§ Order for Second Reading read.
Mr. Deputy Speaker (Mr. Bryant Godman Irvine)
Mr. Speaker's intention is that from 7 o'clock the 10-minute rule will apply in this debate.
§ The Secretary of State for Social Services (Mr. Patrick Jenkin)
I beg to move, That the Bill be now read a Second time.
I am sure that the House will be sorry to hear that my hon. Friend the Minister for Health is unwell and that he will be unable to reply to the debate tonight. If my hon. Friend the Under-Secretary of State catches your eye, Mr. Deputy-Speaker, he hopes to wind up the debate and, of course, we shall deal with any questions that arise in the debate.
The Second Reading of a Bill, by the custom of the House, need not be confined to the substance of the Bill itself, and I have no doubt that today's debate will be no exception. However, I think that it would be right for me at the outset of the debate to say that, although I cannot forecast the business of the House, my right hon. Friend the Chancellor of the Duchy of Lancaster told me that he would give favourable consideration to providing time soon after Christmas for a general debate on the report of the Royal Commission on the National Health Service and on the consultative paper recently issued by my Department and the Welsh Office. I make this clear so that hon. Members in all parts of the House, though of course entirely free to raise any points that are in order, may know that we may reasonably forecast that there will be this further opportunity to deal with more general matters covering the National Health Service than are comprehended within the clauses and schedules of the Bill.
Of course, the first two clauses are not wholly unrelated to the proposals in the consultative paper. I therefore cannot possibly argue, nor indeed would I wish to argue, that this is not an appropriate occasion for putting forward views 649 on that paper. Nevertheless, I should like to make one point as clearly and unequivocally as I can. It is that nothing in the first two clauses of the Bill is intended to prejudge or prejudice in any way the outcome of the consultation son the consultative document. In our foreword my right hon. Friend the Secretary of State for Wales and I said this:We believe that Ministers must now give a firm lead and this is what we are doing. We do however want the views of those concerned and we look forward to receiving these by the end of next April so that we can take final decisions and get the necessary changes moving from the middle of the year.We mean exactly what we have said.
What, then, is the purpose of these two clauses? It is simply to give a permissive power to the Secretary of State to appoint district health authorities. They also allow a family practitioner committee to cover a different territorial area from that of a district or area health authority. In other words, these two clauses do no more than confer greater flexibility on Ministers in determining the most appropriate structure of the Health Service to suit the needs of the Service in different parts of the country. They do not commit anyone to any particular structure.
It will be for right hon. and hon. Members in all parts of the House to decide what line to take in their own speeches. I hope that the House will understand if I say that I intend to reserve my comments on the report of the Royal Commission, and on the substance of the consultative paper, for a future occasion. I have said that my hon. Friend the Under-Secretary will be very happy to deal with any points which right hon. or hon. Members may raise. I stress again that nothing in this Bill prejudges either any debates we may have or our consultations on the consultative paper, or the decisions which we may finally reach in the light of those consultations.
I come to the part of the Bill which I imagine will prove to give rise to most argument, namely, part II, dealing with private practice. Those of us who took part in the debates on the subject of private practice during the last Parliament have no need to be reminded of the passions that were aroused, both inside and outside the House. I certainly do not want to rehearse in detail the events of those unhappy days, except to make the 650 point—which I do without rancour—that I believe some Members of the Labour Party, and in particular the then Secretary of State, Mrs. Barbara Castle, bear a heavy responsibility for fanning the flames of controversy. I also believe, however, that there are many on both sides of the House who will agree with the sentence in The Guardian leader of Monday 10 December in commenting on the Bill:Compared to five years ago the mood is quite different.Our views on this side of the House can be briefly stated. We believe that it is a part of a free society that patients who wish to seek private medical treatment should be free to do so. We believe that doctors who wish to practise privately should have the right to do so. These views are shared by the overwhelming majority of the people.
§ Mr. Jenkin
I will come to the electricians in a moment.
A national opinion poll taken earlier this year showed that 6 out of 10 employees would be interested in having private medical cover as part of their terms of employment, and that included 63 per cent. of male manual workers. In the light of this, I come to the point made by my hon. Friend the Member for Lancaster (Mrs. Kellett-Bowman). It is hardly surprising that some unions are now beginning to include such cover in their negotiations with employers, and this must be welcomed.
The poll showed two further things. Nearly three-quarters of the trade union members polled, including nearly 70 per cent. of National Health Service union members, believed either that their unions should support private medicine or that they should take a wholly neutral stance. Only 11 per cent. said that it was the job of their unions to oppose it. [Interruption.] Perhaps hon. Members opposite will listen to this one: the poll showed that even among Labour supporters nearly twice as many people believed that private prac- 651 tice helped the National Health Service as thought that it was a burden on it.
§ Mr. David Ennals (Norwich, North)
I am not certain what the question was that was put, but, if the policy of any Government is to be determined by what opinion polls show, opinion polls show at present that the Government are extremely unpopular and the Labour Party should be in office. So opinion polls are not the way in which we should take sensible decisions.
§ Mr. Jenkin
I am not asking the House to take decisions on the basis of the opinion polls. I was seeking to answer the question of the right hon. Member for Salford, West (Mr. Orme), who, when I said the overwhelming number of people supported our policy, said I should prove it. I believe that I have proved it.
§ Mr. Reg Race (Wood Green)
Will the Minister tell the House how the opinion poll which he has quoted differs from the many opinion polls which have been reported in newspapers over many years which show great opposition among the public both to private practice within National Health Service Hospitals and to the idea of private practice as a whole?
§ Mr. Jenkin
I am bound to tell the hon. Gentleman, having asked for evidence of all the recent opinion polls that have covered this subject, that my Department was unable to find one which did not bear out what I have said.
Let us take another matter. The presence of pay beds in National Health Service hospitals generates considerable revenue for the NHS. Private patients in those hospitals are expected to bring in over £35 million next year, and when National Health Service spending is under constraint it is folly to throw good money away. Perhaps I could ask the Opposition where else they think in these days that many of that kind is to come from.
The poll showed that 60 per cent. of trade unionists believed that it would be wrong to give up this revenue, and I believe that they are right. So a clear majority favour retaining both private medicine and NHS pay beds.
There is a practical argument to this, too. We need the geographical whole-time consultant. It must be possible for 652 a doctor to see his private and NHS patients in the same hospital. That was a point that was made by Mr. Bevan in a debate over 30 years ago, and it is as true today as it was when he said it.
I recognise that there are many on the Opposition Benches who believe that there should be no independent medical practice at all or, if there has to be, that it should be totally separated. The right hon. Member for Norwich North (Mr. Ennals) shakes his head. He knows of the resolutions that have been passed at his party conferences, and he knows that they are represented on the Opposition Benches. But there are others who believe that there should be private practice but that it should be totally separate from the NHS. That is their view and they are entitled to express it. Nothing that I say will persuade them on the principle of the matter, but many I ask them to consider these further points?
