we have completely socialised medicine, that is a different matter, but we are not going to do that. The two have run, and are to run, side by side and, therefore, I say we should keep the doctors in the hospitals.
In other countries the trend is to allow a consultant to engage in State and private medicine only if he limits his private medical activities to the place where he has his State patients. This keeps the doctors in the hospitals and ensures their maximum efficiency and availability.
§ Mr. Ovenden
My hon. Friend said that this system ensures maximum efficiency for doctors and ensures that they are available. I draw his attention to the evidence given to the Select Committee which pointed to the absence of consultants from ward rounds, from clinics and from operating sessions because they were tending to the needs of private patients. The picture is not as rosy as he tries to paint it.
§ Mr. Tuck
I do not agree. I know of one surgeon in Watford who tells me that when he has seen all his private patients and before going home he goes back to the NHS patients to see whether they are all right. He cares for the two typs of patients side by side. I will come to another example in my own case later.
If we reverse the process and do not allow doctors to have their private practice at the same place as the National Health Service practice, the effect on emergency cover, supervision of junior staff and the length of waiting lists is not very hard to predict. If doctors have to travel for an hour a day to see their private patients, the loss to the Health Service, according to the British Medical 257 Association, would be the equivalent of 500 full-time consultants every year.
In my own case I had to go into hospital privately. The alternative would have been to wait for two years on my back, and my constituency would have suffered. I could have queue-jumped but I preferred not to take somebody's bed in the National Health Service; I preferred to pay.
One of the post-operative procedures I underwent was to have bobbles removed. The bobbles had been applied in order to contain the fat while the operation was healing. Professor Charnley was the surgeon involved in this delicate procedure. During it an emergency arose involving a National Health Service patient. The surgeon said "Mr. Tuck, do not move; I must put a sheet over you. Nothing will happen to you." He went out and returned in 10 minutes, having attended to the emergency. If he had had to go 10 miles to a hospital, where would that surgeon have been when the emergency occurred? He would not have been available to take care of it. There is a further point to which I would draw my hon. Friend's attention
If we do away with private practice in NHS hospitals, we shall create two separate medical services. This will result in the development of two different standards of medical care. We do not want a double standard in medical care, similar to our experience in education with the independent schools system. But that is what we shall get.
This has been brought out very forcefully by Lord Taylor of Harlow in World Medicine for March 1976. I strongly recommend my hon. Friends to read it. My friends on the Front Bench have already read it. In 1945 Lord Taylor was Labour MP for Barnet; in 1948 he was Parliamentary Private Secretary to Herbert Morrison; in 1964 he was Under-Secretary of State for Commonwealth Relations, and he looked after health affairs in the Lords. In 1962 he settled the doctors' strike in Saskatchewan by putting forward a plan agreed by both parties. His views, therefore, are entitled to serious consideration.
He pointed out that the National Health Service was introduced by a post- 258 war Labour Government, but that Government undertook to allow private practice within the National Health Service and, in return, the doctors undertook to co-operate in the NHS. Abolition of private practice therefore would be a breach of that undertaking.
Another matter for consideration is queue-jumping. This is not confined to private patients. It also happens in the National Health Service as I outlined in a previous question to my right hon. Friend in this debate. We shall not stop queue-jumping by abolishing private practice in the NHS hospitals.
My hon. Friends idea of stopping queue jumping by abolishing pay beds reminds me of the man who returned home one day to find his wife on the sofa in a sexual embrace with his best friend. He was very disconsolate for two weeks but after two weeks he brightened up. Someone asked him whether he had found the solution to his problem. He said "Yes, I have sold the sofa" If my hon. friends sell the sofa, it will not stop the queue-jumping. If we try to stop it by phasing out the NHS private beds, we shall merely be tipping the baby out with the bath water. As to my hon. Friend's concern about private patients engaging hospital facilities, they already pay substantially for their hospital facilities through taxation in the usual way, just like any other citizen. Another factor which should not be ignored is that many occupationally based private insurance schemes are in existence, often with premiums paid by an employer, enabling the insured and their families to choose their consultant, to choose privacy if they require it, and to be treated at a convenient time. Four and a half million people use private medicine, of whom 2½ million people are insured with BUPA, PPP and other such organisations. This is a sizeable number, ranging from directors to shipyard workers. What is to happen to them? They cannot be ignored.
It must also be remembered that many people wish to choose the surgeon who is to operate on them. I wanted and got Professor Charnley to carry out my operations because my previous operation had not succeeded. Conversely, the surgeon likes to be chosen for his own self. He 259 develops a reputation nationally and some-times internationally. Another most important factor is that of time. A person may be compelled by his calling, profession or business to have an operation at a particular time of the year. All of these objectives can be secured by having private beds in the hospitals.
But when all this has been said, I acknowledge that the present system of pay beds is wrong. It is wrong because it means that wealth can buy privilege within a public service. At £260 a week, only millionaires, Arabs and those who can pay large insurance premiums can afford such privacy. There can be no justification for this whatsoever. Therefore, I urge upon my right hon. and hon. Friends the view that all those who want privacy on either amenity or medical grounds should be able to have it. Some people enjoy a large ward. Others are made miserable by it. There may be public or private reasons for wanting privacy. Therefore, privacy should be brought within the range of everyone. But this means, surely, that the charge for privacy should be kept within the means of the average man in the street. However, the person who has privacy must have the same treatment, food and nursing care as the National Health Service patient. Therefore, I agree with Lord Taylor when he says:…reduce the price of private beds substantially—perhaps to £20 a week "—and increase their number up to a quarter of all beds so that those who want privacy can have it and so that they have an option to choose their surgeons and the time of their operations if they so wish. We could do this by compulsory insurance, as was done in Sweden in 1955.
Finally, let me quote some words of someone who was a very deep thinker in the earlier part of this century. He said:Suppose I am an enforced patient in a public ward. What chance have I of that tranquility of mind which is essential to recovery? The right to purchase privacy should be the privilege of us all.I wonder whether my right hon. and hon. Friends know who said that. It was Aneurin Bevan.
260 At first, I was inclined to the view that I should vote against the Government on their consultative document. However, I acknowledge that there have since been concessions. Therefore, I shall not vote against the Government tonight. What I do will depend upon whether I am convinced by what my hon. Friend the Minister of State has to say in winding up the debate. I shall not vote against the Government. But if this Bill reaches a Standing Committee, I ask my right hon. and hon. Friends seriously to consider in Committee what I have said today, and I pray that reason and common sense will prevail.
§ 6.33 p.m.
§ Mr. Ronald Bell (Beaconsfield)
Many are well qualified to list the detriments to the practice of medicine and to the National Health Service which would be caused by the separation of private practice from the hospitals. My hon. Friend the Member for Ealing, Acton (Sir G. Young) made an admirable speech about them to which I listened with the greatest interest. I also listened with interest to the speech of the hon. Member for Galloway (Mr. Thompson), who told us a great deal about the system in Scotland, except that it had the effect of sending all the best Scottish doctors south to became consultants here—a process which I have no doubt would be terminated if his party achieved independence for Scotland.
I shall not take up any of the matters referred to by the hon. Member for Watford (Mr. Tuck) in his very interesting speech. It was courageous up to a point, though it was clear from what he said that, if private practice were separated from the hospital service, in his own case he would have had that sheet over him for about two hours, and its cover might have been extended. We should all have been very sorry about that.
I can offer no expert assessment of these detriments. My opposition to the Bill is based on two considerations of the widest generality of which the first is that of personal freedom.
The Bill circumscribes how people may offer their services and how other people may buy them. Legislation which does that needs more justification than I have heard for this Bill. The Secretary of State described the proposition in exactly 261 the words that I have used. He said that the objection to it was that it limited the freedom of people to offer their services and that of others to buy them. But, having correctly so defined the subject, he went on to offer us the sole justification for it that many people were outraged by the existence of private practice in places dedicated to a free public service.
Dedicated by whom? Nearly all of these hospitals were dedicated by their founders and those who nurtured them to secure establishment and in some cases international fame to the private practice of medicine—free in some cases, but always private. They were swept into the Government's maw together with all the endowments of public-spirited benefactors and the accumulated resources of a multitude of voluntary workers. It is those privately created institutions and standards which no Government could ever have created about which this Government and Ministers on the Front Bench now are exuding this sanctimonious exclusivism.
My second objection in principle is the antithesis of the reason which the Minister gave for ending it. He is an equalitarian, and today he voiced the sentiments of an equalitarian Government—
§ Mr. Ronald Bell
I call it "equalitarian". It depends whether one likes to use words which come directly from the Latin or prefers them to have been Gallicised on the way.
I do not take the view, as the Government do, that success in the battles of life is of little account, that the rewards of success should be limited to a few peripheral luxuries like champagne and night clubs, and that all things that matter from education to medical services should be equally shared out, and, in a process amiably called "positive discrimination", sometimes unequally shared out in a ratio inversely related to attainment.
Accordingly, the change that I want to see is that which I was glad to hear the hon. Member for Watford describing —that is to say, the bringing of privacy into the range of every active citizen and the abondonment of the absurd and unjust rule introduced from the beginning of this service which proceeds on the assumption 262 that pay beds should be paid for as though the occupant were not himself a taxpayer with the standard entitlement which that should confer upon him.
The charge for pay beds should clearly be the extra cost which is occasioned by the patient choosing separate accommodation, with the privacy and possibly the more agreeable food that that entails. I can see no reason why people who have earned money by honest work in any capacity in life should not choose to spend it in that way rather than upon some of the expenditures which may appeal to other people. There is a great deal of humbug and hypocrisy about this, especially amongst some of the leaders of the Labour movement, who never hesitate in their own cases to do what is sometimes called queue-jumping and also to obtain privacy for themselves.
Why not be honest about it and admit that certain kinds of people—they tend to be those in more intellectual occupations, though not exclusively so—value privacy more than others? There are those who prefer to be in a public ward. It is matey, cheerful and provides company. There are others for whom privacy is equally important, and that includes nearly all the leaders of the Labour Party when, unfortunately, illness strikes them.
Let us be honest and sensible about this. Let us say that the right course is to diminish what might be termed the exclusivism of this by making it much more widely available through being fair and saying "You are a taxpayer. You have paid for three-quarters of this. But you must pay for the extra quarter which you want as an optional extra" Then the whole of this foolish argument we have heard, which is embodied in this Bill, will fall to the ground.
That is why I shall have the greatest pleasure in voting against this Bill tonight, apparently in company with the Liberal Party, but not in company with my compatriots from Scotland. The Scottish National Party has two voices and it is with the voice of the Left that it has spoken tonight. I am sorry about that, but nevertheless we shall get a close run.
§ 6.41 p.m.
§ Mr. John Dunlop (Mid-Ulster)
Whatever may be the arguments for or against 263 the treatment of private patients in National Health Service institutions, there can be no justification for controlling and rationing the provision of medical care and facilities on a free and voluntary basis when no public money is involved. I refer to Part III of the Bill which is the part to which the Ulster Unionists have most antipathy.
I was intrigued by the claim of the hon. Member for Galloway (Mr. Thompson), speaking on behalf of the Scottish National Party, that there was a superiority in the Health Service in Scotland compared with the rest of Great Britain. I might be forgiven if I mention that we boast about the Health Service in Northern Ireland, which compares very favourably in many aspects with those here on the mainland.
I would refer particularly to the hospital in my own area—the Mid-Ulster Hospital situated in Magherafelt. It is one of the small acute hospitals which is on the list for eventual demotion. There is a long-term scheme for the building of four large area hospitals in Northern Ireland to the detriment of these small acute hospitals which are doing a tremendous service.
This is a phase of the Health Service in Northern Ireland about which we have grave misgivings. It is interesting to note that the Mid-Ulster Hospital was the first hospital to have an intensive care unit, first not only in the United Kingdom but in Western Europe. This intensive care unit has meant the difference between life and death for many people in the context of the violence of Northern Ireland. Many of the victims of IRA savagery in South Derry, East Tyrone and the whole area around Lough Neagh, which is serviced by this hospital, owe their lives to the skill, care and devotion of those who man the intensive care unit of the Mid-Ulster Hospital.
This Bill is a Great Britain measure. At the moment it applies only to the United Kingdom: Northern Ireland is excluded. This is one of the anomalies which occur in this House of Commons. Time and again we have heard Front Bench spokesmen, particularly from the Northern Ireland Office, reiterating that Northern Ireland is part and parcel of the United Kingdom and that it is 264 governed on the same principle and basis as the rest of the United Kingdom. Yet there is this anomaly that when a Bill that will eventually affect Northern Ireland comes to the Floor of the House of Commons, we do not have an opportunity to consider and debate and perhaps amend it. We have to await the Government's good time until they introduce an Order in Council ratifying the legislation and making it applicable to Northern Ireland. However, like the laws of the Medes and Persians, an Order in Council cannot be amended or changed. We are helpless in that respect.
I record that this opportunity is denied us. That is why I have briefly intervened in this debate on behalf of my fellow Ulster Unionists. We must record our opposition at this stage, to this Bill, particularly to Part II. We shall oppose it and we intend to oppose it tonight.
It should be borne in mind that at present facilities for private care outside National Health Service hospitals in Northern Ireland are much more limited than they are in the rest of the United Kingdom. I was intrigued by the brief mention which the right hon. Member for Wanstead and Woodford (Mr. Jenkin) made about Northern Ireland. He mentioned the startling figure that of the 1,000 beds to be phased out he would allocate 200 to Northern Ireland. This gave me a tremendous lift. I think that the rest of my fellow Ulster Members will be greatly heartened, because if this proportion of 20 per cent. is in the mind of the Conservative Opposition and is to be applied possibly by a future Administration, whether in the near or distant future, it will be interesting to see whether this ratio is applied to all important measures accorded to Northern Ireland.
Despite the massive sins of the last Conservative Government against the decent majority of the people in Northern Ireland, this gives us some little cause for encouragement. We look forward not only with interest and encouragement but with zest to see how a Conservative Government will treat the people of Northern Ireland.
§ 6.47 p.m.
§ Mr. Robert Kilroy-Silk (Ormskirk)
In our election manifesto of October 1974 the Government said they intended to phase out pay beds from National Health 265 Service hospitals. What we have today, after a very long wait and series of intense and vitriolic discussions and negotiations, is a shoddy compromise—a compromise which turns the Bill into a series of inept attempts to phase out pay beds. It will not achieve that objective.
The Secretary of State said that the Government had made several concessions. This is not true. They are not concessions: they are surrenders. What we have before us tonight is a series of successive surrenders on the part of the Government to the combined opposition of the doctors led by the ubiquitous Lord Goodman. This Bill was intended to be an attack upon vested interest, privilege, the power of money and class barriers. Instead it serves in effect to maintain the present system and goes even further by legislating to guarantee the existence of private medicine.
The Bill provides that only 1,000 beds are to be phased out within the first six months after it receives the Royal Assent. Yet these 1,000 beds are surplus to requirements and would go anyway. This is the first compromise. Also, the deadline for the total disappearance of pay beds from National Health Service hospitals has disappeared from the Bill.
My right hon. Friend the Member for Blackburn (Mrs. Castle) quoted Lord Goodman from the Daily Telegraph. Let us quote him again. In a speech to the doctors he said:But this is not a Bill to phase out pay beds.This is, of course, the architect of the Bill speaking.It will not achieve that in my lifetime and in some places will never achieve it at all.The Daily Telegraph adds cryptically:Lord Goodman is 62.He may live a very long time and still pay beds will not have been phased out from National Health Service hospitals. It was not right, as my right hon. Friend the Member for Blackburn said, to suggest that Lord Goodman overstated his case. Lord Goodman was telling the truth. Unfortunately, this is not a Bill which will lead to the phasing out of pay beds or their total disappearance.
There is also a compromise in the ceiling on private hospital development. There is one in the preservation of private practice. In the same edition of the 266 Daily Telegraph, Lord Goodman was quoted as saying:The Bill procures the safeguarding of private medicine to a very large extentIt is not our job as a Labour Government, as members of a Socialist party, to legislate to preserve private practice. I have never considered it to be one of our functions to guarantee the existence of private practice.
The whole notion of private medicine is abhorrent and distasteful in a civilised society. I do not necessarily expect the Government to commit themselves to abolishing private practice. I would not be so naive or optimistic. But I certainly do not expect my Government to legislate to preserve and guarantee the existence of private medicine and private practice, as the Bill does. Our job, if we have one at all, is to challenge and attack the power of privilege and wealth and of vested interests. We are not doing that in this shoddy and tatty little Bill.
In another compromise, the Bill gives private patients access to scarce NHS resources and the Secretary of State's powers are severely clipped. This is not, as my right hon. Friend's predecessor said in a debate earlier this year, fulfilling the work started by Nye Bevan. It is reneging on that work. This is not our Bill. It is Lord Goodman's Bill. Who elected him? Who gives Lord Goodman the authority that he arrogates to himself virtually to draft such legislation as the Trade Union and Labour Relations Act or this Bill?
This latter-day, would-be poor man's Kissinger now trots around the Health Service establishment trying for deals, yet repudiated by everyone with whom he has had dealings—whether the consultants, the junior doctors, or my right hon. Friend the Member for Blackburn. This would-be philosopher king has arrogated to himself far too much and the present Secretary of State has blandly and blithely accepted in the Bill far too many of his proposals and those of the doctors.
Pay beds are anathema to those of us who believe in the principles underlying the National Health Service. It was founded on the principle that medical care should be available to all and should be free at the point of use, that access to that medical care should be on the 267 grounds of medical priority alone and not of ability to pay. Pay beds and private medicine in general are a clear affront to that principle.
