§ Motion made, and Question proposed, That this House do now adjourn—[Mr. Bates.]
§ 11.10 p.m.
§ Mr. Donald Anderson (Swansea, East)I am glad of the opportunity to raise the question of the relationship between the community health councils in Wales and the Welsh Office. Community health councils were established to provide a new means of representing the local community's interests in the health services to those responsible for managing those services.
In the reorganised NHS, management of the services and representation of local opinion were said to be distinct but complimentary functions entrusted to 937 separate bodies working in a close relationship. Successful administration of the services depended upon a continuing and constructive exchange of views between the health authorities and the community health councils. It was said that
Membership of the Councils will give a worthwhile and satisfying role to many of the public spirited people who take a particular interest in the quality of their local Health Services".Thus, the CHCs were envisaged as the public watchdog, a democratic element, within the reorganised NHS. My submission is that that aim has not been fully realised.Over the three and a half years of their existence the CHCs have attempted to develop their role to provide an effective means for the public to have a voice in the NHS. However, their early rapid development appears to have caused some reaction among the other bodies involved in the NHS which have not in the past been used to such close monitoring. In my view there has been a counter-attack by the professionals over the past year. This counter-attack is reflected particularly in the attitudes of some of the area health authorities and also, I regret to say, to some extent in policies and decisions made by the Welsh Office.
There is evidence of discontent among the members of the community health councils. It has reached such a peak in some of the CHCs that there is talk of resignations. That discontent is not unique to my own CHC in the Swansea and Lliw Valley but has been discussed by many CHCs, particularly within the meetings of the Welsh Association of CHCs. In particular, the discontent centres around the contractural relationship between the councils and their staff. I understand that a deputation from the Welsh Association will meet my hon. Friend on 25th of this month.
What are the major areas of discontent? I give only some illustrations of these. First, there is the inadequate budget which is allowed to the CHCs. My own CHC received a sum of £18,765 in the last financial year. I concede that that was a fairly substantial increase over the previous year. But, because of the fixed and inevitable costs of accommodation and salaries, this left a sum of only £3,500 for any initiatives which the CHC might be inclined to promote on behalf 938 of local opinion. My own CHC, even within these constraints, has launched initiatives on fluoride and eraldin. Yet the small sum which is allowed to it must be a severe constraint on its activities.
Similarly, there is the problem of inadequate staffing. Although a staffing adviser from the DHSS recommended an additional member of staff, following the council's official application in November 1975, the Welsh Office refused to authorise an additional appointment. Therefore, there is but the secretary and his own personal assistant. In this David and Goliath situation, this can hardly give strength to the CHCs when they face the serried ranks of the professionals in the AHAs or the DHAs. For that reason, they are unable to make a really effective contribution. Indeed, my own CHC learnt only today that the Welsh Office has yet again refused a third member of staff.
Then there is the inadequate accommodation. Plainly, if the CHCs are to do their job clearly in consultation with the public, there must be opportunities for the public to visit the offices. Ideally, there should be a shop window approach, such as that of the jobcentres in Wales, encouraging the public to contact the CHCs.
In Wales the Welsh Office has been wholly unwilling to approve the rents for such premises. Indeed, the Vale of Glamorgan CHC is still trying to find accommodation within the Welsh Office cost guidelines three and a half years after its inception. The Swansea and Lliw Valley CHC has not even applied for this form of shop accommodation because the Welsh Office has made it clear that it could not hope to find accommodation within the approved cost. The present location is wholly inadequate. It is on the second floor of a block of buildings, and the CHC is likely shortly to be given notice in that building.
A further bone of contention is the inappropriate gradings of the saff. It has proved necessary for secretaries to submit applications for regional appeals due to the Welsh Office's refusal to honour what certainly the secretaries believed to have been a previous commitment at the time of the setting up of the CHCs.
It is also alleged by a number of CHCs throughout South Wales that some 939 recent rulings by the Welsh Office demote the CHCs' status in an attempt to clip the wings of this democratic element. They think in particular of representation on other bodies. Over a number of years the Welsh Office has assured CHCs that it is doing its best to encourage the health authorities to involve the CHCs in their deliberations, but this is denied by a number of actual decisions. I shall cite but a few.