Whatever hon. Members opposite may have said, whatever they may have thought they voted for in the last Parliament, it is a fact that even without this Bill pay beds and private patients would have remained in much of the National Health Service indefinitely.
§ Mr. Jenkin
The right hon. Gentleman may say that that is the trouble, but he does not deny that it is the fact. When it comes to legislating for real events involving real people in the real world, the gulf that divides the two sides on the issue of principle tends to narrow down to differences of emphasis, to changes in procedure and changes in timing. I ask the House to look at part II of the Bill very much in that light.
Under the legislation passed by the Labour Government, there was apparently a commitment, first, to phase out pay beds entirely from the NHS and, secondly, to exercise a rigorous control over the development of the private sector. In practice, however, as the right hon. Gentleman acknowledged, with relatively few exceptions the pay beds that have disappeared in the last few years were beds of a very low usage, and, moreover, the so-called Goodman compromise tacitly recognised that in many parts of the country, particularly in small towns and remote areas, pay beds would remain indefinitely in NHS hospitals.
653 It goes further than that. The Labour Government included in their legislation a clause which gave the Secretary of State power to authorise private practice in National Health Service hospitals for highly specialised treatment unlikely to be available in the private sector. No time limit was imposed on that clause and, indeed, the right hon. Member for Norwich, North was at the time of the election actively engaged in consultations with the medical profession on how that clause might best be implemented. That clause envisages a permanent availability of private practice in National Health Service hospitals for the treatments covered by it. That is the fact, and that is the point from which we start.
If one looks to the private sector outside the NHS, it is widely acknowledged that the last five years have seen the biggest expansion of the private sector since the war. Whether or not hon. Members opposite thought that that was what they were voting for, there can be no doubt whatever that that is what has happened. It is equally clear that even if existing legislation had remained in force this expension would continue. The trend is perhaps important because it points the way to the future. The trend in acute private practice has been for the more minor elective procedures to take place in the private sector outside the NHS while urgent or more specialised procedures remain in NHS hospitals. I believe that this trend is likely to continue, though it will not be universal. It seems to me, therefore, that it is right to set the provisions of the Bill not against the passionate denunciations of Labour politicians or against the uncompromising resolutions of Labour conferences but against the background of what was happening and would have happened under their legislation.
In the chapter on private medicine in the report of the Royal Commission, it was said that private practice, both in and outside the NHS, was very small compared with the NHS, too small to have a significant impact on the National Health Service, except perhaps locally and temporarily. The Commission did not consider the presence or absence of pay beds in NHS hospitals to be significant at present from the point of view of the efficient functioning of the National Health Service.
654 It may be asked, therefore, perhaps by some of my right hon. and hon. Friends, why the Government think it necessary to legislate at all. There are good reasons—quite apart from the issues of principle to which I referred.
In the first place, it is rather silly, if pay beds are to remain indefinitely in the Health Service, that Parliament and the public should be invited to pretend otherwise. The Bill, therefore, repeals those provisions which would require—and I stress the word "require"—further progress towards phasing out. If there is no demand, the beds will go anyway. If there is demand, it should be met.
Secondly, if it was right that a good many pay beds would have remained indefinitely, there seems no sense or logic to allow them only where they happened to be located at the time of the 1976 Act. It really is not sensible to preclude anyone from authorising pay beds in new hospitals or expanded hospitals, however great the demand might be. Our Bill, therefore, puts this right.
Thirdly, the Labour Party's Bill placed the decision on whether pay beds should continue or be revoked on a body which was in no way answerable to this House. The Health Services Board had a duty to make proposals which neither my predecessor nor I could do anything about except to implement. I am sure that I am not alone in finding such a provision constitutionally offensive. As Secretary of State, I am answerable to this House for the National Health Service, and that includes the availability of pay beds. Yet, on that issue, the Act passed in the previous Parliament effectively stops the House having any say at all. The Bill, therefore, provides for the transfer from the Health Services Board to the Secretary of State of the power to authorise or revoke authorisations for pay beds, and it abolishes the board.
In my view, the board carried out the duties imposed on it with scrupulous care. It was given a difficult task, and it has performed it admirably. I would like to express my thanks to Lord Wigoder and his colleagues, and to the Scottish and Welsh committees, for all the time and consideration that they devoted to their task.
Those, then, are the changes we propose, and I suggest that they are modest. 655 At the same time, we are keeping and, indeed, improving the safeguards for the NHS. I share fully the concern of those who want to make sure that private practice in no way harms the interests of NHS patients. My overriding concern must always be for the NHS patient.
The most important safeguard is that contained in section 62 of the 1977 Act, that the powers may be exercised only if I am satisfied that anything which I propose to do or allow under those powerswill not to a significant extent interfere with the performanceof my duty to the National Health Service and National Health Service patients, andwill not to a significant extent operate to the disadvantage ofNational Health Service patients. This is a clear legislative safeguard. It remains unchanged both in intent and language.
When my hon. Friend the Minister for Health issued a consultative paper last June about our proposals, he made it quite clear that arrangements for private practice in National Health Service hospitals should operate, and be seen to operate, fairly. We are, therefore, going further than our predecessors ever did in seeking to make this effective.
§ Mr. Frank Haynes (Ashfield)
If the right hon. Gentleman is saying that this is a question of fairness, does he agree that queue-jumping is unfair? That is how I have found the pay bed system to be in my area.
§ Mr. Jenkin
No doubt the hon. Gentleman will seek to catch the eye of the Chair, but I am about to deal with that point because I share his concern about that issue.
The House will remember that the 1976 Act imposed a duty on the Health Services Board to make proposals about common waiting lists. This reflected the concern that was then felt, and is still felt, that private practice can lead to queue-jumping. The report published in May 1977 recommended that there should be common waiting lists for every category of patient, though it made the very important statement that complete responsibility for admitting patients from waiting lists should remain with the consultants.
656 In the event, my predecessor, the right hon. Member for Norwich, North, was unable to go the whole way with the Health Services Board. He introduced common waiting lists only for urgent cases and the seriously ill. It is true that he asked health authorities to enter into discussions about extending common waiting lists to all patients, but, so far as I can ascertain, little progress was ever made in those discussions. The position, therefore, when we came into office remained as the right hon. Member for Norwich, North left it—that common waiting lists existed only for urgent cases and the seriously ill.
§ Mr. Laurie Pavitt(Brent, South) rose—
§ Mr. Jenkin
Perhaps I can develop my argument, and then I shall give way.
It did not seem to us that that went far enough to implement our pledge that private practice in the Health Service should not prejudice the interests of National Health Service patients. We, therefore, approached the medical profession with a number of more far-reaching proposals, and I am happy to say that we have reached agreement with it on six "principles of private practice", which have been endorsed publicly by the BMA and which it will, at the appropriate time, draw to the attention of all consultants practising in the National Health Service.