There have been several references today to criticisms, to which I would not attach a great deal of importance, of queue-jumping. Yet no one has shown that private beds in NHS hospitals do not lead to and encourage queue-jumping. Why else would they exist? It is not for the privacy or the extra consultants. They exist to enable people to climb over the backs of those who are sick but poorer than those with the wherewithal to buy privilege in health.
My hon. Friend the Member for Watford (Mr. Tuck) illustrated this clearly when he said that he would have had to wait two years for his operation but that by paying he could get it done immediately. He then said, as if to excuse it "But the consultant treating me suddenly had an emergency to attend to and rushed off to the hospital to do it." The consultant should have been treating that emergency in the first place instead of treating and feather-bedding private patients.
§ Mr. Raphael Tuck
If my hon. Friend wants private practice phased out altogether, I can understand his argument, but Nye Bevan said that the two would run side by side. If the two are to run side by side, why should not the surgeon, instead of going to a private hospital 10 miles away, where he is unavailable, be available at the NHS hospital?
§ Mr. Kilroy-Silk
My hon. Friend should listen. I said that I wanted the abolition of all private practice. I said so unequivocally.
§ Mr. Kilroy-Silk
Yes, that is different, then.
I was talking about queue-jumping. The right hon. Member for Wanstead and Woodford (Mr. Jenkin) failed manifestly to deal with this point: if the system is not designed for queue-jumping, why have the consultants consistently refused the suggestion by the Minister of State and the Under-Secretary of State for common waiting lists? If the object is not queue-jumping and 268 they will not accept common waiting lists, what is the object of pay beds in NHS hospitals?
The Daily Mail, the unthinking man's newspaper, described in its edition of 26th April, under the fascinating heading "How to be middle class and still win" how to get private medicine. After the headings "Frontline: Hospital" and "This lesson we can all learn from the doctor", it said:After all, to choose to go by taxi does not harm anyone waiting in the bus queue.I like the social snobbery in the distinction for a start. But the point is that these people are not "going by taxi". They are stopping the bus before it reaches the queue, filling it up and paying the bus driver to drive past the queue. That is what is happening with pay beds in NHS hospitals.
Moreover, pay beds are parasitic. Even the right hon. Member for Wanstead and Woodford mentioned some of the abuses of private practice on the National Health Service. The minority of doctors who have been engaged in industrial action have shown their vested interests. The real case against the retention of pay beds in NHS hospitals has been put by them in the broadsheet issued by, I think, the British Medical Association and the dentists. I refer to page 2. They give no reasons in the previous page why pay beds should not be abolished. They give only facts and figures which are suspect.
Then they get to the reasons.Legislation threatens independence of profession".That is their first reason. The next is:Government action which disturbs the earning potential of consultants".That is their priority of reasons—first, independence; second, earning potential. Yet they constantly have the humbug and hypocrisy to pretend to be talking about the welfare of the patients.
They ask:Why do consultants bother with private practice?Their answer is:It allows the doctor to produce a higher standard of medicine because he can devote as long as he likes to a consultation instead of the 5–10 minutes in NHS clinics.So they admit that there are different standards of medicine—a higher standard 269 for those who can afford to pay than is given, for example, to my constituents, to pensioners, to single-parent families and the unemployed, who cannot.
Is there any hon. Member, even on that side of the House, where they are used to defending privilege and vested interests, who can honestly say that he wants a medical system which will give—as the consultants themselves say in this broadsheet— "a higher standard of medicine" for those who can pay as opposed to those who cannot? That is the consultant's own phrase—not mine, not the Government's, not my right hon. Friend's.
Another reason that the consultants give is:More time to think about and discuss difficult problemsAnother is:There is a close doctor/patient relationship which is to the mutual benefit of both parties.Everything is better for the private patient on the basis of ability to pay, not medical need or priority.
We then had from the right hon. Member for Wanstead and Woodford a reference to freedom of choice. It is this freedom that we are supposed to be disturbing or taking away. This phrase "freedom of choice" is always used by the reactionary to defend vested interests. The choice is only for those who have the ability to pay. First, the choice does not exist for the 1,500,000 unemployed. They have no choice—[AN HON. MEMBER: "Whose fault is that?"1 It does not matter whose fault it is. The unemployed exist and they cannot choose to take advantage of private medicine.
This choice does not exist for one-parent families, for those living on poverty incomes—whatever Government are to blame for their situation. They do not have any choice. The widow with 10 children in my constituency has no choice. She has not the economic wherewithal to buy herself privilege in medical treatment. So let us get rid of this idea of choice.
But what about the freedom? Who has this so-called "freedom"? The hon. Member for Sutton Coldfield (Mr. Fowler) made this quite clear when he said that pay-beds enabled the specialiststo preserve for themselves the freedom to practise outside the full-time salaried service." 270 —[Official Report, 5th May 1975, Vol. 891, c. 1086.]So, the freedom we are talking about today is not the freedom of individual patients, but the freedom of consultants and specialists to practise outside the full-time salaried service. It is the doctors' freedom and earning capacity which is the issue behind all this. That has been made clear by their bad drafting of the piece of paper which has been shoved through the letter box of every M.P. It is the doctors' freedom and the doctors' money, not all the humbug we have heard today about patients' freedom which is at issue. Why should the doctors have freedom to move outside a full-time salaried service? What is so special about them? Miners do not have that freedom —and I do not consider them to be slaves —university teachers do not have it, and neither do railwaymen—
§ Mr. Deputy Speaker (Sir Myer Galpern)
Order. Surely we can have some peace and quiet in the Chamber. If hon. Members wish to speak, they can do so only if the hon. Member gives way. Let us have some semblance of peace.
§ Mr. Kilroy-Silk
The Conservative attitude has rubbed off on the doctors' action. They have all been affected by some disease of irresponsibility. This issue is a matter of principle, and for that reason it is a matter for Parliament. We can argue about its effects on the National Health Service and whether it is good or bad in terms of what money comes in or goes out, but that is not at issue. We are told that it will cost £50 million, and I am prepared to pay £50 million for an issue of principle. It is for Parliament to decide and not for a Royal Commission. We should have stuck to the original principles and not kowtowed to the pressure of the doctors and the Lord Goodmans.
This is a disappointing Bill. I shall vote for it, tonight, but I shall do so reluctantly. I shall vote for it only because I cannot join the party of privilege, class warfare, and vested interest in the Lobby tonight.
§ Mr. Deputy Speaker
Order. I heard a request to send for a doctor, but I think I shall have to send for the Serjeant at Arms.
§ Mr. Kilroy-Silk
My right hon. Friend should take a lesson from what is happening in hospitals thoughout the country.
If we do not clear up this issue decisvely tonight, we shall cause people to take direct action. If Parliament cannot be seen to be effective in abolishing pay beds from the National Halth Service, we shall encourage and give sustenance to ancillary workers and other hospital workers who will seek to achieve that objective by industrial and direct action. Perhaps that may be a good thing.
It is time that Parliament did today what it set out to do in terms of principle instead of fudging the edges with tawdry compromises. What we must have but do not have in the Bill is the courage of our convictions, the belief that our values, principles and morals, are not only different from those of the Conservatives, but are better and preferable. We must have the guts to enforce them and to mould society in our image. That is why we are here and we have the opportunity to do so.
§ Mr. Kilroy-Silk
If we do not use that opportunity, we shall be condemned and rightly so. I shall support the Bill tonight, but unless it is substantially altered to ensure that our commitment to phase out pay beds is honoured, I shall find it difficult to support the Government at Report stage or Third Reading.
§ 7.6 p.m.
§ Mr. Paul Dean (Somerset, North)
Hon. Members will have noted the great contrast between the speech by the hon. Member for Ormskirk (Mr. Kilroy-Silk) 272 and the speech made earlier by the hon. Member for Watford (Mr. Tuck). It was interesting because the hon. Member for Watford speaks with great knowledge and experience on medical matters whereas his hon. Friend, with all the cant and humbug with which Left-wing Socialists are so marked, speaks, I suspect, with very little experience. The hon. Member for Ormskirk says that freedom of choice is the voice of the reactionary. I hope he will tell that to the housewives and others in his constituency and see how they react to that sort of reactionary sentiment.
I congratulate the new Secretary of State on his appointment. I remember very well taking over from him in June 1970 at the Department of Health and Social Security. I wish him well in office—for a short period, of course—as he has great responsibilities to discharge.
The Secretary of State is in an unusual position in that he has introduced a Bill for the drafting of which he had no responsibility. He has no recent past of this subject, and he can approach it with a fresh mind. He has the opportunity to heal the wounds, and restore the confidence of the distinguished and dedicated medical profession. He has a big responsibility to listen and consult, and he was recommended to do that in a letter from Lord Goodman in The Times this morning. It seems to summarise the opportunities and responsibilities before the new Secretary of State. Lord Goodman said:The new Secretary of State has a grave and even terrifying responsibility to restore tranquillity to a profession which traditionally wishes to get en with its job. But he also has an historic opportunity. What he says and how he says it will to a considerable extent determine the matter. He must convey to the doctors that he understands their feeling that the profession cannot be restricted to State employment and retain the independence of action and judgment towards their patients about which the struggle is largely concerned.Those are wise words which could well form the motto for the Secretary of State.
It was encouraging to hear him say that he would approach the Bill with an open mind. I beg him not to worry about the wrath of the right hon. Member for Blackburn (Mrs. Castle) or that of his hon. Friend the Member for Ormskirk but to try to heal the ills which 273 have been all too apparent over recent years.
It was rather shocking to hear the right hon. Member for Blackburn, so soon back into her Back Bench form, telling the Government Front Bench and the House of Commons "Do not alter the Bill or else. It was all cut and dried before the Bill came here" Those are surprising sentiments in an old parliamentarian, but they show the difficulties with which the Secretary of State will have to deal.
I declare an interest as the governor of one of our provident associations. I say at once that the Bill is welcome in so far as it bears the marks of a compromise after the bitter conflicts which have characterised the past few years. Goodman is better than no Goodman. The Health Service Board is better than no board. Phasing out over a period is better than phasing out all at once. In so far as there are concessions, I welcome the Bill. I add my tribute to Lord Goodman, to the Independent Hospital Group, to the medical negotiators and to all those who have worked so hard to try to bring about this compromise, including the Minister of State, the hon. Member for Plymouth, Devonport (Dr. Owen).
In spite of that tribute this is still, as my right hon. Friend the Member for Wanstead and Woodford (Mr. Jenkin) said, a bad Bill. I shall vote against it. I shall do so not so much for the Bill itself but for the wider issues involved. This is not really a Bill about 4,000 pay beds in the National Health Service, only 1 per cent of the total. There are wider, deeper and much more fundamental issues which concern my colleagues and myself.
As my right hon. Friend the Member for Wanstead and Woodford said, this is primarily a Bill which, in our judgment, wiil be bad for the future health and strength of the National Health Service and its patients. At a time when the NHS is crying out for more money, the result of the Bill will be to deny it about £40 million each year in terms of the revenue from private patients. That revenue will be lost at a time when the shortages of skilled medical manpower, especially, are as acute as ever. There is at least the risk that the NHS will 274 lose the services of some part-time consultants either by their going private or deciding to emigrate. The two scarcest commodities of all, namely, skilled medical manpower and money, will be still shorter as a result of the Bill. The Government are gambling with the future of the NHS and the needs of patients for the sake of Socialist dogma.
There is another, wider issue over-shadowing the Bill, namely, the freedom of the doctor to practice without undue political interference, to use his medical skills in ways which he thinks right in the interests of his patients, and not have the long arm of the State coming between him and his patients. There is the fear of one monopoly employer. These fears are real and genuine. It is no good the Secretary of State putting them on one side as he did this afternoon. It is no good him saying that the points that are put forward by the Campaign for the Independence of Medicine are merely debating points. They are genuine fears and the right hon. Gentleman must take them seriously.
There are those who want private medicine to be abolished. We had the evidence only a moment ago in the speech of the hon. Member for Ormskirk, who is no longer in his place. We have had the evidence time after time at Labour Party conferences. They have expressed the view repeatedly that private practice should be abolished. We have the evidence of what the Government are doing in education in terms of the direct-grant school. There is the threat to independent schools. The Government are using exactly the same arguments in this sector. There are genuine fears which largely explain the strong feeling in the profession and the highly unusual agreement that there is within it. That helps to explain why the junior doctors, who are not directly involved in these matters, are solidly behind their seniors in the battle they are putting up.
We are concerned with professional people who feel that their professional freedom is being undermined, that politics are being put before patients. But there is another wider issue, namely, the possible effect that the Bill may have on medical manpower within the National Health Service. The Secretary of State, in his opening speech, dismissed that 275 possible effect lightly, but my right hon. Friend the Member for Wanstead and Woodford took it seriously. Indeed, it was one of the main arguments which he used in that part of his speech.
We must recognise that medicine is international. The reputation of British medical schools is such that a British trained doctor can go to almost any part of the world and command a good job. That is very valuable for our country, but it demonstrates that if medical people feel that the conditions in which they are working are hostile to their professional standards and high professional ethics they can take those standards and ethics elsewhere. That is a serious matter which we must take into account.
There is also the question of foreigners coming into the NHS as patients. That is all bound up with our medical reputation. The Secretary of State mentioned it briefly in his opening remarks. What is the position under the Bill? I do not want to go into detail, but it seems that either we are forced into having one law for the British and a more favourable law for the foreigner, or we are to impose on the foreigner conditions which will make it almost certain that he will go elsewhere. It seems that the Government have put themselves in a ridiculous position.
I hope that the Minister of State will shed a little light on the mystery which now surrounds the negotiations which the former Secretary of State, the right hon. Member for Blackburn, was having in various countries, principally Middle East countries, about the conditions under which foreigners can come here for medical attention. We need to know far more about the discussions that have taken place with all Governments and about the commitments that have been made. Till we have that knowledge we cannot judge effectively whether the suspicion that some of us have that there will be one law for the British and another for the foreign private patient will be proved to be accurate.
My final point refers to the licensing system. Licensing for quality, yes. There is much to be said for tidying up the present, rather untidy, arrangements. Licensing for quantity is an entirely different matter, with a sinister ring about it. 276 My hon. Friend the Member for Ealing, Acton (Sir G. Young) referred to this issue. It seems that we are now seeing a doctrine developed in the Bill, which means that we can have a private hospital as long as it does not do better than the NHS, that we can give a choice to patients as long as the standards are the same, but that if the private sector excels it will be at risk. A doctor who succeeds in satisfying his patients is in danger of being put out of business by a jealous NHS. He must be mediocre to survive. That is what the licensing clauses in the Bill look like, and they will need a great deal of probing in Committee.
This is a Bill with an unhappy past. It is somewhat better than were the original proposals the Government put forward, but it is still a Bill which is bad for the NHS, bad for the patient, bad for the medical profession, and it should be thrown out tonight.
§ 7.21 p.m.
§ Mr. D. E. Thomas (Merioneth)
I feel better qualified to speak in the debate on the Bill than I did when I spoke in the general National Health Service debate last year. Twice this year I have had to take advantage of NHS resources, once myself taking advantag of the specialty offered at the University of Wales Hospital, which I so strongly attacked in my last contribution to the debate on the health service. My family were also able to take advantage of the NHS when I became for, happily, a short period of labour an auxiliary midwife in the maternity unit of our local hospital. There is nowhere better for reflection on health care priorities than the hospital waiting room, the general practitioner's surgery, or the first stage room in the maternity unit.
As one who pays for health care through the tax system, wants his family to have the best service available within the NHS and wants the same care for everyone in the United Kingdom, I find the arguments advanced by the Conservatives in support of NHS pay beds and in support of private practice totally unconvincing. We were given a fore-taste of Conservative thinking in the document prepared by the Campaign for Independence in Medicine, which gave reasons for consultants wanting to practise privately. None of the four reasons given stands up to scrutiny.
277 The document refers first to the amount of time devoted to consultation in a NHS clinic as being five to 10 minutes. The time devoted to consultation should be governed only by the medical need of the case, and consultants should be at least sufficiently qualified to take a medical decision about the seriousness of each case.
The second reason given is that there is more time available in private practice for the consultant to think about and discuss difficult problems. Difficult cases which occur in NHS practice must surely require the same amount of time. The third reason is that the doctor-patient relationship is closer in private practice, but that cannot be true. The fourth reason given in support of private practice is freedom and independence from State control.
Is the British Medical Association proposing to revive its advisory panel report of 1970 on Health Service financing which proposed a reduction of 50 per cent. in the finance taxation of the NHS and the imposition of an extensive range of charges to finance the remaining 50 per cent. privately through insurance schemes or through a compulsory State insurance scheme? What was paticularly reprehensible in that document was the proposal that the tax-financed half of the Health Service should cover the services which have had a low priority within the NHS—the geriatric, chronic, mentally ill and mentally subnormal services.
The BMA and other organisations linked in the Campaign for Independence in Medicine, if they do not want to revive the proposals in that 1970 report, at least want us to believe that there is a booming private medical sector for which there is massive demand. The demand for private medicine can speak for itself. Only 4 per cent. of the United Kingdom population take any part in private practice, whereas when the NHS came into being the figure was well over 50 per cent. About 2,250,000 people throughout Britain are covered by private medical insurance. There is no indication that the demand for private medicine is growing, apart from the point of view of the Conservatives on these Benches and the Conservative consultants.
It may be argued that I am biased because I represent a Welsh constituency. In my constituency there is only one 278 pay bed. There are only 60 in the whole NHS in Wales and all are substantially under-utilised, as is evidenced by the occupancy rate. The health authorities which cover a substantial section of the Welsh population in South Glamorgan, Mid-Glamorgan and West Glamorgan have only 12 pay beds among them and our major teaching hospital has none.