The Welsh Office recently set up a working party on standards of patient care for mentally handicapped and mentally ill patients. When the CHC requested an explanation why there was no CHC representation on the working party and asked for representation, the Welsh Office said that it was inappropriate and that it would mean intermeddling in management functions. This response is hardly compatible with an aim of full involvement of the CHCs in local medical decisions.
Again, concerning the family practitioner committees, the Welsh Office seems unwilling to ensure that FPCs provide observer status on their committees for CHC representatives, which could easily be done by regulation. The Cardiff CHC has been particularly vociferous against the Welsh Office attitude on this matter. In England the Secretary of State has taken far more positive steps in formally asking FPCs to consider inviting CHC representatives to attend as observers, and a number have already done so. The Welsh Office has taken a far more timid step in having experimental schemes in three areas.
Concerning the joint consultative committees, one of the 12 functions allocated to the CHCs was to monitor.
the effectiveness of co-operation between the health services and the related local authority services.It has proved totally impossible in practice to carry out this duty as CHCs are being denied membership of the appropriate joint consultative committees between the AHAs and the corresponding local authorities. When the Welsh Office was asked for assistance to ensure that at least observer status was granted to CHCs, the assistance was not forthcoming—merely an assurance that the Welsh Office had no objection to such participation.940 There are complaints about reports of health advisory services being denied to CHCs on the ground that such reports should be confidential, as if the Welsh Office does not have trust in the willingness of CHC members to keep confidential material to themselves.
There is a belief, fostered by many decisions taken by the Welsh Office, that the Welsh Office wishes CHCs to be very much under the wing of and not independent of the area health authorities. That was put in most blunt terms a few days ago by a member of the CHC in my area when he said "We have not even got our own expense forms". More fundamentally, the Welsh Office now suggests that secretaries of CHCs should formally be employed by the AHAs. Three CHCs and the Welsh Association have written to protest as there will be a danger of divided loyalties with such employment. One CHC chairman was recently told by his AHA chairman that he must not make Press statements in conflict with AHA policies.
The whole concept of CHCs being democratic elements within the NHS structure is being thwarted. The original intention of Parliament is being thwarted by the complete lack of support by higher civil servants within the Welsh Office. The CHCs are being reduced to ineffectiveness. Their members are becoming increasingly discontented by the unwillingness to recognise what should be their true role.
I ask my hon. Friend to be more resolute in giving substance to previous declarations of support for the concept of greater participation for CHCs. Even though they may be considered "trouble makers", the best part of democracy comes from those who raise complaints honestly, realistically and forcibly on behalf of those whom they represent.
I ask my hon. Friend actively to encourage CHCs. I am sure that he will seek to do so if he is not constrained by some of the advice that he is receiving. I ask him to give CHC members a worthwhile role and an independence of the AHAs and to ensure that everyone of the decision-makers in the Welsh Office has a notice on his desk stating that "The buck stops here" but that CHCs should be brought into full consultation and their members given a worthwhile role.
§ 11.23 p.m.
§ The Under-Secretary of State for Wales (Mr. Barry Jones)I have listened carefully to the submissions of my hon. Friend the Member for Swansea, East (Mr. Anderson). They began as submissions, but, because of the lateness of the hour, they became something more than that. I appreciate the extremely late hours that each of us has been keeping these past few days, and I understand the testy nature of some of his declarations.
I say immediately that there is no thwarting of Parliament's will and no conspiracy on the part of senior civil servants. It may be that my hon. Friend has taken too pessimistic a view at this late hour. The CHCs in Wales get every ministerial support. They are actively encouraged.
I regard the National Health Service as one of my paramount responsibilities. I am conscious of the important role that is played by CHCs in providing a bridge between the providers of the service and the general public. As a Minister I feel that in some ways I have a similiar role. I try to make myself as accessible as I can to those who manage, run and use the Service. For example, it may be of interest to my hon. Friend to know that I have made 27 official visits to hospitals and other health premises. In addition to my monthly meetings with the AHA chairman, over the past few years I have regular meetings with the chairmen of CHCs and family practitioner committees.
Some 18 months ago I had special meetings with groups of CHC members in various parts of Wales. My hon. Friend will realise that I am not unfamiliar with the work and aspirations of the CHCs and I am well aware of the difficulties which they see confronting them.