The first principle restates the under taking that private practice should not significantly prejudice non-paying patients. That is in the Bill. It will be in the Act.
Secondly, subject to clinical considerations, earlier private consultation should not lead to earlier National Health Service admission or to earlier access to NHS diagnostic procedures. What this means is that it is now clearly recognised by the profession as an abuse of the system to use a private consultation as a device to gain earlier admission to hospital as an NHS patient. That. I believe, by itself will remove one of the major grounds for complaint that has existed in the past.
Thirdly, common waiting lists should be used, as at present, for all urgent and seriously ill cases, but they should be extended to cover highly specialised diagnosis and treatment. The principle adds that 657 the same criteria should be used for categorising paying and non-paying patients.
Fourthly, after admission, access by all patients to diagnostic and treatment facilities should be governed by clinical considerations. This principle is qualified only to the extent that it does not exclude earlier access by private patients to facilities specially arranged for them if these are provided without prejudice to National Health Service patients and without extra expense to the NHS.
Fifthly, standards of clinical care and services provided by the hospital should be the same for all patients. Again, this principle does not affect the provision, on separate payment, of extra amenities, nor the practice of the day-to-day care of private patients usually being undertaken by the consultant engaged by them.
Together, the fourth and fifth principles in effect mean that clinical considerations alone will govern the availability of treatment and care after admission to hospital for NHS and private patients alike.
§ Mr. Jenkin
Perhaps the hon. Lady will allow me to state the sixth principle, and then I shall give way. The last principle says that single rooms should not be held vacant for potential private use longer than the usual time between NHS patient admissions.
§ Mrs. Dunwoody
I hope that the right hon. Gentleman will forgive me if I point out that that is supposed to be the set of principles under which the consultants in the NHS have been operating since the inception of the Service. Indeed, is it not a measure of the disgraceful stage that we have reached that the Secretary of State needs to spell out those principles?
§ Mr. Jenkin
All I can say is that we have gone further on this and have got a clear statement of the principles as well as a clearer commitment from the medical profession than any previous Secretaries of State. I think that that is something that the House should welcome.
§ Mr. Orme
We shall obviously want to look at the proposals in some detail in Committee. However, what about social conditions? What about the woman with a large number of children who needs to be admitted urgently? What about ortho- 658 paedic cases, such as the one of the elderly lady in my constituency? Will they be admitted on an equal basis?
§ Mr. Jenkin
I hope that this point will be examined in Committee, because it is very important. But what the right hon. Gentleman has said, particularly in his first example with regard to social conditions, makes it abundantly clear that in the management of waiting lists—this point is clearly brought out in the report of the Health Services Board—one simply cannot automatically arrange people in orders of clinical importance. There are many other factors that must be taken into account. I am glad to note the support of my predecessor, the right hon. Member for Norwich, North. That is why the board and the right hon. Member for Norwich, North rightly decided that those matters must rest in the hands of the consultants. There is no alternative.
§ Mrs. Kellett-Bowman
That is the point that I wish to make. My right hon. Friend said that payment should not lead to earlier admission. Do not people who pay for private medicine often wish to delay treatment until their other commitments enable them to go into hospital? It is not that they try to jump the queue; they often go back down the queue.
§ Mr. Jenkin
My hon. Friend is quite right. Payment gives a measure of flexibility. It does not necessarily operate to the detriment of National Health Service patients.
§ Mr. Michael Meacher(Oldham, West) rose—
§ Mr. Jenkin
I must go on; I have given way a lot.
There are good arguments, to which I have frequently referred, for treating private patients separately from NHS patients in the same hospital, where that is practicable. However, it can, and sometimes does, give rise to avoidable difficulties because the same nurses and the same ward staff are concerned with private and National Health Service patients. Many hospital authorities recognise those difficulties and do their best to provide for private patients in order to avoid difficulties and embarrassment on that score. However, that is not always possible. The advice that I shall give the health authorities will press that point further.
659 I believe that these principles will go a very long way indeed to reassuring the public and staff in hospitals that there will be fairness between private and National Health Service patients. But this must work both ways. I hope that staff for their part will realise that all patients in National Health Service hospitals, private or NHS, must be treated in the same way and that there should be no reverse discrimination against private patients. I believe that the overwhelming majority of staff, including union members, will want to take a sensible line on that.
I turn to the provisions of the Bill dealing with the private sector outside the National Health Service.
First, clause 14 and schedule 4 propose certain amendments to the nursing homes and mental nursing homes legislation under which private homes and hospitals have to register with the Secretary of State. In practice, they register with the area health authority. These controls are concerned with standards of accommodation and non-clinical care. The Bill proposes to relax the residency requirement for the person in charge and also to bring private day care within the scope of the Act. I believe these are sensible measures which will be welcomed by everyone.
More important are provisions in the Bill covering controls over the development of the private sector. Here I will be frank with the House. I had hoped that we might have found it possible substantially to modify the existing controls. Some people would see no reason why anyone who wants to build and run a hospital should be in any different position from someone who wants to build and run, say, a hotel. But we all recognise that it is not as easy as that. It is a fact that, although on the Continent there are a number of different health care systems, there is not one country that allows a completely free rein to hospital development.
Although the private sector rightly offers a measure of choice to the people of this country, it cannot be said to do so under normal competitive conditions. In particular, the National Health Ser- 660 vice is inevitably constrained in what it can provide by the availability of clinical manpower. In these circumstances, it is not difficult to envisage private sector developments which could—although not necessarily—locally operate to the detriment of a National Health Service hospital. I believe we are right, therefore, to retain a measure of control. However, the Bill significantly simplifies procedures of control and makes some substantive changes. Clauses 10 and 11 make three amendments.
The threshold for authorisation is raised to 120 beds across the country, rather than the present 100 in Greater London and 75 elsewhere. There will also be an exemption for increases in the number of beds over this level, where the increase is less that 20 per cent. in a three-year period. Those two changes relax the controls modestly. The third change tightens control. There will be a new reserve power whereby the Secretary of State would be enabled to designate by regulation areas or parts of areas where all private hospital developments would have to be authorised. This is to meet the point raised by the Royal Commission, which argued that an aggregate of small hospitals could in some places be just as detrimental to NHS interests as a single large one. I see this control very much as a long-stop. The Bill provides that such a control should apply only if a health authority specifically requests it and only for a specified period.
However, with the private sector outside the NHS, just as in the case of pay beds in the NHS, we are anxious to remove any legitimate cause for criticism due to abuse of the system, so with the private sector we are anxious to meet the criticism that has been made that, although it is called independent, it is not truly independent because it depends on the National Health Service for its trained staff. In one sense, of course, the argument is bogus. The public sector education system trains a great many professions, many of them expressly for service in the private sector—one thinks of accountants, lawyers, even clergymen. There is nothing sacrosanct. One does not have to work in the public sector because one was trained in it.