I welcome the proposal to establish a Welsh Committee of the Health Services Board as an important concession. With devolution I hope that it will not be long before not only the 13 beds which the Secretary of State for Wales proposes but the remaining pay beds in Wales are phased out. I pressed the Secretary of State to do this last year at the time of the industrial dispute on the pay beds issue at Morriston Hospital. Now that this question is to be referred to the Welsh Committee, I hope that that Committee will take an early decision to phase out all the pay beds in the NHS in Wales.
I do not believe that the Welsh Committee of the Health Services Board will find a demand in Wales for the setting up of private hospitals. Although the board is charged in the Bill with having regard to alternative facilities in the private sector, it is clear that the 60 under-utilised pay beds in the NHS in Wales do not even meet the minimum viability figure of 75 which is given in the Bill for a private hospital. I confidently expect, therefore, that no authorisation for any private development will be made by the Welsh Committee of the Health Services Board when it is set up.
Even if this House is not prepared or able to phase out private practice altogether, the Welsh Assembly one day will do so. Although there is no substantial demand for private practice in Wales, I am concerned about the effect of private provision more generally throughout the United Kingdom, particularly in England and the South-East of England.
The whole argument about pay beds and private medicine has side-tracked us from the far more important and intractable problem of inequality of distribution of resources within the NHS. There is a regional disparity of resources and provision within the NHS. These inequalities were inherited from the private sector. The stock of manpower and capital which the NHS inherited from 279 the private sector was unequally distributed geographically. The old National Health Insurance Scheme left the distribution of consultants virtually unchanged between the two world wars.
The initial allocation of NHS resources in 1948 exactly reflected the inequality and imbalances before the setting up of the NHS, and the subsequent distributions of manpower and finance have preserved these inequalities. Important comparisons have been drawn within England between, for example, the Oxford and Sheffield regions. That study showed that the Newcastle region had twice as many gynaecologists per female as did Sheffield. The disparity was even higher when the statistics were adjusted according to sex. Birmingham had twice as many whole-time equivalent consultants as Sheffield; Liverpool had twice as many psychiatrists as Manchester; and children in Oxford had twice as many tonsil operations as did children in Sheffield.
These disparities cannot merely reflect the demographic differences in the population. In Wales there is a 30 per cent. higher rate of entitlement to sickness benefit per man at risk. That is not reflected in the extent of the health care provided. Dick Crossman pointed out in 1969 that regional inequalities were the single most difficult problem faced by the NHS. We should be talking tonight about these regional inequalities inherited from the private sector.
I am concerned that these inequalities are likely to be accentuated by an extension of the private sector, particularly in South-East England. My concern is that in this area there should not be a return to pre-NHS days when health care was treated as a commodity, not as a service. It is clear that on the Opposition Benches tonight a substantial proportion of hon. Members still think that health care is a commodity within the market system and not a service. I am concerned that this inequality should not become greater with an expanding private sector in South-East England.
It is extremely important that the Health Services Board should have regard to regional equality of provision according to indicators of need as well as the geographical provision in the private sector in any given area. I do not want the attempts made in the interim 280 report of the Resource Allocation Working Party to be undermined by the transfer of private health care resources into private practice in South-East England. I do not want the trend towards transferring resources to less favoured areas and the deprived areas in North-East England to be reversed by an extension of private practice as a result of the Bill.
The debate has again tended to polarise itself into an individualist versus collectivist conflict, and I hope it will lead us to take a more fundamental view of health care provision. Conservative spokesmen still seem to argue that an individualist's demand for health care is limitless and, therefore, his right to spend whatever proportion of his financial resources he wishes to spend on health care is limitless. But demands made by the individual and his family are not limitless: they are governed by the total amount of resources available within the community for health care, as for any other service.
The debate on public expenditure should have taught the Conservatives that resources are limited and that therefore, priorities must be decided. When deciding priorities in health care we must look at the private sector as well as the public sector. We must allocate resources in the interests, not of 4 per cent. of the population, but of all the population. For all of us who put money aside through the taxation system, as Michael Cooper said, it represents a pooling of risks, and a transfer of purchasing power from the fit to the sick, from the rich to the poor, from the wage earner to the young and retired. A transfer of financial resources is an essential part of the system.
Health care is a service, not a commodity. It is a service which we all need and which must be freely and equally available to us all. My party welcomes the Bill and its aim to abolish private medicine in Wales.
§ 7.32 p.m.
§ Mrs.Renée Short (Wolverhampton, North-East)
The right hon. Member for Wanstead and Woodford (Mr. Jenkin), who opened the debate for the Opposision—it seems many hours ago—went through the easy process which Tories now speaking on the National Health Service always do of making genuflections towards Nye Bevan. But those of 281 us on this side of the House who knew him, his following, charisma and support in the Labour Party and the trade union movement, find that hard to swallow, because members of the Tory Party hated him and everything he stood for. The language which they used is perhaps not heard today, but he was opposed throughout the introduction of the National Health Service Bill. As my right hon. Friend the Member for Blackburn (Mrs. Castle) said, the Tories who voted against him throughout every stage of that Bill now are great advocators of everything that he then said.
§ Mr. Patrick Jenkin
The hon. Member for Wolverhampton, North-East (Mrs. Short) accuses us of hating. We do not hate our political opponents. The first political speech I ever made was in the open market place at Ebbw Vale and Nye Bevan was there. It was an alarming experience.
§ Mrs. Short
I am pleased to hear that the hon. Gentleman experienced that baptism of fire and that he survived it.
The Government are committed to introducing a Bill to abolish private practice. It is extraordinary to hear the Opposition say that in 1946 certain things were said and certain commitments made to the medical profession to persuade it to go along with the National Health Service and to say that such arrangements cannot be altered. Do we not change in 30 years? Must we do the same things and never progress? We cannot accept that. A clear undertaking was given in the Queen's Speech last November that we should introduce legislation on this subject. Those who have opposed us have given no cogent reasons for going back on our commitment.
Many of the old myths of private practice have been rehearsed today. Many of those myths are superficial and they indicate that some people do not understand how hospitals are organised, how doctors work and organise their work, what private practice means to patients and to all those working in the NHS—not just doctors, but nurses, technicians, porters and kitchen staff—all of whom are indispensable in hospitals today. All those workers have strong views about the existence of private practice and the presence 282 of private patients on their wards. There is much evidence of this.
My hon. Friend the Member for Watford (Mr, Tuck), perpetuated the myth about the choice of consultant. No patient chooses his consultant. He is not equipped with the medical knowledge to do so. His general practitioner chooses the consultant and the hospital in which the patient will be treated. Choice does not exist for the patient. He is entirely guided by his general practitioner.
The consultants cry about freedom. Some consultants, but by no means all, have freedom and carry out private practice and, as my right hon. Friend the Member for Blackburn said, they earn considerable amounts of money apart from their National Health Service salaries. To carry out private practice, a consultant sacrifices two-elevenths of his National Health Service salary and of his merit award. He sacrifices about £1,600 of his salary and in return he may do as much private work as he can or wants to do. There is no limit.
Consultants at the top of the salary scale and receiving top merit awards are not badly paid by any standards. They earn between £18,000 and £19,000 a year, which is not bad going for anyone. They sacrifice a small amount of their salary, but they are able to earn considerable sums outside the National Health Service.
§ Mr. David Mitchell
Would it interest the hon. Member for Wolverhampton, North-East (Mrs. Short), to hear that a consultant left a Basingstoke hospital where he was earning £8,000 a year to go to Canada to earn £20,000 with lower tax rates?
§ Mrs. Short
That consultant was obviosuly not quite at the top of the salary scale and did not have a merit award. I am talking about those on the top scale who do private work. By any standards they should be satisfied.
There is opportunity for a considerable amount of income tax evasion. Evidence on this was presented to the Select Committee on Expenditure by a consultant who said that private patients often handed money over in cash instead of by cheque and that payment by cheque when required was higher than it would be by cash. For some consultants and private 283 insurance organisations it is a heyday. Those are the organisations and individuals who make a lot of money out of private practice.
The abuse of the National Health Service has not been much ventilated during the debate. I shall tell the House some of the things that the right hon. Member for Wanstead and Woodford did not report. The admission of private patients can be facilitated within the NHS by a private consultation first and then admission to a National Health Service bed. Or it can take place by admission first into a private bed and then a transfer to a National Health Service bed after two or three days. If that is not queue-jumping, I do not know what is.
Private patients are also able to use staff in a hospital without any payment. This is where the use of National Health Service hospital resources occurs. For example, junior hospital doctors are used to care for private patients on the hospital premises or, even more unacceptably, in the private clinic or nursing home where the consultant sees his private patients. We have evidence of junior hospital doctors being removed from the hospital where they are employed to assist the consultant or to do work for him as a substitute in the private nursing home without additional payment from the consultant.
Diagnostic services, such as path lab facilities for examining specimens and X-ray facilities are used without additional payment by the private patient, partly because it is difficult to monitor their use and perhaps because many staff would be needed to do it. NHS equipment, including anaesthetic gases and sterilised equipment, is used in private nursing homes and so on. Certain consultants fail to do their ward rounds and out-patient clinics and operating sessions, for all of which they are paid by the NHS. The work is left to junior hospital doctors.
We had evidence from a consultant that, although we are told that urgent cases are always admitted to hospital when the need arises, some cancer patients were told that they would have to wait six weeks or so for an NHS bed but that they could be in the next day 284 if they were prepared to pay. They did so. I can think of nothing more urgent than a cancer case, except perhaps an elderly person in his or her eighties or nineties suffering from a cataract. We had evidence of such people being kept on the waiting list for 18 months or more.
Let us not have so much humbug about the queue-jumping and use of NHS resources, which we are told does not happen. It does. We must make sure that the Bill is strong enough to deal with such abuses. I agree with hon. Members who have said that the Bill needs to be strengthened in Committee.
The junior hospital doctors gave a great deal of important evidence to the Expenditure Committee four years ago. The Committee was shocked to find that they worked 102 hours a week before they could claim overtime pay, and that part of their difficulties certainly arose from the additional burdens placed on them by their seniors, on whom they relied for promotion.
Many of them are not in a position to stand up to the consultants and to refuse to do the additional work. It may well have been the attitude of the consultants and the burdens that they put on their juniors that compelled many juniors to emigrate some years ago. But many doctors are returning because they find that after all the NHS is a more congenial atmosphere to work in and that there are other advantages to living in Britain.
The junior hospital doctors will be our consultants in a very short time. According to evidence given at the end of March to a BMA forum of junior doctors, we are producing about 3,000 qualified doctors from our medical schools each year, thanks to the expansion brought about by the present Government and the previous Labour Government, whereas we need only about 2,000 to replace those who die or retire. It looks as though at last we shall have enough doctors in the NHS to fill many of the vacancies in the less attractive specialities where there are not pickings for private work or which happen to be in the less salubrious parts of the British Isles and not in the South-East. This may well create a completely different climate for those working in the NHS. I hope that it does.
285 The threat of mass emigration which we heard from the Opposition Benches is used by doctors to try to persuade us that if we go through with the phasing out of private practice, we shall be in a bad way. We take that threat with a few pinches of salt. I do not believe that that will happen. Many of the countries that have been willing to pinch our doctors—I use that word because they came over here recruiting some years ago —have now tightened up their immigration laws. The plum jobs—certainly in Canada and the United States, where the high salaries were available—are now going to their own people, and they are less likely to accept immigrants from Britain.
§ Mr. Ivan Lawrence (Burton)
Does the hon. Lady concede that the problem is not only that consultants will emigrate but that junior hospital doctors on the threshold of becoming consultants will give up their consultancy and become general practitioners, with an overall loss to the hospital doctor service of trained graduates?
§ Mrs. Short
I shall come to that in a moment, but I want to be as brief as possible.
The existence of public and private sectors leads inevitably to a two-tier system. What I said about admission to hospital and waiting lists is an indication of the existence of the two-tier system. That is unacceptable, and it is time it was ended.
I shall say nothing about Lord Good-man's package, because that has been dealt with by several other hon. Members.
I am very concerned that only 1,000 private beds are to go within the first specified period. We must have an indication from my hon. Friend the Minister of the time scale he foresees for the removal of the rest of the private beds. A board is to be set up. I should prefer my right hon. Friend the Secretary of State to deal with the matter. Why must we have another body to deal with something that is really the Government's responsibility? I should prefer the board not to be set up, but it is part of the package deal to soften up the consultants.
The only way in which we can deal with the problem is to separate the 286 private beds from the NHS completely. Private clinics must be licensed by the Minister, as abortion clinics are, if they are to continue, and then by the planning authority before permission to build is granted. That would concentrate everybody's mind.
The right hon. Member for Wanstead and Woodford said that the Expenditure Committee in 1972 suggested that private practice should be eliminated.
§ Mrs. Short
Exactly. That was the part of the Committee that felt as I did, the Labour Members of the Committee. We were in some conflict with the Conservative Members. We said that to establish a clearer division between the public and private sectors as a means towards reducing abuses arising from the overlap of these sectors, consultants should be encouraged to make a more definite choice of where they wanted to work—full time in the NHS eventually or in the private sector. We added:where private beds are held in a ratio to N.H.S. beds of more than 1:20 by any consultant, he should he limited to a maximum of 5 N.H.S. sessions per week.In other words, his NHS work should be phased out if he wanted to do private work. We continued:consultant contracts should he revised to a 10 session basic contract with extra payments for being on call and available and for doing out-of-hours emergency work, thereby providing a financial incentive for doing N.H.S. work and an opportunity to supplement income without going outside the N.H.S.We also said that full-time consultants should receive at once a pro raw share of merit awards, and that increasingly merit wards should be concentrated exclusively on those who worked full time within the National Health Service. We therefore made provision for the gradual change from part-time to full-time National Health Service work. I think that that would be acceptable to the majority of consultants as more than half the consultants work full time in the National Health Service hospitals.
With the improvement in pay that the Government have introduced both for consultants and for junior hospital doctors, and in the overtime pay of junior hospital doctors, doctors are in a very 287 much better position now than they were some years ago.
I hope that we shall be able to strengthen the Bill in Committee so that private practice is removed. After all, private practice is really an anachronism, a hangover from the last century. The way in which many consultants work within hospitals, doing private work, organising themselves into "firms", is again an anachronism, because increasingly medical practice, particularly surgical practice, is teamwork.
It is no longer a matter of the consultant, the great man, coming down and doing his operations on his own. It is concentrated, highly technical and technologically skilled teamwork that is required now, with many complicated and new processes. Therefore the present system is an anachronism, and I hope that we shall be able to end it very soon.
§ 7.52 p.m.
§ Mrs. Jill Knight (Birmingham, Edgbaston)
There are many reasons why I object to the Bill, but perhaps the reason that comes uppermost in my mind is that there is not a line, not a word not a syllable, anywhere in it which will improve health care for sick people. This is at a time when the standards of such care have declined very drastically, and patently and obviously on the slide for still further decline. It is a national scandal that Parliament, instead of turning its mind to halting this disastrous trend, should instead be debating the spiteful and damaging measure now before the House.
Last June, in an Adjournment debate, I raised the question of the falling standards of medical care in the West Mid-lands. I aid how disastrous this was for cancer patients in that area, and I gave many examples. I spoke of the trouble faced by accident victims in the West Midlands and of the very severe troubles of the eye hospital patients. I spoke also of the patients in the children's hospital who were also experiencing great difficulties.
The position of all these people today is no better than it was when I raised their plight in the House. In some respects it is even worse. But what do the Government do about it? They intro- 288 duce a Bill which, far from alleviating the situation, actually makes it worse. The Government remind me of a doctor who, faced with a sick person, prescribes paraquat instead of Paracetamol. Whatever is wrong with the National Health Service, it can by no stretch of the imagination be diagnosed as the presence of private patients in National Health Service hospitals.
I was very interested to hear what the hon. Lady the Member for Wolverhampton, North-East (Mrs. Short) said about the instances where desperately sick people had been denied entry to hospitals because private patients had taken precedence. I should like to look at these examples very carefully indeed, because I have visited many hospitals and asked specific questions in this regard. There is no one on this side of the House in my party who would support a system which would deny care for desperately sick people because rich people with minor complaints had taken the beds. Let us have that absolutely clear. It is no part of our beliefs. Of course, if the private patients were as sick as or sicker than the NHS patients, the question surely would not arise, even under the Bill.
A great deal of nonsense has been talked about queue-jumping. I have tried to find out all I could about this, and my experience is that where queue-jumping exists it is for the non-essential and non-urgent hospital care. Hon. Members who need hospital care that can wait tend to have that care in the recess, or at a time when they can conveniently fit it in with their duties.
Not very long ago a Minister of the Crown in this Government unfortunately fell sick and went to hospital as an NHS patient. I should be very surprised if he went into a general ward and simply had exactly the same care as any other patient, because a Minister of the Crown has specific duties and needs to be able to carry them out as soon as he is well enough to do so. He needs to be able to read his papers and to go through his boxes. I do not blame him at all if he wants a private room.
What I object to strongly is that such a man uses political weight and influence instead of honestly paying for what he is getting, particularly when he is in receipt of a far bigger salary than many 289 who would be competing for this care in the National Health Service. It seems to me to be far more honest to pay one's way and to contribute to the benefits one is getting than simply to say "I am who I am and I therefore must be given priority. You must not only let me in when I wish to come in but you must give me a private room."
Pay beds have always been available for those who did not pay when no other beds were available in the hospital. It is perfectly true, as many hon. Members have said, that there is no shortage of beds in the NHS today. In fact, we have heard examples in this very debate of one hospital which will simply have to lock away the beds which will no longer be available, as a result of this Bill, to private patients. Those beds will not be filled. They will be empty.