I think that my hon. Friend will agree that we were very unhappy with the Conservative Government's proposals for reorganisation. Indeed, we warned the then Government, when we debated those proposals in the Welsh Grand Committee, of the disastrous consequences which would result. Nevertheless, the decision to set up community health councils in every health district in Wales to act as watchdogs for the consumers was one of the few redeeming features.
I agree with my hon. Friend that the community health council is the voice 942 of the consumer within the NHS. It exists to ensure that the consumer does not lose out. However, this does not mean that each CHC can get everything at once. If each CHC were to retain and obtain for its community everything it wants, this would be prohibitive within any framework of health expenditure that can be envisaged. I think it would be fair to say that the CHCs have undertaken their role of monitoring the NHS conscientiously and, on the whole, in Wales, successfully.
It is not the prime object of CHCs to badger the area health authorities indiscriminately, but, in their proper appraisal and criticism of health care arrangements and plans for development and change, the CHCs have made their presence felt in no uncertain manner. I am sure that the AHAs would readily acknowledge that their own attitudes have been sharpened by the constructive criticisms of the CHCs. At the same time, the CHCs in Wales themselves are becoming more aware that at a time of national economic difficulty, they have to be realistic in their expectations.
The CHCs are very conscious that their image is not as clearly defined in the public mind as they would like. This is partly a reflection of their own slight uncertainty at the start in establishing their role in the scheme of things, but it is also due to the general lack of appreciation of the value of consumer organisations and, sadly, the willingness of a vast majority of our population to accept their lot, whatever their misfortunes, without seeking the help of those institutions which are specifically designed to assist and advise them. It is perhaps in this area that CHCs in Wales are most aware that much still needs to be done.
My hon. Friend referred to the inadequate budget. I want to refer briefly to finance. Sadly, the early years of the CHCs have coincided with a period, to put it mildly, of most severe constraint in the deployment of resources, and this has made it extremely difficult for us to help them as much as they and we and civil servants in the Department would have liked. Nevertheless, we have made a very special effort on their behalf and, so far as has been practicable, we have met their demands for financial resources to widen and publicise their activities. I 943 do not accept, therefore, the charge that we have restricted their budgets unduly. The strength of our effort can be judged from the fact that CHC expenditure in Wales in 1975–76 was £150,000 and that it increased successively to £191,000 and then to £240,000 by 1977–78. We have provisionally allocated £262,000 to CHCs for the current year, and extra money is available for any new accommodation needed, special projects and research. I do not think we can justly be accused of being niggardly towards them.
My hon. Friend mentioned accommodation and the need, in effect, for a shop window. Some councils have a real problem. When they were first established, lack of finance demanded that, where-ever possible, CHC offices should make use of NHS accommodation. As a result, few of them have been situated in places readily accessible to the public, and some have been unsatisfactory in other respects, too. Nevertheless, we have made progress on this score and we have enabled eight CHCs in Wales to move to improved premises in the last year or so and other moves are under consideration. I would not want the matter to get out of perspective by dealing with only one council's attitudes and problems.
Ideally, in order to display themselves fully in the public eye, CHCs should have High Street premises, but high costs are involved and this objective will not be easily attained. However, I was pleased last October formally to open the new Cardiff CHC premises which are attractively situated near the central station, and I very much hope that all CHCs will be able to have similarly convenient and attractive accommodation in the not-too-distant future.
With regard to Swansea and Lliw Valley CHC, I can only say to my hon. Friend that I have had no indication from it that its present accommodation is unsatisfactory but, if it wishes to come forward with any specific proposals for a move, the case will be considered on its merits.
In recognition of the understandable desire of the councils to improve their public image, I have made available a special allocation of £6,000 to be used for publicity purposes. They have decided 944 to use this to finance the production of a publicity film.
My hon. Friend referred to inadequate staffing. I am well aware that CHCs feel that their activities are to some extent constrained by lack of staff resources. It was difficult to anticipate at the outset what the potential workload was. This is why in 1976 I arranged a review of CHC posts by the staffing advisory service. The work was undertaken by a very experienced officer who had undertaken similar reviews in England and was thus able to make direct comparisons. A number of changes were agreed including the upgrading of 12 secretary posts and a comparable number of supporting posts. Naturally, those secretaries whose posts were not upgraded were disappointed, but they have a right of appeal if they feel that they have a strong case. We have to cut our coat to suit our cloth. This is not a time when we can encourage any great expansion of administrative and clerical staff. My hon. Friend will know that AHAs themselves are at present subject to an exercise, that they find difficult, involving a 5 per cent. reduction in management costs by the end of 1979–80.