§ Mr. Jenkin
I am coming to that. The right hon. Gentleman really must contain his impatience. I shall get to that point in a moment.
However, why should it be different for doctors and nurses?
In another sense, the argument may have some force. If the main reason for putting a quantitative control on private hospital development is that it could threaten shortages of skilled clinical manpower for adjacent NHS hospitals, should not the private sector itself do more to contribute to the pool of trained people? I believe that it should and that it could, and I am greatly encouraged to find that this is a view widely held in the private sector itself. Of course, some private hospitals have for years contributed to nurse training. I mention the arrangements which the Royal Masonic hospital has had with Queen Mary's hospital, Roehampton. I have now initiated talks with a number of other private hospitals with a view to their making a contribution to nurse training.
Of course, any such arrangements would have to secure the approval of the appropriate authorities, particularly the General Nursing Council. I am sure there is scope for training nurses and perhaps other professions in the private sector, and it is excellent that the private sector has accepted my challenge to do more.
Clause 4 gives health authorities a power to raise money from voluntary sources to supplement their funds. I am bound to say that I am surprised and a little saddened by the reaction of the Opposition Front Bench to this proposal. Health authorities have always been free to accept voluntary contributions and to hold and administer trust funds, but they have been precluded from being involved directly in fund raising.
§ Mr. Jenkin
I have always understood that the reason for this was that, when the National Health Service was set up, Mr. Bevan wanted, quite reasonably perhaps, to break down the demarcation between the old voluntary hospitals and the municipal hospitals. Therefore, he intro- 662 duced the rule that no hospital should appeal for funds.
I believe that today the restriction is unnecessary and unreasonable. We all recognise that the Health Service is unable to meet all the demands made upon it. All Governments in recent years have found and every Secretary of State has had to make speeches explaining that there are waiting lists and that important projects must wait and why there is not enough money available. The right hon. Member for Norwich, North had to do that and I must do it. At the same time, there is undoubtedly great public concern about the well-being of local hospital services, and there are welcome signs that more people want to do something about it. Of course, leagues of friends and other similar bodies can raise substantial sums and channel them into the Health Service. But it really seems absurd that health authorities themselves should not have power to appeal for funds to supplement what they get from my Department.
The proposals in the Bill are modest and scarcely justify the hysterical reaction of the right hon. Member for Salford, West. He talked about running casinos and implied that the clause spelt the end of a Health Service free at the point of use. With great respect to the right hon. Gentleman, that is absolute rubbish. Clause 4 does not give any power to run casinos, which he would have discovered had he devoted time to reading it before delivering his outburst. Moreover, there is a reserve power to forbid any activity that the Secretary of State thinks unsuitable. The power to raise funds no more undermines the principle of a National Health Service free at the point of use than does its present powers to accept voluntary gifts.
What are we looking for here? If a small local hospital is threatened with closure because resources are needed to finance the commissioning of a modern new hospital—and I am sure that we can all think of examples of that—is it unreasonable that the health authority could indicate that, if voluntary funds were forthcoming to meet the whole or part of the cost of keeping that small hospital open, it would be happy to make an arrangement to do just that?
Is it really obscene—to use the right hon. Gentleman's word—that if a health authority ands that it does not have the 663 money to modernise a nursing home, as is the case in my constituency at present, upgrade an old ward or install a sophisticated piece of equipment it should make such projects known to the public and appeal for funds?
I believe that the right hon. Gentleman and his hon. Friends do themselves no credit at all by their absurd reaction to this clause. I believe that the public will fully understand its purpose, and I hope that they will respond generously when appeals are made. I am convinced that a hospital will best serve the community if it can be persuaded to look outwards towards the community rather than for ever upwards to the hand that feeds it.
§ Mr. A. J. Beith (Berwick-upon-Tweed)
I agree with what the right hon. Gentleman is saying, but what kind of undertaking can he give to health authorities that allocations made to them will not be subsequently reduced because of voluntary cntributions that have been received?
§ Mr. Jenkin
That matter is dealt with in the Bill and can, no doubt, be examined and elaborated in Committee. Between £10 million and £15 million is currently paid voluntarily to the Health Service, and that contribution makes no difference to the allocation to the authorities. Those sums are additions, and that is what people want. I am sure that our hospital services will thrive to the extent that they look outward to the community and the community responds. They should not constantly have to appeal to me for more and more money.
§ Mr. David Mellor (Putney)
Does my right hon. Friend agree that in any case every major London hospital has a substantial capital fund yielding substantial income, which is used for the benefit of all patients? The proposal is only the extension of a long-established practice.
§ Mr. Jenkin
My hon. Friend is absolutely right, but that point applies not only to London but to hospitals all over the country which have trust funds. We want to seek to increase that sort of finance.
Clause 5 brings up to date the provisions for the financial control of health authorities. Under existing procedures, I am under a duty to advance sums to meet whatever a given approval of ex- 664 penditure might require. The House will recognise that that duty, as worded, is now totally incompatible with the system of cash limits instituted by the Labour Government. It is necessary to change that duty to give health authorities advances not exceeding a predetermined sum which is compatible with the Department's cash limits. Secretaries of State, as my predecessor, the hon. Member for Norwich, North, will recognise, cannot be in the position of having a duty to advance more money than is available.
Clause 5 also places a duty on health authorities to contain their expenditure within the cash limit allotted to them, together with any other sums that they receive—for instance, by way of pay bed revenue. It was, I think, the absence of any such clear statutory duty that contributed to the unfortunate events in the Lambeth, Southwark and Lewisham area health authority in recent years. In view of pending litigation, I cannot say more about that today. I believe that this clause is necessary to put beyond doubt a duty that successive Governments—and I have read all the correspondence of my predecessor—have certainly expected health authorities to fulfil.
The Bill contains a sensible, moderate package of reform, which should attract support from all sensible, moderate opinion. I have no doubt that right hon. and hon. Members on both sides of the House will wish to scrutinise the details carefully in Committee, and that is as it should be.
At the last election, the Conservative Party undertook to simplify and decentralise the National Health Service and cut back bureaucracy. Clauses 1 and 2 of the Bill give us the power to do just that, if the consultations on "Patients First" endorse our proposals. The right of health authorities to appeal for funds will once again enable local communities to demonstrate practical support for their hospital.
In our manifesto we also undertook to allow pay beds to be provided where there is a demand for them and to end Labour's vendetta against the private health sector. Part II of the Bill implements that pledge in a reasonable and balanced way. The undertakings given by the medical profession demonstrate 665 its commitment to the belief that the right to practise privately carries with it corresponding responsibilities. The six principles to which it has agreed go further in that direction than ever before and meet all the real objections to private practice in the National Health Service.
These are all commonsense measures, and as such I commend them to the House.
§ 5.5 pm
§ Mr. Stanley Orme (Salford, West)
I welcome what the Secretary of State has said about a debate on the report of the Royal Commission, and I assume that it will be early in the new year. There are wider aspects than those covered in the Bill that we want to discuss.