It is a great shame that things said in debate in the House so rarely change the minds of people in the Division Lobby It is a shame that more people are not here to listen to the debate. If they were, and if they had heard the trenchant points made by my hon. Friends, I cannot see how they could troop into the Lobby in support of the Bill this evening.
If the Bill is enacted, great and lasting harm will be done to the NHS. We have heard of the commuting consultant. I was appalled that the Secretary of State brushed him aside as being no problem. It was suggested that it did not matter and that there was no problem. Of course, it has been said, he would be able to do just about as much work, when made to commute from his private hospital to the NHS hospital, as he does at the moment.
I do not know whether the Secretary of State has often tried to get through the rush hour at any particular time in London, but it seems to me ludicrous to suppose that a doctor who is forced by the Bill to work in one hospital here and in another hospital several miles away will be able to undertake his work for the ordinary NHS patients as he does at present when he can have his patients all under one roof. But is not only that he will have less time for his ordinary patients. He will certainly, as the hon. Member for Watford (Mr. Tuck) pointed out, have less time and be less available 290 to deal with emergencies as they crop up. He will also have less time for teaching. Teaching is an important function of the work of these medical personnel. I am appalled that we should be considering cutting down the time which such people have available for this extremely important work.
The hon. Member for Ormskirk (Mr. Kilroy-Silk), who would seem to be more at home in the Kremlin than in West. minster, made great fun of freedom of choice. He implied that this was a reactionary goal. That is not the case at all. The British people support freedom of choice, and the hon. Gentleman would do well to remember that. The patient's freedom of choice to enter a local NHS hospital is a freedom which we should preserve. When a person chooses to go into hospital as a private patient, he often chooses his consultant. He is permitted to do so when he goes in as a private patient. Why should he not do so?
It seems to me extraordinary that a Labour Government object so strongly to people spending their money in the way they choose after they have made their proper and full contribution to rates and taxes which in turn go to support services for the benefit of others. Apparently it is considered proper for people to spend their money on drink or bingo but, on the other hand, it is considered sinful if a person wants to spend his money on looking after himself and his family. That seems to me to be an extra-ordinary attitude to adopt.
Labour Members might consider the fact that not all BUPA members and supporters of private insurance schemes are wealthy people. Many people would rather spend their hard-earned money on subscriptions to BUPA so that they are given medical care when they require it rather than spend that money on drink or bingo. In a free country why should they not have this choice?
I should like to hear more about the oil sheikhs who are supposed to be coming to this country for medical treatment. [HON. MEMBERS: "Oh".] It is all very well for Labour Members to sneer, but the right hon. Lady the Member for Blackburn (Mrs. Castle), speaking as a Former Secretary of State for Social Services, made it clear that oil sheikhs and 291 other people from abroad would be permitted to come to this country as private patients. Where are such people covered in the Bill? I wonder whether the right hon. Lady, or the present incumbent of her former office, understand how deeply British people resent the fact that people should be permitted to come here from abroad to enjoy facilities which are not available to the ordinary indigenous hard-working, tax-paying Britisher. I presume that in Committee we shall hear a great deal more about the medical treatment of oil sheikhs.
We must not fool ourselves. We must realise that the National Health Service and the country needs the money which these foreign visitors who use the National Health Service are able and ready to pay. These people often need medical care which is not available in their own country. The NHS will be much poorer if we are denied that money. I do not object to their coming to this country. I object to the fact that the ordinary Britisher is not able to take advantage of similar facilities.
The cost of getting rid of private patient care has been disputed. However, we have heard a great deal of detail about how the phasing out of private patients will hamper the work of hospitals in different areas. That is certainly the case in the Queen Elizabeth Hospital in Birmingham, to which private patients contribute a good deal. A cancer consultant said to me only recently that the hospital will be denied in his specialty the money provided by former patients. A denial of that money will be sadly felt by future cancer patients.
The fact that this legislation will result in a falling off in standards and in patient care is unanswerable and is certainly unforgivable. The consultant who cares a great deal about his patients is worried about the situation. He will be harried by extra travel. But there is more. The Bill represents a serious breach of agreed working conditions for consultants. It is a breach which the Government would not tolerate for one moment if a private employer tried to inflict it on a trade unionist.
I grant the fact that the Labour Government care very little about pleasing 292 or even playing fair with professional people, but surely even this Government can see the dangers of antagonising those who are so greatly needed that the NHS would collapse without them and, secondly, who can get a job almost anywhere they choose outside Britain with far better pay and conditions than those obtaining here.
In the West Midlands alone we have lost so many top surgeons and consultants —many of them young—that we cannot afford to lose even one more if standards of care in some specialties are to be even half sound. The Government know that that is so because they have been told it time and again. There has been completely unanimous, reasoned opposition to the Bill by all bodies representing senior clinical staff, administrative staff, nurses and the junior hospital doctors. All those people have objected strongly to the Bill.
Instead of listening to those people. who are experts, the Government listen to anarchist agitators. such as the young telephonist at Westminster Hospital with no experience whatever of the medical profession or to Mrs. Esther Brookstone, COHSE branch secretary at Charing Cross Hospital, who is known as "the angel with the saw-edged bed pan". Instead of listening to people who can give their knowledge and experience to the Government, the Government prefer to listen to agitators of that kind.
I hope to have a chance to move many amendments to the Bill, if I am fortunate enough to be a member of the Committee. There are many more aspects of the Bill which are a cause for concern.
Let me deal briefly with the subject of the licensing of private patient hospitals. No mandate has ever been given for that. Indeed, it will put further administrative burdens on suffering tax payers and also will charge them for curtailing their freedom. There is also the question whether the Bill may not be forcing down the size of private hospitals too far for them to be economic. Lord Goodman has described the Bill as quite unnecessary. It is a Bill that offends in its unfairness, gravely worries in the harm that it will inflict, and appals in its vicious attack on personal freedom.
§ 8.8 p.m.
§ Mr. David Penhaligon (Truro)
I have listened to virtually every contribution since the debate started, and I must be the only Member who regards this issue as unimportant. I do not believe that the retention or abolition of private medicine will either substantially improve the National Health Service or worsen it. Indeed, I wish that the time spent discussing this Bill today had been used to discuss the relatively declining standards in the NHS.
It is difficult to compare health services in various nations, but there are one or two common criteria. We can study a nation's life expectancy or its infant mortality rate. In the European league, there is no doubt that since the early 1950s the United Kingdom has declined relative to the rest of Europe. As somebody who is relatively young, I can remember living under no other system than the NHS, and arguments about what happened in 1946 and all the rest of it are academic to me.
In retrospect, it appears that the National Health Service was set up on a premise which events have proved to be somewhat questionable. It appears that at the time people believed that by providing better care, demand would be reduced. It appears, however, that the planners of that time forgot the effects of time. I am now just over 30 years old. It is possible that at 40 I might catch tuberculosis. The NHS would quite probably cure me of that. At 50 I might have a coronary. At 60 I might have a stroke. At 70 I might be in welfare housing and receiving welfare meals. One could argue that it would be cheaper if I passed away at 40. I have a vested interest. I hope that at the age of 40 I shall survive the initial hurdle.
However, this indicates that curing one medical problem does not basically reduce the level of demand. The demand for medicine is open ended and will never be totally satisfied. If one has that situation, at least in some of the less essential aspects of medicine quite clearly one has a perpetual waiting list, and in such a situation it is my clear view that someone will have a vested interest in doing some queue-jumping.
I have been amazed when listening to so many Opposition Members pretending 294 that queue-jumping does not exist, or at least, does not exist in their areas although it might exist somewhere else. Some say that in their experience of politics and of meeting members of the medical profession they have never come across a single case. I know that if one speaks to one's friends and acquaintances one must know of occasions when this happens.
I appreciated the contribution of the hon. Member for Watford (Mr. Tuck). It was interesting that he said that he was a case who had jumped the queue. He said that he had been told that he would have to wait for two years if he went for attention through the NHS but by going to Wigan—I never realised that Wigan was one of these special areas—he had special attention from a consultant.
The serious point about that story is that presumably there are people in the hon. Member's constituency who have the same ailment that he has but who have to wait for two years for attention. That is where the fallacy lies. If one abolished private medicine, no doubt one could make the hon. Member for Watford wait the due X months, but to what would one reduce the average waiting list for the hon. Member's constituents who had similar ailments? It is an impossible calculation. I rather suspect, however, that one would make everyone wait for 23 months as opposed to the 24 months that has been mentioned.
The main scandal of queue-jumping is the use that doctors make of it. I know that some people with non-fatal illnesses can receive attention and jump the queue by approaching the right medical man at the right time with the right amount of money. Therefore, queue-jumping is a scandal. Certainly some hon. Members are being naive if they do not think that majority of their constituents think that it is a scandal. That is why I welcome the part of the Bill that refers to joint waiting lists.
I am a little cynical about politics, but my doubts about some sections of the medical profession in this country were increased when the profession refused the suggestion made some months ago. It was turned down flat. One hon. Member has said that he is looking forward to serving on the Committee. I do not 295 know whether I am quite in that category but if a Liberal Member is a member of the Committee, the idea of the joint waiting lists will receive support from the Liberal Party.
I am not against people paying twice for medicine, or against private practice but I believe that a great deal of the appeal of pay beds to certain groups will be reduced if an effective system of joint waiting lists is introduced.
I have managed to acquire some figures in relation to another section of the Bill for which I have great sympathy. I speak of the South-West, for obvious reasons. I know the area better than I know most other areas. In fact, it is the only area that I really know. The South-West had 214 pay beds at the end of December 1974. There has been a slight reduction since then. However, the interesting figure in the chart made available to me is that the average occupancy of those beds is only 88.
One can add up the figures, and the document says that people want to reduce the number of pay beds by another 50. It will not do anyone any great harm to reduce the number of pay beds by another 50 in the South-West. Unless anyone convinces me that the South-West is unique in that respect, certainly in Committee my support would be given to the removal of 920 or 1,000 pay beds, whatever the total is.
I cannot support the Committee of Five. It appears that the Government are making the same great mistake, as did the Conservative Party. When sometimes the Government have been in a little trouble trying to defend themselves on health issues, they have been able to say "It was you who introduced the bureaucracy that is costing so much", and with justification. However, I am afraid that the Government are now treading down the same weary path.
How will a board of five men succeed in getting through £250,000 a year? It is not bad going for five men. Perhaps they want a neutral chairman. However, for me the stumbling block in supporting this legislation is this provision.
I shall not now argue against some licensing of medicine. Hon. Members are again being naïve if they do not realise that the Government need at least 296 some potential control over the expansion of private medicine. I could imagine an enormous growth of private medicine in a single town or area that would totally destroy the equilibrium of existing medicine. I can also understand some of the cynicism felt towards regulation from outside. This matter needs to be looked at carefully and in detail. The duty of Opposition Members, of whom I am one, is to see whether the regulations are being introduced by the Government genuinely to make sure that they have the powers if they are needed.
I come back to the figure of £250,000. In my constituency a young man commutes at weekly intervals from St. Austell to London for dialysis treatment. I think that I am insane to commute from St. Austell to London each week, but at least when I get here I am paid. I volunteered for the job. This young man did not volunteer for uncomfortable treatment that he receives or such a journey. The sum of £250,000 could provide dialysis treatment for about 250 people.
On behalf of my colleagues, I say that we shall do something rather different from what the Liberal Party has ever done previously. On previous occasions we have said that we would vote for a Second Reading in the hope that a Bill would be improved and then we would support it on Third Reading. On this occasion, it will be the other way round. We shall not vote for the Bill on Second Reading, but if the Bill is improved, particularly in the areas that I have outlined—the increase in bureaucracy—I assure the Government that they might get some support at other times.
§ Dr. Owen
The hon. Gentleman is speaking for a party and intimating which way Liberal Members will vote. The only criticism of the Bill that he has made so far relates to the proposal to have an independent committee of five to supervise the licensing and to look at any quantity licensing. Does he not recognise that the reason for establishing this independent board is solely that the medical profession would not accept anything less, and that the Government have made a concession to the profession in that regard?
§ Mr. Penhaligon
That may be so, but following to that aspect of the medical 297 profession is costing £250,000. I recollect that much of the bureaucracy in the medical profession was requested by the profession itself.
It is one of the duties of Governments to ensure that bureaucracies are kept down, and this is the aspect of the Bill about which I am particularly concerned.
§ 8.20 p.m.
§ Mr. Laurie Pavitt (Brent, South)
I hope the medical profession will take note of the remarks of the hon. Member for Truro (Mr. Penhaligon), particularly in regard to common waiting lists, which is a matter requiring urgent consideration and which is included in the Bill.
In regard to what he said about a constituent having to commute from the West Country to London for renal dialysis, I have recently taken up a case of a patient who has to commute for treatment and I understand that the problem is that the hospital in his locality will not put him on a kidney machine because it fears that infective hepatitis might result. I do not understand how they get this idea, which is complete nonsense, but that appears to be where the problem lies.
I was rather pleased that I did not follow the hon. Lady the Member for Birmingham, Edgbaston (Mrs. Knight) because she strains my chivalry to a great extent. I have followed her many times in health debates in the House and in Committee, and although she usually brings considerable compassion to the debates, she seemed to have left it outside today. She made no mention of the good things that are happening in Birmingham. I was sorry that she did not refer to the Birmingham Accident Hospital and what it has done for this specialty, but as an example for the rest of the country.
§ Mrs. Knight
I did not go into detail because I have gone into so much detail before and many hon. Members wish to speak in this debate.
§ Mr. Pavitt
The hon. Lady must not tempt me to follow her too closely.
A number of hon. Members have expressed concern about the effect the Bill will have on NHS patients in hospital. I am very fortunate to have excellent liaison with the Central Middlesex Hospital in my constituency—one of the finest in 298 Europe. It has 750 beds and the gastro-enterologist, Sir Francis Avery-Jones, is one of the greatest in this country and has an international reputation. Only eight of the beds are reserved for all private patients so his department would not command many. But Sir Francis' first-class service to NHS patients always had the highest priority and did not prevent his doing private work at the London Clinic.
The Bill is not against private practice. It merely takes it out of the NHS—off the NHS's back in some cases—and into a separate sector where it can develop as it wishes with help from those who have enough money to support it.
I welcome my right hon. Friend the Secretary of State to his new post. I have participated in most health debates since 1959 under many Ministers. I extend a special welcome to my right hon Friend because he and I served in the same Department for two years from 1968 and I had a good deal to do with him at that time. He brings to these matters a mind and understanding which will mean nothing but good for the NHS. I hope that he will enjoy his stay as Secretary of State.
There have been some virulent attacks on my right hon. Friend's predecessor and I very much welcome the Secretary of State's opening comments about her. No Minister in my time in this House has done more for the NHS than my right hon. Friend the Member for Blackburn (Mrs. Castle). I know of no other Minister who could have got the share of the gross national product devoted to the NHS increased from 4.9 per cent. to 5.4 per cent.—an extra £750 million—in the current economic climate.
I remember the days when a person speaking to a general practitioner would get the impression that Nye Bevan was the devil incarnate. Everybody now recognises his worth. It will not be many years before the medical profession realises how much my right hon. Friend the Member for Blackburn has done for it.
Let us put the Bill into perspective. There are nearly 500,000 NHS beds and we intend to phase out, by agreement under Schedule 2 of the Bill, about 1,000. This is a negligible percentage of all the beds. We realise that once the Bill is 299 on the statute book, there will still be the wide areas of concern with which my hon. Friend the Minister of State and others have been concerned over the past two years and they, and the House, will continue this involvement.
In the debate, everybody has been talking about the doctors and there have been few mentions of the professions supplementary to medicine, and other NHS employees. There are 450,000 ancillary workers without whom nobody would be able to get hospital treatment.
The total amount contributed by private practice, including prescription charges, welfare foods, teeth and spectacles, represents 3¾ per cent. of the total budget—just under £160 million in 1974/75. It is a false dawn to think that if only one adds to this sector one solves the major problem.
The Opposition are wrong to give the impression that by finding an odd £5 million or £10 million there may not be a need for a massive programme to increase real resources for the NHS whichever Government is in power. When the Opposition talk of raising an extra £25 million by prescription charges, they give people the illusion that the problem can be solved by this sort of action. In fact, that would only be touching at the corners and leaving the real problem unresolved.
It is significant that the one section of the profession which is opposed to the Bill is the Royal College of Surgeons—not the physicians, the obstetricians or the pediatricians. Everybody has been thinking in terms of surgery and the dramatic surgical operation, but thousands of patients do not have surgery. They have the kind of treatment which we are all so grateful to see provided in our hospitals. However, there is still this concentration on a small group of surgeons with the dramatic operations which can save lives at the last minute. It throws out of focus the attention the House should be giving to the NHS.
Doctors have opposed every step forward. The BMA opposed Lloyd-George's "fourpence for ninepence" Act of 1911. Under Charles Hill, the BMA had a referendum and most members did not want to go into the NHS. Nearly every 300 step taken to produce better standards for ordinary people has been opposed by the profession.
Medico-politicians are terrible. Our doctors, consultants and general practitioners are the best in the world, but once the trained clinicians start entering the world of politics, they make as much of a mess as I would if I put up a brass plate and tried to perform an operation on the right hon. Member for Wanstead and Woodford (Mr. Jenkin).
The right hon. Member for Leeds, North-East (Sir K. Joseph) had a similar problem. Small numbers of doctors engaged in medico-politics and did so without a proper background in politics. Their background is in medicine. Consequently they get themselves into a mess time after time. Fortunately, after four or five years they usually accept that the Government were right in the first place and drop their opposition.