I want to defend my Department from charges of a negative attitude, because that was implied in my hon. Friend's speech. I am very sorry indeed if some CHCs think we are negative in our attitude, but this presupposes that we should say "Yes" to every request that is put to us. Clearly, this cannot be so because we have to balance demands and arguments from all quarters before we arrive at what we consider to be the right decision in the interests of the NHS as a whole. We have shown that we are amenable to any reasonable request which does not involve unacceptable disadvantages elsewhere and I and my officials try to be accessible as we can to the CHCs. My hon. Friend may like to know that I shall be meeting CHC chairmen on 22nd June and I shall be addressing the annual conference of the Association of Welsh CHCs on 30th June.
My hon. Friend referred to the "counter-attack" of AHAs. With regard to the attitude of AHAs, there is very real danger of a them and us situation arising in the liaison with the CHCs. It can be said that CHCs have the task of helping the AHAs to develop the 945 Health Service to meet local needs. I get the impression at times that some CHCs see their role in a somewhat different light, possibly as a purely negative, critical one while, on the other hand, some AHAs fail fully to recognise that CHCs have a constructive role to play. I think all would benefit from more self-appraisal and a close examination of the contribution each makes in the liaison process.
In some cases relations are good, in others there is something to be desired and, while I would not wish to defend any unco-operative AHA, I think that there is an onus on CHCs to demonstrate that they are responsible bodies and that they recognise that AHAs cannot possibly satisfy all the demands made on them.
I would particularly commend the attitude of those CHCs which, being dissatisfied with some aspects of the Service in their areas, were not content just to voice their criticisms but took the positive step of investigating the problems themselves and prepared reports which, although contentious in some respects, made a constructive—and I emphasise that—contribution the totality of knowledge available to the AHAs. I recall particularly—and was glad of it—the survey of minor casualty services, the report on services for the mentally handicapped undertaken by the Cardiff and Vale of Glamorgan CHCs and the survey of visiting arrangements and facilities at Neath General Hospital undertaken by the Neath-Afan CHC. They are excellent examples of constructive, positive contributions.
My hon. Friend said some hard words about family practitioners. I refute his strictures. CHCs wish to send observers to family practitioner committee meetings in the same way as they attend AHA meetings. I frequently encourage closer working relationships between CHCs and FPCs. Subject to adequate safeguards on the question of confidentiality I think there would be advantage in FPCs admitting observers.
To seek to impose a particular pattern of co-operation by regulation might not be helpful because this would not engender good relationships nor would it be good for the service as a whole. My right hon. 946 Friend the Secretary of State for Social Services has expressed similar views.
At my request the Powys FPC is admitting CHC observers for a trial period. If this proves successful, I hope that it will encourage other FPCs to follow suit. In any case I shall be raising this matter again with FPC chairmen when I meet them next in the near future.
I have given a good deal of thought to the question of the availability to CHCs of health advisory service reports. I have concluded that it would be unwise to alter the present arrangement whereby the AHAs provide CHCs with summaries of the reports rather than the complete documents. The effectiveness of the detailed investigations carried out by the HAS into services for the mentally infirm depends very much on what is learned from staff at all levels.
The staff are encouraged to speak freely to the investigating teams in the confident knowledge that what they have to say will not be widely disseminated and possibly become the subject of distorted publicity.
I cannot ignore the danger that the knowledge that the reports might be subject to a wider circulation than at present might unduly inhibit staff in their responses to HAS teams and consequently greatly reduce the value of the reports. CHCs rightly have a keen interest in the work of the advisory service and areas are given every encouragement to make the report summaries as helpful as possible.
My hon. Friend also referred to the employment of staff. In Wales there was a straight choice between direct Welsh Office employment or an agency arrangement through the AHAs. We opted for the second course because it seemed a more convenient way of dealing with local salaries and so forth. I recognise that a point of principle is involved and, consequently, I have arranged for my officials to receive a deputation from the Association of Welsh CHCs next Wednesday to enable the case to be explained in detail.
§ Question put and agreed to.
§ Adjourned accordingly at twenty-one minutes to Twelve o'clock.