This Bill will not help the National Health Service. We recognise that there are problems in the Service. The developments that have taken place in its 31 years of existence—increased technology, improved conditions and earnings for those working in the Health Service, the demographic change for the elderly—will create problems that as a nation we shall have to face, and we need a National Health Service that can cope with them. We should therefore look at the Bill to see whether it takes us along that road.
The Secretary of State talked of Conservative philosophy and the question of principle. We agree that the Bill is not so much about technology but about philosophy and general approach. The right hon. Gentleman should not be under any illusion. We disagree vehemently with the general direction of the Bill.
This is the first step by this Government down the road towards a two-tier Health Service, and it amounts to a private patients' charter. It is an important step away from local democracy, accountability, and the principles of health care free at the point of use. We have already seen the Government's emphasis on charging and the increased prescription charges. It is also an important step along the road to financing the National Health Service—and I want to say more about clause 5, which is extremely important—through raffles, bazaars, and so forth. I repeat that it is obscene that people's health should depend on such practices.
The right hon. Gentleman has the effrontery to quote Aneurin Bevan on the National Health Service. When the 666 National Health Service was created, it was intended to be free at the time of use to everybody and to be financed through direct taxation of the community as a whole. We do not deviate from that basic principle.
§ Mr. Patrick Jenkin
In that case, why, under the previous Labour Government and, indeed, under every Labour Government since the war, have voluntary funds been cheerfully accepted? The right hon. Member for Norwich, North (Mr. Ennals), my predecessor, praised the giving of voluntary funds whenever the matter was referred to. What is so different about accepting voluntary funds in addition and appealing for voluntary funds? The right hon. Gentleman is being foolish on this point.
§ Mr. Orme
There is a world of difference between the friends of a hospital raising money to provide a television set, chairs or amenities and nurses on the street with collecting boxes.
I should like to deal with four main points in relation to the Bill: the Health Service reorganisation, the powers of the health authorities to engage in voluntary fund raising, financial matters and private medicine, both within and outside the National Health Service.
We are all in favour of better service and getting rid of bureaucracy. On the question of reorganisation, we should look in some detail at the proposals to get rid of the third tier within the NHS. I remind the House that the present Secretary of State for Industry put in that third tier. His reorganisation—the 1973 Bill—was based on the Kinsey report that was commissioned by the Government of the day—
§ Mr. Orme
Not Saatchi and Saatchi, of course.
The question of reorganisation raises some basic principles about democracy. In the Bill, the regional and area health authorities are greatly strengthened. They are given more powers, including the right to determine boundaries. Alongside those powers, the consultative document, which, for a document of its sort, contains many firm proposals, states in paragraph 23—on the subject of the membership of the new boards and whether the present one-third local 667 authority membership is necessary—that there should be four local authority representatives on district health authorities. That is a reduction of local health representatives on all bodies. At the moment, bodies with 20 such members will have that membership reduced to six or seven, while a membership of 30 will be reduced to 10.
That input of local authority representation is the only indirect democratic link, as opposed to appointment within the area health authorities. If hon. Members or local councillors in their wards went on to the street and took a poll, they would find out how many people knew who their representatives were on district or area health authorities—very few. It is a fundamental matter which we should like to examine in detail.
I notice that the Royal Commission report referred to the question of local authority representation and whether the NHS should be devolved to local government. In paragraph 20.61, the report states:We concluded in Chapter 16 that the NHS should not be transferred to local government at the present time but that the question should be looked at again if regional government became a possibility in England.It rightly posed the possibility that there is something wrong in the democratic structure of the NHS. We should take account of that fact.
My right hon. Friend the Member for Norwich, North (Mr. Ennals), when he was Secretary of State, put forward proposals for industrial democracy and trade union representation of those working in the NHS. Those proposals have now been dropped and there has been no reference to them by the Secretary of State. If we take into account that the right hon. Gentleman does not accept the Royal Commission recommendation that family practitioner committees should be brought within the district or area health authorities, that is another block against the extension of democracy.
The problem of the community health councils cannot be excluded. I found it strange that the consultative document called "Patients First" should refer in paragraph 26 to community health councils—themselves representative bodies—representing patients. The latter part of paragraph 26 states: 668The need for separate consumer representation in these circumstances is less clear; next year the councils will cost over £4 million. The Government will welcome views on whether community health councils should be retained when the new district health authority structure has been implemented.I see that as the death knell for the CHCs, which have played an important role and which have often been a thorn in the flesh of the AHAs and RHAs.
§ Mr. Orme
The CHCs did a good job. The report on the difficulties experienced at Normansfield mental hospital commended the CHCs. I am glad to see that the Secretary of State concurs with that commendation. They did not give up, like others did, in the attempt to get the scandals publicised, recognised and dealt with.
§ Mr. Patrick Jenkin
The right hon. Gentleman said that paragraph 26 sounded the death knell of the CHCs. I should like to state publicly that the Government's mind on this point is absolutely open. Paragraph 26 makes that clear. Whether or not the CHCs will stay depends greatly on representations that may be made to us between now and next April. I should like that fact to be understood. I have made no decision on the matter.
§ Mr. David Atkinson (Bournemouth, East)
Is it not reasonable to suggest that, once the new district health authorities have been established, including, as they will, local councillors, there may not be a case for community health councils to continue in existence? The local view will already be represented on the district health authorities.
§ Mr. Orme
The CHCs will still represent large numbers of people. There is insufficient democracy in the NHS, and I believe that we must explore ways of trying to achieve sufficient democracy. I have no easy answer to that—it is a difficult question. Many of my hon. Friends would like to keep open the question of putting the NHS into the local authority ambit. However, there are difficulties for the regional health authorities and I recognise that fact. If education and other 669 services can be carried out on a local basis, why not health services?
§ Mr. Race
Does my right hon. Friend agree that one of the most important functions that the community health councils have—and one of the powers that they have—is an ability to refer to the Minister any hospital closure decision made by an area health authority? Does he agree, therefore, that if a proposal to abolish the CHCs was accepted by the Government it would be fair to ask who, if anybody, would then exercise the power to object to closures by area health authorities? Does not this reflect on the essential nature of moving away from democratic accountability by CHCs?
§ Mr. Orme
My hon. Friend the Member for Wood Green (Mr. Race), who has great experience of the National Health Service, has gone straight to the point. Without wearying the House, I shall refer to the speech by the Secretary of State in March 1973, when the new structure was proposed, in which he said:the consumer's voice is clearly taken into account via the new community health councils."—[Official Report, 26 March 1973; Vol. 853, c. 925.]I listened carefully to what the Secretary of State had to say, and I shall weigh his words and watch his actions during the coming months. The Royal Commission recommended the strengthening of the CHCs. We support that and will probably say more about it when we debate the Royal Commission report.