Several hon. Members have drawn attention to the fact that this Bill is concerned with cash—the extra amount that a consultant with an A-merit award might get for a bit of private practice. But there are other matters which give cash advantages. Involved in the whole question of part-time appointment are tax advantages. There are tax advantages in having some private practice and some State practice. There is an insurance interest as well—BUPA, the Private Patients' Plan and others who organise groups who pay so much a week to have the advantage of private facilities. This is a vested interest which has been mounting a massive campaign in the Press day after day supposedly for the benefit of patients care, including private patients.
No one appears to have said very much about amenity beds, which will remain. Indeed, my right hon. Friend has promised to increase the numbers of amenity beds. The campaign in the Press has been mounted on behalf of the insurance industry which has a nice commercial concern. In my view, no one should make a profit out of illness or the treatment of illness. The labourer is worthy of his hire. A good doctor is worthy of his payment. But the idea of a commercial concern, whether to provide private beds or a locum service for family doctors by people on the periphery of the NHS, and making a profit is immoral.
§ Mr. Patrick Jenkin
On other occasions in my hearing the hon. Gentleman, with great force, has said that the country needs more resources in health care. If private clinics or private insurance will bring more resources into health care, why does he condemn that practice?
§ Mr. Pavitt
I have tried already to explain that, and I dispute the right hon. Gentleman's figures. Recently he and I debated at a meeting of the Royal College of Physicians. On that occasion, I differed from his figures. I accept the figures given by my right hon. Friend in his opening speech of £3 million or £4 million in the first year. But, even taking the maximum of £40 million out of the total of £4,500 million, we are looking at a sector which cannot possibly do the job that we need. We divert people from the real intention because eventually we must reach a climate of opinion where they say "This is our Health Service and we are prepared to pay for it."
The Health Service is not free. Everybody pays for it. The average taxpayer pays about £120 per year towards the Health Service. I refer here to the analogy put forward by my hon. Friend the Member for Ormskirk (Mr. Kilroy-Silk) about people having a taxi and a better ride. I think that is better put if we consider that we have paid for the bus, but only those who are prepared to pay twice should ride and the others must wait until the next one arrives.
I should like to echo what my right hon. Friend said about the junior hospital doctors. I can claim to do that, because at one time mine was the only voice raised in this House on behalf of the junior hospital doctors when the BMA was trying to eliminate them from consultations with the Government. In my view, Dr. Piggott and Kathleen Bradley did one of the greatest and most courageous jobs I have ever seen for a group of people who had been dispossessed for so long. However, in their present campaign I believe that the junior hospital doctors are entirely misguided. They should be paying attention to what the Minister of State has been discussing for more than 12 months—namely, a whole new career structure for doctors.
Under the 1973 Act, we are trying to achieve a medical faculty which is completely comprehensive. We want a service 302 where doctors are not divided between one group and another or one section and another. I fear that the junior hospital doctors, instead of looking to a sensible structure, are being deluded into following the wrong course. At the moment, the system is that a doctor will get the plum at the end if he is lucky, but in the meantime he must be a dogs-body and do all the dirty work, so to speak, until he gets past the senior registrar stage. The junior hospital doctors should be concentrating on the restructuring of the service and taking heed of the suggestions which have been made in that direction.
My hon. Friend the Member for Ormskirk, in a colourful speech, put his reservations, which I share, in an extremely forceful way. I am not such a forceful or colourful speaker as is my hon. Friend. However, I draw the attention of the Secretary of State and the Minister of State to my Early-Day Motion No. 339. Many of my hon. Friends feel that the Government, in good faith, have accepted a compromise which takes them too far. As chairman of the Back-Bench Health Group I say that we reserve the right in Committee to go into this matter and to amend the Bill, because Parliament must decide this issue. Most of the Members who signed that motion are members of the Back-Bench Health Group. We are not being critical or destructive. We are seeking to be as helpful as possible. However, we shall pay great attention to all these matters in the Bill in Committee and at Report stage.
Lord Goodman has done the NHS a great disservice. His idea of having tran-quillity by appeasement has never yet worked in any sphere. It certainly will not work in this one.
§ 8.35 p.m.
§ Mr. David Crouch (Canterbury)
The hon. Member for Brent, South (Mr. Pavitt) is a deceptive speaker. He is so full of sweet reason that one almost wishes he were on the Front Bench. Knowing him personally, I sometimes think the Front Bench would be greatly strengthened by his presence. On health matters he has an inner strength. Whilst not having the passion of the hon. Member for Ormskirk (Mr. Kilroy-Silk), there is a consistency in his demeanour 303 and attitude on health matters which I would enjoy better if I could argue with him over a longer period. He is capable of conviction, but he has not convinced me this evening. He has gone up the wrong path altogether.
I welcome the Secretary of State for Social Services, to the Front Bench in his new capacity. I have known him for a long time and have come to respect his judgment and his even balance of views. These are the qualities which will be required of him, not only regarding this Bill but regarding so much legislation in health and social service matters. I wish him well in the tasks that confront him. We are fortunate to have a person who has such a readiness to remain a democrat and to listen to all points of view within the House and outside it. It is absolutely right that he should listen to outside views. I agree with the hon. Member for Brent, South in saying that ultimately Parliament will decide.
I am involved in the service. I sit on a regional health authority in that much-criticised area of the South East which is said to be so rich. I accept that the provision in the South East over the years has probably been greater than in some other regions. That is not what this Bill is about. It is for the Secretary of State to put those situations right. I am not speaking for my region alone. I am concerned with the health provision for all the people of this country. This must be evened out and put right.
This is a ridiculous Bill. It is a monstrous insult to Parliament, to the medical profession and to all those people who use the Health Service. It is an irrelevance and a very costly one. We might argue that £20 million or £40 million is not a very great sum, but it is a cost. I wish we were directing our energies to those things which matter. If only Parliament had an understanding of what the people of this country want Parliament to do. Parliament should concern itself with what is happening in this country and with the economic problems that we face. Parliament should concern itself with the health provisions which are needed and should be voting money for them, rather than trying to tidy up this problem. I know that it is a problem of the pay beds and 304 the private sector working within the National Health Service, but this is a piece of spiteful legislation. It has nothing to do with better medical care. It is born out of a new, vicious attitude which has developed in what used to be great reforming party. There are Government supporters who sit below the Gangway who still belong to that great tradition, but there are others among them who are no longer the proper inheritors of the traditions of the party which Keir Hardy brought into this House.
The new Secretary of State should have the honesty and the guts to consign this Bill to the bonfire. If he goes through with it, he will not only ruin his own promising career but do irreparable harm to the health care that we all seek to provide for the public.
What is the purpose of this Bill, with its 23 clauses? We are told in the Explanatory Memorandum that the object is…to separate from NHS hospitals accommodation and facilities used for the private practice of medicine and to introduce new powers of control over private hospital building".For what? To safeguard the NHS.
That is a cruelly misleading statement, and it is also a joke in the worst possible taste. To safeguard the NHS? This Bill? To safeguard it from what? From the emergence of a second health service—a private health service. But unfortunately that is just what the Bill will create. It will create a monster out of this fiddling little Bill. It will drive people out of the National Health Service into the private health service which it will create. It will cause some of our most able medical men and women to desert the NHS for purely private practice. This is the danger which Aneurin Bevan sought to avoid in his original introduction of the NHS in 1948.
I can see that the Secretary of State is prepared for this eventuality. He intends to take powers in the Bill to prevent the private health service emerging and, therefore, he will take new powers of control. We may think of him as a benevolent man who is even in his balance. But here we see the emergence of Big Brother. We are beginning to see what life in Socialist Britain will be like.
There are no fewer than eight clauses in the Bill designed to effect this new 305 area of State control over the freedom of people to provide better health care for themselves. But what is so wrong about that? The Minister seeks to take the absolute power of veto against the private provision of medical care outside the NHS. He will appoint inspectors with powers of entry to investigate all private hospitals, nursing homes and clinics. His inspectors would be better occupied looking at some of the hospitals provided by the NHS already which are a disgrace to his Department and to our nation.
I know of hospitals which would never get past the scrutiny of his inspectors working to the standards required by this Bill. Let them look in my area of the South-East Thames Regional Hospital Authority at the South Darenth Hospital at Dartford, built more than 100 years ago to the design of a prison. Let them meet the patients there who are living in conditions which would never get past what is required in this Bill of the private sector. Let them look at the Royal Sea Bathing Hospital at Margate. Let them spend a day looking at the 600-bed acute hospital at Orpington, as I did last Friday. Such a hospital would not be allowed to be built under this Bill, yet it has been sitting there since 1916. It would not pass the planning regulations of this Bill. The Department would refuse to give such a hospital a licence because it would be regarded not as a hospital hut as a hutted camp not fit for use as a hospital, where patients are kept in old Army huts built in 1916 for the 1914–18 War.
As I say, I spent a day there last Friday. I have no criticism of the health and medical care provided in that hospital, because I think that it is remarkable. Morale is marvellous amongst all the staff, from the consultants down to pupil and student nurses, and also amongst the patients. There is a very good atmosphere there. People get better there. It has a very high standard in medical provision. People like going there because it is a good hospital inside if one can ignore how awful it looks. We should be spending our money giving the medical profession the best tools to do their job, and providing them with the proper buildings to replace these crumbling asbestos huts I have been talking about.
306 We have heard talk this afternoon about queue jumping and about the fact that waiting lists are unfair to the non-paying patient. I do not accept that we should allow such abuse to continue —not for a moment. I do not think anyone would accept queue jumping by paying a fee. I certainly do not. At present private beds represent some 1 per cent. of all the beds in our NHS hospitals and they should be used when required for non-private-paying patients. They are not all used, or taken up, as hon. Members from various regions and parts of the country have said. As far as waiting lists are concerned no one should ever have to wait for an emergency operation.
What saddens me is that I have to waste time on a Bill of this nature. There is much more important work to be done in the Health Service today—work which is so worth while and satisfying; but this Government will do nothing to improve health care for anyone.
I believe that the Bill will have a positively harmful effect. It will deny the use of NHS services to people who are entitled to them. What does the Minister mean when he talks of a "private" patient? Is a person registered as an NHS patient, who also wants to pay extra for a private room, no longer on the NHS and suddenly regarded as a private patient? Is that person's national health insurance contributions over many years to be disregarded because he or she chooses to provide himself or herself with a little extra aid towards recovery, namely privacy, and at very high personal cost to himself or herself?
There is in this Bill a complete denial of the individual's right to have a say about the treatment he should get. He should have a say about wanting privacy if he thinks it will help his recovery. He should be allowed to pay for this because probably he has insured himself for many years. He should equally have a say about the hospital, the surgeon and the physician, the location of the consultations and the timing and availability of access for his family to visit him. These are individual human rights. They are not to be ignored. We cannot ignore them as we consider the problems which face us in this Bill. Not even this Left-inclined Government can ignore them. I 307 refuse to allow them to go on trampling down on our basic freedoms.
I do not think that this Bill is a pay bed Bill. That is not what I am fighting for. I am fighting against a Government who seem to have gone mad and who have decided to break up the NHS, to destroy the morale of all those who work in it and to ruin the service they provide. The doctors, nurses, and all the other workers in our hospitals, are not fighting for pay beds. They are asking for the Government to come to their senses and to stop interfering with our system of providing good medical care to the sick and injured.
I was with the Bromley Area Health Authority last week. There are some 2,900 beds available in that area serving a population of 300,000 people. There are precisely 33 pay beds in that area. I visited two hospitals—one in Farnborough and one in Orpington. At Farnborough there were 592 beds available in the public wards and the average number occupied out of 592 was 372. Of 570 beds at Orpington, 413 were occupied. Another 33 beds in that area on top of a total of 2,900 will make no difference to the service available. There is plenty of room in the general wards, but what is needed is not another room or two but more lavatories and bath-rooms, operating theatres and new equipment, to bring the hospitals up to 1976 standards.
There are plenty of private rooms available already, which were not being used, in the hospitals that I saw for patients whose recovery depends on privacy. I am referring not to private pay beds or to amenity beds but to beds provided for medical reasons when privacy is an essential part of recovery. At Farnborough there is an excellent infectious diseases unit where every patient is in an air-conditioned private room. There are 17 such rooms available for anyone who needs that treatment—nothing to do with pay beds—but only 12 were occupied. At this hospital there is also an excellent new psychiatric wing with many private rooms for patients, most of which were empty when I visited it.
The danger of the Bill is that it will make us lose sight of the things which really matter. We should not be fussy 308 about 1 per cent. of beds in an area where they need a new district general hospital, a more modern operating theatre, new X-ray equipment and better nurses' accommodation.
About 32 per cent. of those who die this year in the Bromley area will die from heart disease. Anyone who is lucky enough in those circumstances to get into the intensive care unit will have a very good chance of survival. The equipment is excellent—modern and very expensive. No expense has been spared. The nursing staff are highly trained specialists. The unit is an open ward, full of life-saving equipment, which is more important than privacy when fighting for one's life.
Privacy is not always the best cure, of course. Children's wards are very happy places because children are gregarious and like talking to each other. They are also wonderful in having no class consciousness. One of the secrets of geriatric nursing is to get old people interested in life and in meeting other old people. That is half the battle. The day rooms in a geriatric ward are jolly places, not lonely.
We should not make such a thing about private beds. They fit naturally and without difficulty into a vast National Health Service. They do not harm the service or anyone else. If they did, I should support the Minister in removing such harm.
There is so much that is good in the Health Service but there is also much that is still wrong. One of its major weaknesses is that it is still too much of a State service, too dependent on centralised administrators and Government policy directives. It should be allowed to get on with its job of caring for and curing the public. Instead of trying to clamp down on a tiny area of intiative, individualism and investment, we should be finding ways to improve medical care and enlarging the opportunity of the individual to play a bigger part in maintaining and improving his own health.
The Government are going in the wrong direction with this Bill. They should change direction while there is still time, or at least abandon the Bill and offer the choice and chance to the Royal Commission to report impartially.
§ 8.54 p.m.
§ Mr. John Ovenden (Gravesend)
I should like to see the same sort of improvements in the quality of service in the National Health Service as the hon. Member for Canterbury (Mr. Crouch) but I suspect that they will be difficult to achieve in the light of the public expenditure review and totally impossible in the light of the Conservative Party's dedication to massive cuts in public expenditure. I want to get back to the issue of private medicine in the NHS. This is basically a simple issue—the issue of privilege. It is unfortunate that, throughout this debate, Conservative Members have refused to understand the difference between envy and our objecting to privilege. Every time we object to privilege, they accuse us of being envious. I suspect that there is some gap in their political education which makes it impossible for them to grasp the simplicity of this point.
But despite the attempts to confuse and complicate this discussion by Conservative Members, particularly the right hon. Member for Wanstead and Woodford (Mr. Jenkin), who succeeded only in confusing himself, the issue is basically simple. It is whether a small section of the community should continue to receive special treatment in NHS hospitals at the expense and to the detriment of their fellow citizens.
We have to decide whether medical need or the size of the individual's bank balance determines the priority for medical treatment. Conservatives talk as though medical treatment can be dealt with in the same way as buying a bag of potatoes, a car, or a fur coat. Those who can afford to can buy the best, and those who cannot have to make do with second best. One cannot treat medicine and good health in this way, yet that is what we are doing at present. Private medicine within the Health Service means dual standards, and tackling that is long overdue.
Conservatives ask why we have managed to put up with this for 30 years. I do not know why it has taken so long, I am only happy that we now have a Government who want to tackle the problem. The Government will be bitterly opposed by those whose vested interests will be threatened, not only the private patients and the part-time consultants, 310 but the insurance companies to whom private medicine is big and very profitable business. Despite these voices, the principle of the Bill will be welcomed by the overwhelming majority of Health Service staff and the millions of people who deplore the scandalous abuse which private practice represents.
A system which forces the majority of people to wait for hospital treatment while others are allowed to buy their way to the front of the queue is indefensible and a denial of the central principle on which the Health Service was established. Maybe when it was established it was necessary to accept second best and to compromise. But I suggest to my hon. Friends that the time has come when we can finish with that compromise and carry the principles of the Health Service one step forward.
What ethics exist in a system where sick people can wait for a bed for months unless they can pay, in which case they can receive immediate treatment? The majority of decent people regard that position as scandalous. The aim of the Bill must be to see as speedily as possible that all hospital beds are available to all patients and that our priorities are based on medical need alone. In achieving that the Bill has certain serious weaknesses which I hope we may remedy at a later stage. But it is a step in the right direction.
The advocates of private medicine have done their case enormous harm by their wild exaggerations of its benefits. Private medicine benefits very few. It does not benefit the majority of patients and Health Service staff. It does not even benefit the majority of consultants, because only a slight minority actually indulge in private medicine. Very few people have anything to lose from the elimination of private medicine from the Health Service.
My objection to private medicine stems basically from my objections to queue-jumping, and there has been no convincing denial from the Conservatives that queue-jumping takes place. If that was not one of the main reasons for private medicine, I cannot think of another. If patients were able to go into Health Service beds without long delays I suspect that the demand for private medicine would be even less than it is, and the 311 occupancy of private beds would be even smaller than it is now.
My objections stem not only from that but from the fact that the system leads to other objectionable features. First, it brings about a distortion in the allocation of resources in the National Health Service. The powerful position which is enjoyed by the part-time consultant in the process of determining priorities has led inevitably to a system in which emphasis is placed on the areas where the opportunities to make profit out of private medicine are best.
It is no coincidence that the Cinderella areas of the National Health Service are the areas in which the scope for private practice is the least. Additionally, the system of private medicine within the NHS ensures that there is a concentration of consultants in the areas where private practice is most profitable. That leads to a distortion in the allocation of skills throughout the Health Service. It also leads to many consultants using their time on operations where their skills are not really demanded. They spend their time and energies on private operations which could well be carried out by junior staff while junior staff are left to carry out some of the major operations on NHS patients.
Private medicine is held out by many of its supporters as making a financial contribution to the Health Service. As my hon. Friends have already said, the amount it raises is insignificant in terms of the total Health Service budget. But, more important than that, we should apply the stringent test of whether the occupiers of pay beds pay their fair share of costs if they are not to be considered a burden on the NHS. The fees paid should be sufficient to finance the provision of alternative beds.
It is necessary to examine the cost of providing a modern hospital and to establish the figure that a patient should pay for the rent of a bed. I believe that at the last estimate the figure was about £45 a week. However, the fees for private patients include only a notional sum for rent.
I suggest that private practice is not even paying its way. It is not making a proper contribution to the NHS. One of 312 our main concerns should be to ensure the most efficient use of resources within the service. Pay beds represent an inefficient use of resources because the occupancy rate is low. I understand that there is a large regional variation, but the average occupancy rate for a private pay bed is about 60 per cent. while the National Health Service occupancy rate is 80 per cent. to 90 per cent. I suggest that private pay beds are a grossly inefficient use of resources. They are deplorable when viewed in the light of the long waiting lists in many areas.
I believe that we can have a more efficient Health Service which will offer better care to meet the needs of patients if we abolish pay beds. We could have a system whereby consultants pay proper and fair attention to NHS patients. I am sorry that the lack of time prevents my going into this matter in detail.
I refer the House to the report of the Select Committee which considered this subject. It pointed to the neglect of health service work which arises as a result of consultants dealing in private medicine. It provided figures illustrating the small number of emergencies dealt with by consultants. It is evident that private medicine means that Health Service patients do not get their fair share of NHS resources or consultant time.
§ 9.3 p.m.
§ Dr. Gerard Vaughan (Reading, South)
I suppose that I should not have been surprised that most of the contributions from Labour Members centred with varying degrees of envy in attacking private practice. I mean envy, despite what has been said by the hon. Member for Gravesend (Mr. Ovenden). The abolition of privileges is of value only if as a result it confers some sort of benefit on the rest of society. That is the point that the Opposition make. It is envy if there is merely a will to destroy things for the sake of destroying them.
There has been little from Labour Members as to how the Bill can help the NHS in any way. It is the NHS that 98 per cent. of patients will use. It is not surprising that we have heard little about the Bill helping the NHS because it will do virtually nothing to help the care of patients in the service. Indeed, there are great risks that it will do much harm.
313 Like my hon. Friends the Members for Ealing, Acton (Sir G. Young) and Canterbury (Mr. Crouch), I wish we could have discussed instead the immense problems of the NHS and the care of patients. It is the standard of patient care, which has been falling steadily in recent years, which concerns me most. We have heard virtually nothing from the Government benches about the care of patients. Anyone who wants to know why the medical profession feels so bitterly misunderstood and frustrated has only to read the intolerant and inaccurate speech made by the right hon. Member for Blackburn (Mrs. Castle). I ask the House, who speaks the greater truth? Do she and the hon. Member for Ormskirk (Mr. Kilroy-Silk) speak it when they say that there is no room for compromise over the Bill, or does the Secretary of State speak it when he says that he is prepared to enter the Committee stage of the Bill with an open mind? Time and events will show who speaks the greater truth.
I congratulate the Secretary of State on his new office and on the moderation with which he spoke today. He will know that many people, including those of us who oppose him bitterly over the Bill, hope sincerely that he will reintroduce peace or, as Lord Goodman said in his letter in The Times today, "tranquillity" into the National Health Service. With that in mind we can almost, but not quite, forgive the Secretary of State for his apparent lack of knowledge which showed up in some of his statements today.
Does the Secretary of State really put the cost so low? The figures that were given by his predecessor are quite different. We have figures—the Secretary of State may correct them subsequently —which point to very different levels. My figures show that the expected revenue income for 1976–77 from the regional hospital boards and acute general hospitals is just over £19 million, from provincial teaching hospitals nearly £3 million and from London teaching and undergraduate hospitals just over £11 million. We assume in a full year that there will be a loss from those hospitals alone of nearly £33 million. In addition, there is over £400,000 from Wales, nearly £2 million from Scotland and just over £1 million from Northern 314 Ireland. That gives a total of just over £37 million in a full year. The Secretary of State, with all his resources, may correct us and say that those figures are wrong. They certainly bear no relation to the figures which he gave us today.
Does the Secretary of State believe that the waiting lists will be reduced? We heard from the letter written by the Department to the surgeon, Mr. Nigel Harris, that we can expect no reduction in waiting list time as a result of the Bill. The hon. Member for Watford (Mr. Tuck) was right when he said that waiting lists were contributed to by faulty administration and shortage of staff. The Minister of State conceded that many times when we questioned him about it.
There are 11,000 beds empty every day because of shortage of staff. Of the 70,000 to 80,000 beds which are empty because of patient turnover, at least 11,000 are empty because of shortage of staff and resources. Some are in new units which cannot be opened because of shortage of staff. With this in mind was the right hon. Gentleman surprised when my hon. Friend the Member for Ealing, Acton said that an empty private wing had been closed? I have information about another wing in which 24 private beds have been withdrawn and the room has been made available for use by the administration. Those beds will not come back into patient care and be available for patients in the NHS. We shall find it very difficult to convert the withdrawal of pay beds into extra facilities for NHS patients.
Does the right hon. Gentleman realise that his predecessor was incorrect when she said consultants had rejected the common waiting list? I was astonished to hear her say this and to hear her faithful henchman, the hon. Member for Ormskirk, support her, not knowing the facts. In December 1974 the BMA wrote to the DHSS giving the names of members who intended to examine the problem with representatives from the Department. That offer was never taken up and yet the right hon. Member for Blackburn says that the suggestion was opposed and rejected by the medical profession. Words such as those fed the anxiety and opposition of the medical professions over what she was doing.
Does the Secretary of State mean that the phasing out of pay beds will increase 315 the number of consultants? That is an extraordinary thing to say. Does he not realise that there are already several hundred empty consultant posts? Only this week the Minister of State listed them and said that 197 had been vacant for more than a year and that in 120 cases the appointments committee had been unable to find a suitable candidate. I know of many cases where jobs have been advertised and where the field has either been negligible and no appointment has been made, or so poor that there was no choice, as it lay between one or two people at the most. In the Chamber recently I quoted a London hospital which had 26 applicants for a desirable surgical post, but 24 of them came from overseas and, for obvious reasons, were not strong runners for the appointment. I cannot see where all the extra consultant posts will come from.
My hon. Friend the Member for Ealing, Acton told us of the case of a consultant who wanted to become full time but there was no money available. If he has not already done so, the Secretary of State will soon learn that there are many doctors who would like to become full time but cannot do so because there is no money.
I cannot see that the phasing out of pay beds will increase the availability of consultants in the NHS. Far from improving the situation for consultant posts in the National Health Service, the Bill will probably make it worse. Little increase in emigration is needed to bring some specialties to a complete stop in some areas of the country. I am sure that the Secretary of State could confirm that.
I was interested in the details of the Bill given by the Secretary of State. This is not the time to go into detail because there will be ample opportunity in Committee. But it was helpful to us for the Secretary of State to go into so much detail. I was particularly interested in his remarks about notification and the conveying of approval to local planning authorities. I hope that he will undertake to speak about industrial blacking of buildings in the same robust terms he used when speaking of industrial strife within the Health Service as a whole. I hope that he will stand up and say those 316 words when people behind the scenes try to stop the building of an approved project. We welcome what he said about industrial strife generally. We have been saying that for some time, but the previous Secretary of State said not a single word of that kind. We have used such words many times. Tension and friction in the service would have been reduced if she had openly come out against the petty industrial action taken against patients over meals and patient care.
Sadly, I must tell the right hon. Gentleman that he is already building up some disappointment and anxiety, not because he has failed dramatically to change his policies—we should not have expected that of him—but because he could so easily have delayed the Bill for a little while. He could have given himself a little more time to have a proper look at it, and not just a weekend. That went down very badly in the health world. His remarks were not understood or appreciated. I understand that he brought the Bill forward by a few days—
§ Dr. Vaughan
I am glad to see the right hon. Gentleman shake his head. The rumour has been going around—
§ Mr. Ennals
I did not bring the Bill forward at all. I brought it out on the day originally planned.
§ Dr. Vaughan
I am reassured that at least we can scotch that rumour.
The right hon. Gentleman might have taken the bold and imaginative step—dare I suggest this after the earlier discussions?—of referring the Bill to the Royal Commission. His argument against that is not very strong. The Royal Commission has completely changed the position of the manifesto that we hear quoted so very often.
The right hon. Gentleman could have allowed a little more consultation to take place. He told us today that there had been a great deal of consultation. His predecessor said the same. A good deal of consultation took place in the last few days, but in many people's minds it was not proper consultation of the kind they would have expected. When a little did occur, the term "consult" far too often became "insult", in the experience 317 of those people. A very nasty taste was left in their mouths.
Viewing the Bill, one must ask the fundamental question, why should people who are not normally inclined to industrial action—the doctors, dentists, so many of the nurses and the hospital administrators—all be so opposed to the Bill? Why should whole-time and research staff, who will never engage in private practice, and do not want to, unite with their colleagues in opposing the Bill?
There are two major reasons, which have been touched on in the debate. First, whatever the Secretary of State says, the profession still believes that there will be a loss of personal freedom both for patients and for its members. It believes that the Bill will lead to genuine, serious damage to care of patients. It may be wrong, but that is what it believes.
Secondly, the profession sees the Bill —and I do not think that the right hon. Gentleman can argue against this—resulting in an extravagant and damaging loss of income at a time when money is desperately needed in the NHS. I should like to explain a little more the idea of loss of freedom. I begin by quoting the President of the Royal College of Surgeons, one of our most senior colleges, who said after the Queen's Speech in November:There is no doubt that doctors, almost without exception, believe the independence of the profession and the freedom of patients to be in very great peril.He said that they sawParliament allowing every element of Independent medicine to be removed from NHS hospitals and its replacement outside the NHS frustrated by licensing restrictions.My hon. Friend the Member for Somerset, North (Mr. Dean) had that in mind when making some of his remarks. The President added,If this occurred the State would then have a stranglehold upon independent medicine.This is the fear, whether we agree with it or not, which lies behind the medical opposition to the Bill.
I was astonished, listening to the right hon. Lady earlier this evening, when she was talking about how the medical profession feels and thinks, because that is 318 not the medical profession I meet. I should like to refer to a remarkable article by Lord Taylor, who is a doctor and a Socialist peer. I recommend the article to anybody who has not yet read it. He says thatone of the difficulties of health service planning is to make the laity understand the importance of medical care.He adds that they find it very difficult indeed to judge the quality of medicine. They can see the quantity but not the quality. To many people, certainly to most Labour Party Members, a doctor is a doctor, and that is that. That is certainly the unenlightened view of the hon. Member for Ormskirk, who spoke earlier.
Lord Taylor also says thatdoctors doing clinical medicine are nature's self-employed; they seem to need the stimulus of self-employment if they are to do their best work.These are very serious words from some-body who has spent most of his life within the health profession. Lord Taylor says further thatclinical medicine is a tough and difficult profession.…Decisions must be swift and brave.…If the 'tidier-uppers' were to win the day and build in controls to the practice of medicine the victim would be medicine itself.…Wherever this has been done, the result has been mediocrity.If we want to benefit from experiences in other parts of the world, we should abandon this Bill tonight, because every country that has followed this line has ended up in disaster.
§ Dr. Vaughan
I am coming to it. Sweden is one example. The hon. Member for Watford talked about it. Not a single medical advance of any importance has come out of Soviet medicine.
§ Dr. Vaughan
What I have said is true. But more relevant is the experience in Sweden which, as has been pointed out, phased out its private beds in 1960. Swedish medicine was the pride of Sweden, and looked upon by other countries in the world as having a remarkable standard. It has since gone into a decline and fallen into mediocrity. Any hon. Members who doubt this can go there and see for themselves.
319 This is why we have great anxiety about the Bill, When speaking about what appeared to them to be the advantages of the Bill, hon. Members do not seem to have considered the long-term consequences that their proposals will have on the care of patients. The doctors' anxieties are based on Labour Party statements. They are based on the statements coming from the trade unions. My hon. Friend the Member for Somerset, North referred to that. The Labour Party wishes to see a totally State service, regardless of any sacrifice in medical standards. The hon. Member for Ormskirk said that that is what he wants to see.
§ Mr. Kilroy-Silk
If the hon. Gentleman wishes to paraphrase what I said, let him try to get it correct. I said that should like to see the abolition of private medicine, and I do not go back on that. I did not say that this would lead to a reduction in standards in the National Health Service. I believe that it would increase the standard of the quality of care.
§ Dr. Vaughan
I take that point. I do not think that the hon. Member realises the consequences of what he is proposing. The medical profession is looking now for assurances that, having been trained to take initiatives, doctors will not be restrained from putting into practice the highest services to medicine. This is the assurance that it is seeking. The statements from the Labour Party, the Goodman proposals and the statements of the former Prime Minister have done nothing to remove that anxiety. This is the reality of the situation. Hon. Members opposite may not like to hear it.
I believe that the emigration figures are two years out of date. All the figures I have obtained from individual places suggest that emigration has shot up in recent months. In a year or two when we get the figures, we shall be wringing our hands in distress. It is a national disgrace that because we can-not fill the gap in this country, we are required to take doctors from countries where they are greatly needed.
320 Fears have been expressed about the loss of freedom. There is also the fear that money is being lost at a time when it is desperately needed for the NHS. We feel that this Bill is irrelevant to the main problems of the NHS.
There is deep resentment about this matter. We heard the other day about one hospital where staff are washing bandages by hand and re-using them to effect economies. I know another hospital whose administrators have been told to cut their budget by £500,000. They assure me that this must result in a cut in services. A directive has just been issued as a result of the appalling muddle over junior doctors. The cost of paying the extra salaries must come out of existing budgets. That will mean a cut in services.
The loss of a sum of £40 million—we believe that figure to be correct—means that we are losing money that could be used to pay for the whole upgrading of the services for the mentally ill. That sum would cover the full cost of hospital treatment for 100,000 acutely ill patients. It would provide the NHS with 140 EMI brain scanners. It would build five 300-bed nucleus hospitals. It could create over 2,000 places in medical schools. That is what we are losing. It could pay for the training, right through to qualification, of over 1,000 doctors. Further-more, that money could restore almost a quarter of the cuts imposed by the Chancellor of the Exchequer on the social service budget for 1978. This is why so many people feel resentment over the Government's actions.
I was a member of the Expenditure Sub-Committee which sat under the enlightened guidance of the hon. Lady the Member for Wolverhampton, North-East (Mrs. Short). She knows that we found no supporting evidence whatever of serious or widespread abuse. We heard submissions from junior hospital doctors, but we had no supporting evidence.
§ Mrs. Renée Short
If the hon. Gentleman wishes to quote from the Report, he must quote correctly. There was broad evidence from doctors, nurses, consultants, junior hospital doctors, and also from the hospital unions, all to the same effect. The hon. Gentleman obviously 321 has forgotten the details of the Report and should re-read it.
§ Dr. Vaughan
The hon. Lady's memory is faulty. Isolated examples were given to us, but they were not substantiated.
§ Dr. Vaughan
I was a member of that Select Committee, as was the hon. Lady.
There is a widespread belief that, in the long term, this legislation will achieve exactly the opposite to what the Government intend. We know that it will do nothing to cut waiting lists. We know that it is unlikely to increase the number of beds available to patients.
I have an uncomfortable suspicion that the Secretary of State for Social Services believes that he has only to get this Bill out of the way in order to achieve peace and quiet in the NHS. I hope that he is right, but that may not prove to be the case. The passage of the Bill could be just the beginning. Staffs may become more awkward rather than less so. I may be wrong, but from what I hear they could well become more difficult. We ask those in this House who have said that they believe in the preservation of individual and professional freedom, those who, like the Leader of the Liberal Party, have suggested that this matter should be put to the Royal Commission, and those who have spoken passionately about the need to improve the NHS as a whole, to join us in opposing the Bill. We believe it to be totally misconceived and out of keeping with the real needs of the NHS. That is why I ask hon. Members to vote against the Bill tonight.
§ 9.30 p.m.
§ The Minister of State, Department of Health and Social Security (Dr. David Owen)
Ever since the creation of the National Health Service, doctors in Britain have attached great importance to their right to practise both within the framework of the NHS and outside. The general practitioner has always been able to treat NHS patients and private patients. The hospital consultant has always had the option to practise part time for the NHS and to retain the right to practise privately. This right has never been 322 challenged by the present Government over the last two years and this Bill specifically prevents the introduction of an exclusively whole-time work force.
The profession has been assured that legislation over pay beds will reiterate these guarantees, and this Bill has reiterated the guarantees about the right to practise privately. Whatever views we in the House may take about the encouragement of whole-time commitment to the NHS—which I make no secret is something I would wish to see freely entered into by doctors—if the hon. Member for Reading, South (Dr. Vaughan) has any evidence of consultants who wish to become whole time but are prevented from doing so by their employing authorities, I hope that he will give me chapter and verse about them, because I should be only too happy to look into the matter. However, the NHS, over its long history now, has undoubtedly gained from the public spirited work by many consultants who have devoted long hours to the NHS and who have given considerable value for money to the NHS. That should be put firmly on record.
However, the controversy over the place of private practice within the NHS has a long history. It was argued over when the Act went through the House. Private practice was controversial even before that time when it took place in private hospitals prior to the introduction of the NHS. The controversy has been building up steadily now for a decade or more.