§ Mr. J. D. Concannon (Mansfield)
I should like my right hon. Friend to agree that we, as public representatives, have found the CHCs helpful when dealing with all National Health Service problems. This is the one point at which public representatives come into play. I have an excellent CHC in my area. That CHC owes some gratitude to my hon. Friend the Member for Ashfield (Mr. Haynes), who used to be its chairman. My hon. Friend ran that CHC well, and it is the kind of organisation we should maintain.
§ Mr. Orme
I thank my right hon. Friend. My right hon and hon. Friends have underlined the importance of the CHCs. When one is a Minister, CHCs can often be a nuisance; they can be 670 critical and raise questions. But that is what CHCs are for in a democracy. Ministers should be accountable. It appears that the Government—there is a further example in the Bill—are placing all the power in the hands of the Secretary of State, and we are opposed to that.
§ Mr. David Crouch (Canterbury)
There are only two members of regional health authorities in the House, and I am one. We should not confuse the function of the CHCs as representing public opinion—which is important and which should continue—with participation in the management of the National Health Service. There seems to have been some confusion during the last five minutes about where CHCs fit in. The role of CHCs is to represent the public concern about health care through the NHS.
§ Mr. Orme
I thank the hon. Member for Canterbury (Mr. Crouch) for his constructive point. I believe in strengthening the CHCs. They are often the poor relation in the Health Service structure. From what has been said to me by area and regional health administrators, I understand that they would like to see the back of the CHCs, and for that reason I want to maintain them.
I turn now to private practice, which the right hon. Gentleman made a central point of his contribution.
§ Mrs. Jill Knight (Birmingham, Edgbaston)
The right hon. Gentleman has made a strong case for the CHCs. Does he believe that there should be no deletion of any tier?
§ Mr. Orme
No. I am sorry if the hon. Member for Birmingham, Edgbaston (Mrs. Knight) misunderstood me. I said that we were in favour of improving the Health Service. If this measure will improve the Health Service, we will not oppose it. But we believe that three tiers are too many. What we are concerned about is what happens to democracy and representation. I am not opposed to looking at the basic structure as such.
The second major proposal in the Bill deals with private practice, both within and outside the Health Service. As the right hon. Gentleman said, the Bill recommends the abolition of the Health Services Board, the reversal of the phasing out of pay beds and an increase in the number of private hospitals before 671 Government clearance to go ahead is obtained. The number of private beds authorised will be 120 throughout the country as opposed to the present 75 in the provinces and 100 in London.
I recognise that the Bill contains a small measure of tightening up in the private sector. As I read the Bill, that will affect the abortion clinics. We believe that these three provisons amount to a positive step by the Government to encourage the private sector and allow it to flourish and develop.
There is a fundamental difference between the Opposition and the Government. In principle, we should like to see a National Health Service with no private sector. However, we accept that a private sector exists, and no doubt we shall have a private sector in one form or another for some time. But the basic principle from which we start, and upon which the Health Service was founded, is to provide a service for the whole community. As with education, once people are allowed to buy themselves out, the pressure to improve the service is weakened.
§ Mr. F. A. Burden(Gillingham) rose—
§ Mr. Orme
I must develop this point.
I find it odd that we have to argue about the issue of common waiting lists. If a person needs to go into hospital—not necessarily urgently—he should not have to compete with the private sector. I raised this point with the right hon. Gentleman, and he did not answer. I pointed out the problems that would flow from having to compete with the private sector. Often the consultants are not prepared to take non-urgent cases into account. In many instances the consultant makes only a clinical judgment. We feel extremely strongly about this proposition.
§ Mr. Burden
The right hon. Gentleman stated that the private sector, because of its advantages, would depress the public sector. Surely the opposite is true. If we have something that is better than that which is generally available for everyone, there is a pressure from those below, who do not receive those advantages, for higher standards. That happens in every walk of life.
§ Mr. Orme
Health should not be dependent on payment. That is the moral point from which I start.
The House knows that it was the desire of Aneurin Bevan to bring the whole medical profession into the National Health Service on a salary basis. That was unacceptable at that time to the medical profession. To launch the National Health Service, he had to concede that point. He recognised that he could not persuade the medical profession to accept what he was advocating. Thirty-one years later, I still think that that basic argument is right and I re-emphasise it.
The Government are to abolish the Health Services Board. This is an independent body, yet the Tories still cannot trust it so they abolish it. The Secretary of State takes powers unto himself—and tomorrow in the Social Security Bill he will take more powers unto himself—and abolishes independent bodies which are appointed to perform a service for the community. Their abolition is all tied up with this word "quango" Apparently, because they are called quangos, they must be wrong. We do not accept that attitude. In fairness to the Secretary of State, he paid tribute to the people who have worked on the Health Services Board, and, of course, he has just reappointed them—
§ Mr. Patrick Jenkin
That is an example of what I was referring to. The board is in no way answerable to this House, and therefore I have no option under the existing Act but to reappoint the members until this Bill becomes law. I should have thought that accountability to the House of Commons was something that the right hon. Member, as a House of Commons man, would appreciate. Surely there is some merit in accountability—a merit which he has not recognised.
§ Mr. Orme
I do not accept that interpretation of accountability. Everything cannot be accountable. Personal cases cannot be accountable. Of course, the Secretary of State has given us an incentive. The longer we keep this Bill in Committee and elsewhere, the longer he will have to wait for the abolition of the Health Services Board.
I come to the serious point that the Secretary of State made about industrial 673 relations in relation to the phasing back in of pay beds and the abolition of the Health Services Board. He keeps on about industrial relations. He keeps referring to last winter and the problems that arose then. In abolishing the independent board and phasing pay beds back into the NHS, the right hon. Gentleman will do more harm to Health Service industrial relations than he could have done by any other single measure. We shall see a return to queue-jumping at the taxpayers' expense. I have never understood how this could be justified. The green light to private hospitals will further undermine the National Health Service. It is already difficult to attract staff at all levels, and now more personnel will be siphoned off. Nowhere is there a duty laid down to assess private sector development in the interests of NHS patients, who form the vast majority.
How long will it be before the Secretary of State's much-vaunted insurance proposals, which would take us further down the road to the destruction of the NHS, see the light of day? What views does the Secretary of State have on the effect of these on the size of the administration? He often speaks of the insurance principle. Perhaps he has seen the recent lecture of Professor Brian Abel-Smith, who made this point:The only problem which a switch to health insurance could help to resolve would be that of unemployment. If we followed the French or German examples it would mean creating some 150,000 to 200,000 extra bureaucratic jobs to collect…contributions and bills.…The elimination of separate billing is one of the largest economies from having a National Health Service.That is a central point. When the Royal Commission examined overseas health services, it came to the view that the administration costs of the NHS were possibly the lowest in any modern developed society.