The extraordinary part about the speeches of Opposition Members, particularly that of the right hon. Member for Wanstead and Woodford (Mr. Jenkin), has been the almost complete absence of any understanding of how controversial this issue has become within the NHS. The most worrying aspect of the controversy has been the way in which it has split the traditional partnership between health care workers in hospitals. It has become for some of them a deeply divisive issue in which some nurses, doctors, porters and technicians find themselves at loggerheads. The issue has been taken as the basis of industrial action by individual health workers since May 1974, though from differing view-points.
323 This controversy has gone on for a very considerable length of time. It first came into discussion in the House in the report of the Expenditure Committee, which has been referred to often in the debate, back in 1971. But it was controversial before then. People ask "What will the Bill do for the NHS?" What I hope it will do will be to bring peace to the Health Service. It has not helped the NHS to have had a period of industrial action, from both sides, which has resulted in a considerable lengthening of waiting lists and waiting time. It has not helped patient care to have ill feeling within the NHS over this period. It has not improved standards of care to have this controversy.
The hon. Member for Reading, South claimed that this Bill has been motivated by political spite. I totally reject that view. Those hon. Members and those who have worked in the NHS who feel strongly about this issue have used every democratic means at their disposal to get a commitment from an incoming Government, a manifesto commitment, to make a change in the arrangements. In a democracy, that is a perfectly legitimate way of making a change in society. It would be an appalling situation if such a change, democratically arrived at, and a decision made by an incoming Government after two years of consultation, could not be introduced merely because of the virulent opposition of some members of the medical profession.
Doctors are not unanimous on this issue, though the percentage in favour of the abolition of private practice would be very small, even among those committed whole time to the NHS. However, a sizeable percentage see positive merit in the separation of private practice from the NHS, or are prepared to accept separation providing there are adequate safe-guards. The Bill provides those safe-guards. This is not the abolition of private practice by the back door. Radical reform often requires compromise and no one should be ashamed to admit it.
§ Mr. Patrick Jenkin
Before the Minister leaves the question—which I did not attempt to blur—of the resentment felt by some people working in the NHS, will he recognise that there 324 has to be a difference in one's reaction to resentment based upon real detriment to the NHS, its patients or employees and resentment which is based on jealousy of privilege and other similar arguments we have heard from below the Gangway opposite today? What are the real advantages to National Health Service patients of phasing out pay beds?
§ Dr. Owen
I reject totally and absolutely the right hon. Member's suggestion that our view that private practice should be separated from the National Health Service is based on envy or political spite. It is based on a philosophical belief, challenged by the Opposition throughout the discussions on the original creation of the NHS, that the basis of the Health Service and health care should be medical need and not ability to pay. That has been a controversial issue between the parties for a long time.
In a free, democratic society, it is a difficult principle to establish completely and that is why the private sector exists. It is a safety valve to the system. The question is whether that sector should exist within the NHS.
The genius of Nye Bevan was that he recognised in 1946 that he had to make a compromise. We hear eulogies from the Opposition about Nye Bevan. They quote the speeches he made in 1946 and 1947, but omit to mention his view on pay beds, published in the book "In Place of Fear" in 1952. He made clear that he thought pay beds would eventually have to go because of the abuse factor.
I had the privilege to serve under my right hon. Friend the Member for Black-burn (Mrs. Castle) for two years. It may take time for her contribution to the NHS to be appreciated, but it was real and it will be long standing.
Many thousands of people in the NHS will not laugh in the ridiculous manner in which some hon. Members opposite are now laughing. While my right hon. Friend was Secretary of State, nurses received justice at long last in their pay scales, with 60 per cent. pay increases for many nurses. We also kept faith with the doctors' pay claim and they received a 35 per cent. increase in April 1975.
In December last year, my right hon. Friend hammered out what she openly 325 described to the House as a compromise. She made what she called a reasonable compromise because, like all of us, she saw that the dispute of the time was damaging the NHS.
The proposals presented to the House on 15th December were a compromise which upheld certain basic fundamental principles—first, that the separation of private practice should take place, but also that the medical profession should have a guaranteed right to practise and that the separation should be supervised by an independent board.
Many people in the profession did not believe that the Bill would enact the December proposals. However, the House can see that we have been faithful and honourable in presenting in legislative form the proposals put before the House in December. We now look for a similar honouring of the arrangements hammered out in December on behalf of the medical profession.
I think that the profession will recognise that, as both it and the Government compromised in December, the compromise must be maintained and upheld by both sides.
I accept the point made by the right hon. Member for Wanstead and Woodford that those proposals are now subject to legislative scrutiny in the House. Legislation is made here. That is why we condemn industrial action by either side in the Health Service and why I gladly say that we do not approve of any abuse of the planning system which is meant to be impartial and objective in its application to private hospitals.
The issue before the House is whether we should give the Bill a Second Reading. believe that the Bill offers a prospect of ending the divisions and the damage within the Health Service.
Considerable play has been made by right hon. and hon. Gentlemen opposite with the reduction in income to the NHS resulting from the separation of pay beds. A suggestion has been made that the loss of income could amount to £40 million. That is a grossly exaggerated estimate. Without this Bill, in a full year, taking account of the 30 per cent. increase in pay bed charges operative from 1st April 1976, income from pay beds is expected at most to be no more than 326 £23 million in England. That is based on estimates of £18 million for 1975–76.
The right hon. Gentleman rightly referred to an answer in November last year. At that time income from pay beds in 1973–74 was given as £14.3 million and an estimate of £26 million was given for 1975–76. That was only an estimate. The outturn appears to be less, for reasons which are difficult to estimate in advance, because it depends on occupancy and other factors.
If the Bill is passed, as the Financial Memorandum shows, the initial loss of income in the current year is expected to be between £3 million and £4 million. Again, it is difficult to estimate because it depends on occupancy. It will become a bigger loss in future years as pay beds are phased out, depending on the rate at which they are recommended to be phased out.
The money available to the NHS has been increased in advance to take account of this expected loss of income. The public expenditure programme for the NHS was fully compensated for this change last spring when, on 5th May, my right hon. Friend announced that the Government had decided that appropriate funds would be made available so that the revenue allocations of health authorities would not be affected in consequence of the phasing out of pay beds. The record that this extra money has been made available is in the recent White Paper on Public Expenditure, page 94, paragraph 5, and the figure covering this and other matters is shown in the tables on page 142 as plus £26 million for 1976–77 and plus £51 million for 1977–78.
The NHS has already received additional money to cover a specific Government commitment and policy. Because the Government believe that the Bill is necessary for the NHS, they decided to cover the cost. The resources available to the NHS are not affected. Nothing will have to be given up. Those pay beds, operating theatres, facilities and staff, which are of value to the NHS, will be retained. To the extent that private patients opt for the NHS, they will continue to make use of these or similar facilities. To the extent that they do not, the facilities will be an addition to the NHS. Some of those facilities are extremely valuable.
327 The Charing Cross Hospital has 40 private beds. The capital cost of providing them at current prices would be £1.8 million. The Royal Free Hospital has 36 beds, the capital cost of which would be about £1.4 million. These are modern hospitals. St. Thomas's Hospital has about 48 private beds, the estimated cost of which would be about £2.6 million.
There are many other parts of the country where private beds will eventually be made available in brand new, modem hospitals which will be a considerable addition to the Health Service. I totally reject the suggestion that this policy will mean an absolute drain on the NHS.
My hon. Friend the Member for Watford (Mr. Tuck), whose sincerity on this issue I respect, argued that politics is the art of the possible. He asked whether this proposal was possible against the views of the medical profession. I do not think that can be the only factor. The views of the medical profession are important, but so are the views of many other people in this country.
My hon. Friend said that there was a distinction between waiting lists based on medical need and waiting lists which allowed some people to jump the queue purely on the ability to pay. My hon. Friend made a great point about privacy and rightly quoted Aneurin Bevan who introduced the concept of privacy into the NHS through amenity beds. That point has constantly been reiterated.
As far as possible, without taking a single room which might be used by a patient who is ill and needs it, it is right for the NHS to provide privacy. It is right, too, as far as possible, for the NHS to give more attention to people being able to choose their time of admission. One of the greatest problems about private medicine is in giving people the right to choose the doctors who will conduct a particular and maybe highly specialised, or perhaps not very specialised, operation. There has to be a rationing of scarce medical skills.
The most serious and difficult operations are often carried out by the most experienced doctors. If all their time is pre-empted by private money, it will mean that a doctor's skills could be 328 totally taken up by doing operations which demand less than his own skills. It is unrealistic, because the private sector is small. Were the private sector bigger that degree of distortion of medical skills would be very great.
We cannot give within the National Health Service the right to every patient to choose the doctor of his choice to do the actual operation. With the help of his general practitioner, the patient can choose the consultant who will supervise it. But the former would be a certain recipe for distorting scarce skills in the NHS and would fundamentally under-mine the principles on which the NHS was established.
The Scottish nationalists support the Bill. They drew attention, as did many of my hon. Friends representing Scottish constituencies, to the fact that this is not a divisive issue in Scotland. The NHS in Scotland has provided a very good service for the Scottish people without a very large number of private beds. Opposition Members totally omitted any reference to the fact that this is not a divisive issue in certain parts of the United Kingdom. This needs to be given attention.
The hon. Member for Reading, South said that the doctors had never rejected common waiting lists. He ought to know that at the British Medical Association Annual Representative Meeting, held in Leeds in 1975, a motion in the name of East Kent:That this Meeting rejects any proposal for a common waiting list for admission to public and private wards in the NHSwas accepted. I quote from the British Medical Journal:Dr. Astley…said his Committee had no sympathy for the common waiting list: in its view, pay beds were part of a mixed economy. Britain was after all, still a capitalist country and the committee would refuse to have anything to do with common waiting lists.It was a great mistake that the medical profession did not take common waiting lists seriously. The Liberal Party, the Scottish nationalists, the Welsh nationalists and my hon. Friends all welcomed the provision in the Bill for the independent board to report within six months on the possibility and feasibility of introducing common waiting lists for those pay beds remaining in the NHS during the period of phase-out.
329 There were two main points on which hon. Members opposite wanted greater reassurance. One was consultation. Amongst those hon. Members who have come in late, there is no doubt some anxiety about individual pay beds in individual constituencies. This is related to the schedule.
We have never made any secret of the fact that we want continuing consultation on the schedule. This consultation will go on during the Committee stage. My right hon. Friend said earlier that he would like the list in the schedule to be an agreed list if possible. He said he was therefore inviting the profession and the Independent Hospitals Group to consult him to see whether it could be mutually agreed which 1,000 beds were to be withdrawn In doing this, we should, of course, want to take account of local representations. He said that he also intended to invite the Committee considering this Bill to accept a motion which would enable the committee's discussion of the schedule to be taken towards the end of the Committee's deliberations. Then, if an agreed schedule can be brought forward, my right hon. Friend will be able to table it in substitution of that now in the Bill. This offers the prospect of considerable consultation with the profession
§ Mr. Patrick Jenkin
But the letter from Mr. Nodder to the area health authorities spoke about consultation continuing even after Royal Assent. Will the Government now undertake to introduce a power into the Bill to amend the schedule by order after the Bill is passed?
§ Dr. Owen
We do not need that power, because the schedule refers to the area health authority, and the consultations continuing afterwards, if they were necessary, would be at the level of the individual hospital. The 1,000 beds are in the discretion of the Secretary of State who has already got that discretionary power. His discretionary power ceases once the 1,000 beds are out, and this then becomes a matter for the independent board. Flexibility is there if it is necessary, though I hope that it will not be necessary. One other way of considering it is by looking at group designations which would allow continued flexibility on this point.
330 As for Northern Ireland, one of the most interesting features was the speech by the hon. Member for Mid-Ulster (Mr. Dunlop), who made it clear, as I understood him, that the main criticism of the Ulster Unionists was not against Part I and Part II of the Bill but against Part III. He was under no illusion that the Bill and the discussions leading up to the Bill had excluded Northern Ireland, and he made a strong plea that this should not happen again.
At no time have the Government contemplated the extension of the Bill to Northern Ireland. This was made clear in the statement to the House by my right hon. Friend the Member for Blackburn on 15th December. The practice in Health Service matters, which was criticised by the hon. Member for Mid-Ulster, is for the Northern Ireland Department of Health and Social Services to consult the appropriate bodies in Northern Ireland about the application in the Province of measures introduced or proposals made for Great Britain and there-after to legislate separately for the Province.
Much was made of the presence of the Secretary of State for Northern Ireland at a meeting. That was a meeting about the Royal Commission. It was not a meeting about pay beds legislation. That was the genus of that meeting.
The more that one looks at these questions, the more one sees that there is a greater understanding of the problems, not surprisingly perhaps, amongst Members representing Northern Ireland constituencies who were rather alarmed at the prospect that they would be expected under a Conservative Administration to give up 200 beds. As the hon. Member for Mid-Ulster said, the fear was that one-fifth of the total number of beds would be foisted on to Northern Ireland and that that seemed a strange way of rewarding Northern Ireland's share of the population of the whole of the United Kingdom.
Dealing with the Part III objections raised by the hon. Member for Mid-Ulster, it has to be borne in mind that a medical journal such as Lancet was able to say that what is surprising is the high upper limit on the number of beds in projected private acute hospitals above which limit the board must grant 331 authorisation before planning permission can be sought. The limit is 100 or more beds in Greater London and 75 or more elsewhere. Most of the criticisms from the Lancet and from others is that the Government have been too generous on this measure. My right hon. Friend the Member for Blackburn seemed to suggest that she thought she had been too generous on it. But it was an attempt to get a solution of the problem which was necessary.
As regards the cost of the independent board, we reach the most extraordinary situation. I hope that all members of the Liberal Party will read the speech of the hon. Member for Truro (Mr. Penhaligon). It was an extraordinary speech. He said that he was in favour of the Bill in almost all its aspects. He was in favour of phasing out. He did not object to the licensing provisions though he would wish to look at them. He thought that the Government were acting fairly and honourably. What the Liberal Party objects to is the fact that there is to be an independent body at the cost of too high a bureaucracy. In other words, the Liberal Party, which committed itself before the election to phasing out pay beds and which has vaccilated on this issue over the past year or so, is now committed under the most extraordinary terms to voting against the Second Reading of this Bill on the basis that there is an independent board.
When I challenged the hon. Gentleman about this, on the basis that the only reason that the Government had given up the powers from the Secretary of State to the independent board was the adamant insistence of the medical profession that this was necessary and that it was absolutely vital to getting any form of agreement, he accused us of kow towing to the medical profession. So now, the official spokesman for the Liberal Party and my hon. Friend the Member for Ormskirk (Mr. Kilroy-Silk) are reserving their position about the Bill on Third Reading because they do not think that it is tough enough. That is an extraordinary reason.
I do not know what the hon. Member for Cornwall, North (Mr. Pardoe) will do today. He and I share the same local 332 newspaper. To find out what the Liberal Party is doing, one has to read what it says in local newspapers, because it varies in different parts of the country. The House will wish to know that the hon. Gentleman said:The Conservative Party and some doctors seem to think that the Government's decision to phase out pay beds in National Health Service hospitals is a cut-and-dried case of Socialist wickedness.He went on:It is nothing of the sort. It is one thing for people to insure themselves privately against ill-health and to use private hospitals and doctors. It is quite another that all these facilities should be made available below cost price in National Health Service hospitals. There is nothing very Socialist about wishing to draw a clear line between public and private medicine. It is time the doctors realized that they cannot have their cake and eat it.It is time that the Members of the Liberal Party realised that they cannot have their cake and eat it.
More serious issues lie behind the Bill. The necessity for it is a belief on this side of the House that it has become necessary to try to seek a solution to this problem. It is the divisive nature of this issue in the Health Service which raises its importance and which has meant that Ministers and the House have had to spend such a long time upon it. The medical profession plays an important role in the National Health Service and no one should lightly discount the fact that its members dislike many parts of this legislation.
But there is nothing in the Bill which challenges the fundamentals of professional freedom. No profession—law, medicine or teaching—can isolate itself from the community it serves. Any profession is right to champion and to fight for fundamental freedoms, but there are grave dangers in being seen by society to be the champions of a narrow professional self-interest.
In 1946, when the representatives of the medical profession opposed the creation of the National Health Service, much was made of the supposed challenge to professional and clinical freedom. The profession's rhetoric proved to be false and the challenge illusory then. Exactly the same mistakes are being made by the profession's spokesmen today and surprisingly similar language is being used. 333 The responsible interpretation of fundamental freedoms is an important issue. George Bernard Shaw once wrote:Freedom incurs responsibility. That is why so many men fear it.The medical profession, no less than the House, has a responsibility to ensure that the predominant pattern of health care in this country remains firmly based on judgments about an individual patient's medical need, not on a patient's ability to pay. That is an ethical responsibility
§ which I believe society wishes the medical profession to champion and not to challenge.
§ I recommend the Bill to the House in the hope that it will bring peace to the Health Service, strengthen it and end this divisive issue.
§ Question put, That the Bill be now read a Second time:—
§ The House divided: Ayes 289, Noes 269.337
|Division No. 111.||AYES||10.0 p.m|
|Abse, Leo||Doig, Peter||Johnson, James (Hull West)|
|Allaun, Frank||Dormand, J. D.||Johnson, Walter (Derby S)|
|Anderson, Donald||Douglas-Mann, Bruce||Jones, Alec (Rhondda)|
|Archer, Peter||Duffy, A. E. P.||Jones, Barry (East Flint)|
|Armstrong, Ernest||Dunn, James A.||Jones, Dan (Burnley)|
|Ashley, Jack||Dunnett, Jack||Judd, Frank|
|Ashton, Joe||Eadie, Alex||Kaufman, Gerald|
|Atkins, Ronald (Preston N)||Edge, Geoff||Kelley, Richard|
|Atkinson, Norman||Edwards, Robert (Wolv SE)||Kerr, Russell|
|Bagler, Gordon A. T.||Ellis, John (Brigg & Scun)||Kilroy-Silk, Robert|
|Bain, Mrs Margaret||English, Michael||Kinnock Nell|
|Barnett, Guy (Greenwich)||Ennals, David||Lambie, David|
|Barnett, Rt Hon Joel (Heywood)||Evans, Fred (Caerphilly)||Lamborn, Harry|
|Bates, Alf||Evans, Ioan (Aberdare)||Lamond, James|
|Bean, R. E.||Ewing, Harry (Stirling)||Lalham, Arthur (Paddington)|
|Benn, Rt Hn Anthony Wedgwood||Ewing, Mrs Winifred (Moray)||Leadbitter, Ted|
|Bennett, Andrew (Stockport N)||Faulds, Andrew||Lee, John|
|Bidwell, Sydney||Fernyhough, Rt Hon E.||Lestor, Miss Joan (Elon & Slough)|
|Bishop, E. S.||Fitch, Alan (Wigan)||Lever, Rt Hon Harold|
|Blenkinsop, Arthur||Flannery, Martin||Lewis, Arthur (Newham N)|
|Boardman, H.||Fletcher, Raymond (llkeston)||Lewis, Ron (Carlisle)|
|Booth, Rt Hon Albert||Fletcher, Ted (Darlington)||Lipton, Marcus|
|Boothroyd, Miss Betty||Foot, Rt Hon Michael||Litterick, Tom|
|Boyden, James (Bish Auck)||Ford, Ben||Loyden, Eddie|
|Bradley, Tom||Forrester, John||Luard, Evan|
|Bray, Dr Jeremy||Fowler, Gerald (The Wrekin)||Lyon, Alexander (York)|
|Brown, Hugh D. (Provan)||Fraser, John (Lambeth, N'w'd)||Lyons, Edward (Bradford W)|
|Brown, Robert C. (Newcastle W)||Freeson, Reginald||Mabon, Dr. J. Dickson|
|Buchan, Norman||Garrett, John (Norwich S)||McCartney, Hugh|
|Buchanan, Richard||Garrett, W. E. (Wallsend)||McElhone, Frank|
|Butler, Mrs Joyce(Wood Green)||George, Bruce||MacFarquhar, Roderick|
|Callaghan, Rt Hon J. (Cardiff SE)||Gilbert, Dr John||McGuire, Michael (Ince)|
|Callaghan, Jim (Middleton & P)||Ginsburg, David||Mackenzie, Gregor|
|Campbell, Ian||Golding, John||Macintosh, John P.|
|Canavan, Dennis||Gould, Bryan||Maclennan, Robert|
|Cant, R. B.||Gourlay, Harry||McMillan, Tom (Glasgow C)|
|Carmichael, Neil||Graham, Ted||McNamara, Kevin|
|Carter, Ray||Grant, George (Morpeth)||Madden, Max|
|Carter-Jones, Lewis||Grant, John (Isllington C)||Magee, Bryan|
|Cartwright, John||Grocott, Bruce||Mahon, Simon|
|Castle, Rt Hon Barbara||Hardy, Peter||Mallalieu, J. P. W.|
|Clemitson, Ivor||Harrison, Walter (Wakefield)||Marks, Kenneth|
|Cocks, Michael (Bristol S)||Hart, Rt Hon Judith||Marquand, David|
|Coleman, Donald||Hattersley, Rt Hon Roy||Marshall, Dr Edmund (Goole)|
|Colquhoun, Ms Maureen||Hatton, Frank||Marshall, Jim (Leicester S)|
|Concannon, J. D.||Hayman, Mrs Helene||Mason, Rt Hon Roy|
|Conlan, Bernard||Healey, Rt Hon Denis||Maynard, Miss Joan|
|Cook, Robin F. (Edin C)||Heffer, Eric S.||Meacher, Michael|
|Corbett, Robin||Horam, John||Mellish, Rt Hon Robert|
|Cox, Thomas (Tooting)||Howell, Rt Hon Denis||Mendelson, John|
|Craigen, J. M. (Maryhill)||Hoyle, Doug (Nelson)||Mikardo, Ian|
|Crawshaw, Richard||Huckfield, Les||Millan, Bruce|
|Crosland, Rt Hon Anthony||Hughes, Rt Hon C. (Anglesey)||Miller, Dr M. S. (E Kilbride)|
|Cryer, Bob||Hughes, Robert (Aberdeen N)||Miller, Mrs Millie (Ilford N)|
|Cunningham, G. (Islington S)||Hughes, Roy (Newport)||Molloy, William|
|Davidson, Arthur||Hunter, Adam||Morris, Alfred (Wythenshawe)|
|Davies, Bryan (Enfield N)||Irvine, Rt Hon Sir A. (Edge Hill)||Morris, Charles R. (Openshaw)|
|Davies, Denzil (Llanelli)||Irving, Rt Hon S. (Dartford)||Morris, Rt Hon J. (Aberavon)|
|Davies, Ifor (Gower)||Jackson, Colin (Brighouse)||Moyle, Roland|
|Davis, Clinton (Hackney, C)||Jackson, Miss Margaret (Lincoln)||Murray, Rt Hon Ronald King|
|Deakins, Eric||Janner, Greville||Newens, Stanley|
|Dean, Joseph (Leeds W)||Jay, Rt Hon Douglas||Noble, Mike|
|Delargy, Hugh||Jeger, Mrs Lena||Oakes, Gordon|
|Dell, Rt Hon Edmund||Jenkins, Rt Hon Roy (Stechford)||Ogden, Eric|
|Dempsey, James||John Brynmor||O'Halloran, Michael|
|Orbach, Maurice||Short, Rt Hon E. (Newcastle C)||Wainwright, Edwin (Dearne V)|
|Orme, Rt Hon Stanley||Short, Mrs Renée (Wolv NE)||Walker, Harold (Doncaster)|
|Ovenden, John||Silkin, Rt Hon John (Deptford)||Walker, Terry (Kingswood)|
|Owen, Dr David||Silkin, Rt Hon S. C. (Dulwich)||Ward, Michael|
|Padley, Walter||Sillars, James||Watkins, David|
|Park, George||Silverman, Julius||Watkinson, John|
|Parker, John||Skinner, Dennis||Weetch, Ken|
|Parry, Robert||Small, William||Weitzman, David|
|Pavitt, Laurie||Smith, John (N Lanarkshire)||Welibeloved, James|
|Peart, Rt Hon Fred||Snape, Peter||Welsh, Andrew|
|Pendry, Tom||Spearing, Nigel||White, Frank R. (Bury)|
|Perry, Ernest||Spriggs, Leslie||White, James (Pollok)|
|Phipps, Dr Colin||Stallard, A. W.||Whitehead, Phillip|
|Prentice, Rt Hon Reg||Stewart, Rt Hon M. (Fulham)||Whitlock, William|
|Price, C. (Lewisham W)||Stoddart, David||Wigley, Dafydd|
|Price, William (Rugby)||Stonehouse, Rt Hon John||Willey, Rt Hon Frederick|
|Radice, Giles||Stott, Roger||Williams, Alan (Swansea W)|
|Richardson, Miss Jo||Strang, Gavin||Williams, Alan Lee (Hornch'ch)|
|Roberts, Gwilym (Cannock)||Strauss, Rt Hon G. R.||Williams, Rt Hon Shirley (Hertford)|
|Robinson, Geoffrey||Summerskill, Hon Dr Shirley||Wilson, Alexander (Hamilton)|
|Roderick, Caerwyn||Swain, Thomas||Wilson, Gordon (Dundee E)|
|Rodgers, George (Chorley)||Taylor, Mrs Ann (Bolton W)||Wilson, Rt Hon H. (Huyton)|
|Rodgers, William (Stockton)||Thomas, Dafydd (Merioneth)||Wilson, William (Coventry SE)|
|Rooker, J. W.||Thomas, Ron (Bristol NW)||Wise, Mrs Audrey|
|Roper, John||Thompson, George||Woodall, Alec|
|Rose, Paul B.||Thorne, Stan (Preston South)||Woof, Robert|
|Ross, Rt Hon W. (Kilmarnock)||Tierney, Sydney||Wrigglesworth, Ian|
|Sandelson, Neville||Tinn, James||Young, David (Bolton E)|
|Sedgemore, Brian||Tomney, Frank|
|Selby, Harry||Torney, Tom||TELLERS FOR THE AYES:|
|Shaw, Arnold (Ilford South)||Tuck, Raphael||Mr. James Hamilton and|
|Sheldon, Robert (Ashton-u-Lyre)||Urwin, T. W.||Mr. Joseph Harper.|
|Shore, Rt Hon Peter||Varley, Rt Hon Eric G.|
|Adley, Robert||Costain, A. P.||Hall, Sir John|
|Aitken, Jonathan||Craig, Rt Hon W. (Belfast E)||Hall-Davis, A. G. F.|
|Alison, Michael||Critchley, Julian||Hamilton, Michael (Salisbury)|
|Amery, Rt Hon Julian||Crouch, David||Hampson, Dr Keith|
|Arnold, Tom||Crowder, F. P.||Hannam, John|
|Atkins, Rt Hon H. (Spelthorne)||Davies, Rt Hon J. (Knutsford)||Harrison, Col Sir Harwood (Eye)|
|Awdry, Daniel||Dean, Paul (N Somerset)||Harvle Anderson, Rt Hon Miss|
|Baker, Kenneth||Dodsworth, Geoffrey||Havers, Sir Michael|
|Banks, Robert||Douglas-Hamilton, Lord James||Hayhoe, Barney|
|Beith, A. J.||Drayson, Burnaby||Heath, Rt Hon Edward|
|Bell, Ronald||du Cann, Rt Hon Edward||Heseltine, Michael|
|Bennett, Sir Frederic (Torbay)||Dunlop, John||Hicks, Robert|
|Bennett, Dr Reginald (Fareham)||Dykes, Hugh||Higgins, Terence L.|
|Benyon, W.||Eden, Rt Hon Sir John||Holland, Philip|
|Berry, Hon Anthony||Edwards, Nicholas (Pembroke)||Hooson, Emlyn|
|Biffen, John||Elliott, Sir William||Hordern, Peter|
|Blaker, Peter||Emery, Peter||Howe, Rt Hon Sir Geoffrey|
|Body, Richard||Eyre, Reginald||Howell, David (Guildford)|
|Boscawen, Hon Robert||Fairbairn, Nicholas||Howells, Geraint (Cardigan)|
|Bottomley, Peter||Fairgrieve, Russell||Hunt, David (Wirral)|
|Bowden, A. (Brighton, Kemptown)||Fell, Anthony||Hunt, John|
|Boyson, Dr Rhodes (Brent)||Finsberg, Geoffrey||Hurd, Douglas|
|Bradford, Rev Robert||Fisher, Sir Nigel||Hutchison, Michael Clark|
|Braine, Sir Bernard||Fletcher-Cooke, Charles||Irving, Charles (Cheltenham)|
|Britten, Leon||Fookes, Miss Janet||James, David|
|Brocklebank-Fowler, C.||Forman, Nigel||Jenkin, Rt Hn P. (Wanst'd & W'df'd)|
|Brotherton, Michael||Fowler, Norman (Sutton C'f'd)||Jessel, Toby|
|Brown, Sir Edward (Bath)||Fox, Marcus||Johnson Smith, G. (E Grinstead)|
|Bryan, Sir Paul||Fraser, Rt Hon H. (Stafford & St)||Johnston, Russell (Inverness)|
|Buchanan-Smith, Alick||Freud, Clement||Jones, Arthur (Daventry)|
|Buck, Anthony||Fry, Peter||Jopling, Michael|
|Budgen, Nick||Galbraith, Hon T. G. D.||Joseph, Rt Hon Sir Keith|
|Bulmer, Esmond||Gardiner, George (Reigate)||Kaberry, Sir Donald|
|Burden, F. A.||Gardner, Edward (S Fylde)||Kilfedder, James|
|Butler, Adam (Bosworth)||Gilmour, Rt Hon Ian (Chesham)||Kimball, Marcus|
|Carlisle, Mark||Gilmour, Sir John (East Fife)||King, Evelyn (South Dorset)|
|Carson, John||Glyn, Dr Alan||King, Tom (Bridgwater)|
|Chalker, Mrs Lynda||Godber, Rt Hon Joseph||Knight, Mrs Jill|
|Channon, Paul||Goodhart, Philip||Knox, David|
|Churchill, W. S.||Goodhew, Victor||Lamont, Norman|
|Clark, Alan (Plymouth, Sutton)||Goodlad, Alastair||Lane, David|
|Clark, William(Croydon S)||Gorst, John||Langford-Holt, Sir John|
|Clarke, Kenneth (Rushcliffe)||Gow, Ian (Eastbourne)||Latham, Michael (Melton)|
|Clegg, Walter||Gower, Sir Raymond (Barry)||Lawrence, Ivan|
|Cockcroft, John||Grand, Anthony (Harrow C)||Lawson, Nigel|
|Cooke, Robert (Bristol W)||Gray, Hamish||Lester, Jim (Beeston)|
|Cope, John||Griffiths, Eldon||Lewis, Kenneth (Rutland)|
|Cordie, John H.||Grimond, Rt Hon J.||Luce, Richard|
|Cormack, Patrick||Grist, Ian||Loveridge, John|
|Corrie, John||Grylls, Michael||McAdden, Sir Stephen|
|McCrindle, Robert||Pattle, Geoffrey||Spicer, Michael (S Worcester)|
|McCusker, H.||Penhaligon, David||Stainton, Keith|
|Macfarlane, Nell||Percival, Ian||Stanbrook, Ivor|
|MacGregor, John||Peyton, Rt Hon John||Stanley, John|
|Macmillan, Rt Hon M. (Farnham)||Pink, R. Bonner||Steel, David (Roxburgh)|
|McNair-Wilson, M. (Newbury)||Powell, Rt Hon J. Enoch||Steen, Anthony (Wavertree)|
|McNair-Wilson, P. (New Forest)||Price, David (Eastleigh)||Stewart, Ian (Hitchin)|
|Madel, David||Prior, Rt Hon James||Stokes, John|
|Marshall, Michael (Arundel)||Pym, Rt Hon Francis||Stradling Thomas, J.|
|Marten, Nell||Raison, Timothy||Tapsell, Peter|
|Mates, Michael||Rathbone, Tim||Taylor, R. (Croydon NW)|
|Mather, Carol||Rawlinson, Rt Hon Sir Peter||Taylor, Teddy (Cathcart)|
|Maude, Angus||Rees, Peter (Dover & Deal)||Temple-Morris, Peter|
|Maudling, Rt Hon Reginald||Rees-Davies, W. R.||Thatcher, Rt Hon Margaret|
|Mawby, Ray||Renton, Rt Hon Sir D. (Hunts)||Thomas, Rt Hon P.(Hendon S)|
|Maxwell-Hyslop, Robin||Renton, Tim (Mid-Sussex)||Thorpe, Rt Hon Jeremy (N Devon)|
|Mayhew, Patrick||Ridley, Hon Nicholas||Townsend, Cyril D.|
|Meyer, Sir Anthony||Ridsdale, Julian||Trotter, Neville|
|Miller, Hal (Bromagrove)||Rifkind, Malcolm||Tugendhat, Christopher|
|Miscampbell, Norman||Rippon, Rt Hon Geoffrey||van Straubenzee, W. R.|
|Mitchell, David (Basingstoke)||Roberts, Michael (Cardiff NW)||Vaughan, Dr Gerard|
|Moate, Roger||Roberts, Wyn (Conway)||Viggers, Peter|
|Monro, Hector||Ross, Stephen (Isle of Wight)||Wainwright, Richard (Coins V)|
|Montgomery, Fergus||Ross, William (Londonderry)||Wakeham, John|
|Moore, John (Croydon C)||Rossl, Hugh (Hornsey)||Welder, David (Clitheroe)|
|More, Jasper (Ludlow)||Royle, Sir Anthony||Walker, Rt Hon P. (Worcester)|
|Morgan, Geraint||Sainsbury, Tim||Walker-Smith, Rt Hon Sir Derek|
|Morgan-Giles, Rear-Admiral||St. John-Stevas, Norman||Walters, Dennis|
|Morris, Michael (Northampton S)||Scott, Nicholas||Warren, Kenneth|
|Morrison, Charles (Devizes)||Shaw, Giles (Pudsey)||Weatherill, Bernard|
|Morrison, Hon Peter (Chester)||Shelton, William (Streatham)||Wells, John|
|Mudd, David||Shepherd, Colin||Whitelaw, Rt Hon William|
|Heave, Airey||Shersby, Michael||Wiggin, Jerry|
|Nelson, Anthony||Slivester, Fred||Winterton, Nicholas|
|Neubert, Michael||Sims, Roger||Wood, Rt Hon Richard|
|Newton, Tony||Sinclair, Sir George||Young, Sir G. (Ealing, Acton,[...]|
|Normanton, Tom||Skeet, T. H. H.||Younger, Hon George|
|Nott, John||Smith, Cyril (Rochdale)|
|Oppenheim, Mrs Sally||Smith, Dudley (Warwick)||TELLERS FOR THE NOES:|
|Page, Rt Hon R. Graham (Crosby)||Speed, Keith||Mr. Spencer Le Marchant and|
|Pardoe, John||Spence, John||Mr. Cecil Parkinson.|
§ Question accordingly agreed to.
§ Bill read a Second time.
§ Bill committed to a Standing Committee pursuant to Standing Order No. 40 (Commital of Bills).