I turn to the question of voluntary fund-raising, which is not unconnected with the previous point. I do not take back one word that I have said on this issue. Earlier I quoted what Aneurin Bevan said in 1948 when he was appointed Minister of Health. If there was one thing that he wanted, it was to stop the practice whereby nurses had to go around with collecting boxes two or three times a year to subsidise or help finance their local hospital. This is absolutely 674 different from the question of raising money to improve a room or buy a chair or television set.
In principle, there are objections to voluntary fund-raising. It favours the popular hospitals. It favours richer districts where money is easy to raise and this increases inequality between the rich and the disadvantaged. No doubt the Secretary of State has seen what the Royal Commission said about the under-privileged areas in the inner cities. This is one aspect on which I criticise the Royal Commission because, while it refers to this matter, it does not take on board the seriousness of the situation. I represent an inner city area, and I know the problems. Fund-raising also leads to unhelpful annual variations in revenue and may encourage last-minute cuts. It favours popular specialities, such as cancer, at the expense of the mentally ill or geriatrics.
Let us take the example of the "Blue Peter" campaign on Kampuchea. The voluntary organisations have complained that this campaign has sucked away from them the moneys which would otherwise have come to them. We have the classic example of the fund-raising case in the North-West. I believe that this is a bizarre way to apportion money.
Clause 4(3) says:The activities authorised by this section include public appeals or collections and competitions, entertainments, bazaars, sales of produce or other goods and other similar activities, and the activities may involve the use of land, premises or other property held by or for the benefit of the health authority or the Board exercising the power.The Secretary of State said that he was taking powers of control. He said that there would not be casinos. But I wonder whether he will allow nurses to raise collections. Will he issue a code of guidance on this matter to area or regional health authorities?
§ Mrs. Kellett-Bowman
The right hon. Gentleman really cannot have it both ways. First, he says that fund-raising provides chairs and television sets and then he goes on indirectly to attack the Pat Seed cancer campaign in the North-West which has raised money for specialised equipment in dealing with cancer. Fund-raising goes far beyond that. It provides kidney machines and, in my own hospital, it has provided apparatus in the Intensive care unit. This equipment would not have 675 been provided with the money supplied by the previous Government.
§ Mr. Orme
I give credit to the magnificent work done by Mrs. Pat Seed, but, quite frankly, it should not have been her responsibility to raise £1,750,000. That is a question of financing, and if equipment is so essential and needed so badly it should be provided by the State. The right hon. Gentleman told the House that he could stop certain things and allow certain things. We are entitled to know what they are.
§ Mr. Patrick Jenkin
The words "casinos" and "lotteries", as I understand it, do not come within the clause. They would be the subject of legislation from another Department. My control would be exercised through the opening words of clause 4(3):Subject to any directions of the Secretary of State excluding specified descriptions of activity".
§ Mr. Orme
It becomes more confusing. We shall examine the clause in Committee and consider any further proposals put forward by the Home Office.
In the financial provisions in clause 5, the sections on financial duties are ridiculously rigid. They confer vast powers on the DHSS and the regional health authorities to order around district authorities, and make it a legal duty to remain within cash limits. At a time of unexpected changes in inflation rates, it seems unfair and impracticable to set out that sort of duty, especially as the Government are creating the inflation. It only increases the pressure to make large panic cuts, leading to gross under spending. Funding would be reduced by the Treasury.
We shall wish to examine that clause in great detail. It provides powers to remove authorities which do not carry out the Secretary of State's wishes or which he feels have failed to carry out their statutory obligations as laid down in the Bill. In Lambeth and Southwark he has suspended the authorities, but he cannot remove them. It is important to note that in the Bill he takes powers to sack authorities if he so desires.
I shall put many questions to the right hon. Gentleman. If he is unable to answer them, we shall await consideration of them in Committee. Would the 676 money that the Government expect to save from the reorganisation be added to the Health Service Vote or would it go into the Treasury coffers? How much would be saved?
I regret that the Minister for Health is not present. I hope that he soon recovers from his indisposition. He is on record as saying that the reorganisation would save £30 million. I have never known any reorganisation that has saved money. There has been local government reorganisation and Health Service reorganisation, and both have cost money. Will the Secretary of State spell out from where the £30 million would come? It could come only from salaries and job losses, because those are the real changes that are to be made.
What powers of direction does the Secretary of State intend to take over the health authorities which spend over their cash limits? Would health authorities continue to be allowed the opportunity that we gave them to carry over to the next financial year 1 per cent. of underspending? Is that flexibility to remain? Does the Secretary of State agree that the interests of National Health Service patients must be the major criterion in deciding whether to allow further expansion of private medicine? The right hon. Gentleman has acknowledged that he has reappointed the Health Services Board. Would it be able to carry on phasing out pay beds? It is a statutorily legally appointed board.
Clause 15 amends section 2 of the National Health Service Act 1966, whichenables the General Practice Finance Corporation to make loans to medical practitioners providing general medical services for the provision of premises and to acquire and lease to such practitioners sites required for such services".Will the right hon. Gentleman spell out whether that means that there will be basic changes?
§ Dr. Alan Glyn (Windsor and Maidenhead)
I am sure that the right hon. Gentleman understands how difficult, indeed almost impossible, it is for general practitioners to find premises in view of the high cost of property in London and other central areas. I believe that that is the reasoning behind the clause.
§ Mr. Orme
I note that point, but we wish to know the intentions of the Secretary of State.
677 This is a thoroughly bad Bill that attacks the fundamentals of the Health Service. We oppose it and we shall fight it. I restate the Royal Commission's endorsement that the National Health Service should be free at the point of use for all and paid for by the community through direct taxation. I re-emphasise that, and I shall continue to do so.
The National Health Service, with all its problems, is a credit to the nation, yet it is under central attack. We regard it as an outstanding post-war achievement. I assure the Government that they will have a major fight on their hands. We are defending something which we created and in which we believe. We shall continue to fight for it.
§ Mr. Charles Morrison (Devizes)
Much of the speech of the right hon. Member for Salford, West (Mr. Orme) was taken up with fears that have been based on myth and his imagination. He sought skeletons in cupboards that do not exist. During the course of my remarks I shall refer to some of the issues that he raised.
I say at the outset, especially as I shall be making some fairly critical comments on the reorganisation, that I am in complete agreement with the objectives of the Bill. Undoubtedly there is a need for changes in the administration of the National Health Service. From the beginning, some of us feared that the present structure would be too bureaucratic. Regrettably, our fears have proved well founded.
The previous Government's Health Services Act 1976 was based on dogma and not on common sense. It did not have any regard to the growing public demand for private medicine, not least from the trade unions, to which my right hon. Friend the Secretary of State has already referred.
Phasing out pay beds is contrary to public demand. It removes from the National Health Service a source of income. It divides private and public medicine and unnecessarily complicates the lives of doctors and consultants, some of whom have been tempted to opt out of the National Health Service altogether.
Providing health authorities with the powers to raise money by appeals and collections is good not only in that it 678 provides a small source of extra funds but because it should have the effect of stimulating community involvement and interest in local Health Service provisions. Thus, money-raising could be one more way of keeping the Health Service authorities in touch with, and making them responsive to, public opinion. The right hon. Member for Salford, West utters ridiculous nonsense when he says that it is a bizarre way of allocating money. Such remarks demonstrate the opposition of Labour Members to any form of personal choice.
I shall address most of my remarks to the method of rationalising the structure of the NHS administration. I was especially glad when my right hon. Friend the Secretary of State said that no conclusions have yet been drawn about the future organisation of the Health Service. It may not be popular to say so, but the simple truth is that the bulk of part I of the Bill is before us because we made nonsense of reorganisation in 1974. I suspect that the reason was much too much theory and not enough practical thought given to reorganisation. I have a nasty feeling that unless we are careful the same may prove true again.
My first plea to the Secretary of State is that he should bear in mind constantly the emphasis in the Royal Commission's report on variety and flexibility of organisation. Every time that my right hon. Friend draws a conclusion about the Health Service organisation in one area, he should turn to page 324 of the report and remind himself of the contents of paragraph 20.48, which states:The NHS is not a tidy construction and it still bears the marks of the haphazard growth of health services before 1948.The sentence that I wish to emphasise reads:Arrangements which suit one part of the United Kingdom well will be wholly unsuited to another.I hope that my right hon. Friend will keep that paragraph before him throughout his consideration of the future Health Service organisation. That is one of many paragraphs that stress the need for variety. Again and again, the Royal Commission stresses the need for flexibility.
That stated, I shall produce a little theory of my own. I ask the House to consider the pyramid of Health Service administration. At the top is the Depart- 679 ment. Underneath are the regional health authorities, the area health authorities, the existing district health authorities, and the community health councils. My right hon. Friend correctly wishes to remove one tier. It seems clear that the nearer the base of the pyramid from which the tier is removed, the greater the size of the bureaucracy which may be involved and the greater potential, therefore, for saving administration costs. However, that is not what my right hon. Friend seems to be proposing in the lead that he has given in his consultative paper.
The consultative paper tells us that my right hon. Friend would like to get rid of area health authorities and build up district health authorities. That seems rather odd. First, it means that for most area health authority quangos now in existence there will be several district health authority quangos in future. I know that there is a view that there are not enough quangos to go round to meet the demand for places on them, but I understand that that is a view that is repudiated by the Conservative Party and by the Government.
Secondly, every quango generates its own bureaucracy and costs. Quangos have done so in the past, whatever responsibilities they have had. Miracles happen, but not very often. I fear that, if district health councils are established, the expected saving of £30 million on bureaucracy will prove meaningless. I shall give two small examples to illustrate my argument. There are currently 17 members of the Wiltshire area health authority. If each of the three districts within that authority becomes an authority in itself, there could be a total of 60 appointed members. The consultative paper suggests that there could be up to 20 members of each district health authority. If there are 60 in total in Wiltshire, the cost of travel and of servicing the 60 will not be inconsiderable.
At present the Wiltshire county council deals with one area health authority. In future its actions may have to be tripled. The extra time that may be taken by officers will not be inexpensive. The Association of County Councils is much exercised on that score. It believes that area health authorities should be coterminous with county councils.
680 My third argument refers to the natural evolution of the Health Service since it has been reorganised. In his speech to the Conservative conference at Black pool this year, my hon. Friend the Minister for Health praised the Somerset area health authority for saving over £200,000 by simplifying its administration. It did so by abolishing two health districts and centralising on the area, not by doing the reverse. Furthermore, I believe that 39 of the 90 area health authorities are now single district areas. On the tenth page of the consultative paper, which is entitled "Patients First", it is suggested that single district area authorities should not be changed unless there are substantial advantages. Thus, in that context it seems that my right hon. Friend recognises the value of centralising at area level.
That value can be proved in a number of ways. I shall take one example from my own experience. The Wiltshire area health authority has decided to centralise its stores. That will save £100,000 a year. However, that decision has been made in the teeth of opposition from districts. I think that my right hon. Friend or my hon. Friend the Minister for Health will know of that opposition because representations were made to one or other of them from one or more of the districts.
Fourthly, I put a question to the Minister who is to reply. In calculating the saving of £30 million, has account been taken of the fact that, under the currently prevailing Whitley council regulations, if a district management team becomes a district health authority all chief officers and some of their staff will be upgraded and, as a consequence, salary costs will rise?
Fifthly, the implication of what has been said about the reorganisation—this is the implication of the consultative document as I read it—is that all area health authority responsibilities will go to district health authorities. Is that really so? I have no doubt that many duties which are above district level will go to regional health authorities. If I am right, decision-making will be taken further away from the community. At present, Chippenham, which is the headquarters of the Wiltshire area healthauthority—an area represented so ably here by my hon. Friend the Member for Chippenham (Mr. Needham)—has 681 liaison with the districts of Bath, Swindon and Salisbury. In future, distant Winchester, the headquarters of the regional health authority, could be telling those districts what to do.
The Government are looking to the regional health authorities to review the structure of the National Health Service. If they continue to look in that direction, they can be certain of the conclusions before they are reached and forwarded back to the Government. It is a matter of human nature. People like power. By getting rid of area health authorities, the regional health authorities will increase their own power and will be in the position of being able to divide and rule the districts. I have no doubt whatever about that.
The Association of County Councils has advocated the abolition of the regional health authorities. It makes the point—not an unfair one—that education is adequately dealt with at county level. Counties are directly responsible to the Department of Education and Science. Why, therefore, could not the Health Service be organised on similar lines?
I refer again to the consultative paper entitled "Patients First". We all applaud that sentiment, but we must remember also that prevention is better than cure. I fear that that will be forgotten at the district level, where opinion is likely to be more subjective than at area level at present.
Those are only some of the reasons why I doubt the wisdom of a wholesale slaughter of area health authorities. I should like reassurance—which I fear will not be forthcoming—before I am convinced otherwise.
It is a not uninteresting fact that in their short existence every health district within the Wiltshire area health authority has overspent its budget in one year or another. Who has to get the district back on the rails? Who, in effect, has to discipline the district authorities? It is the area health authority. In doing so, it has incurred, not surprisingly, some unpopularity with districts and doctors. That is one reason why many doctors support the abolition of the area health authority. Should district health authorities be established, will their budgeting be any better, particularly in the face of the highly articulate advocacy of doctors and 682 consultants, whose voices will be even stronger at district level than at area level?
The Secretary of State, rightly, has attached great importance to good mangement, particularly in hospitals. I fear that much of the best hospital management was dissipated by the 1974 reorganisation. Good management must be attracted back to hospitals. There is a shortage of good management in hospitals, as in many other spheres in the United Kingdom. Is it wise to spread the available management talent even more thinly than it is spread today by increasing the number of health authorities?
Many existing area staff are worried that if areas are abolished they will not be offered service with district health authorities, which will make automatic appointments from among existing district staff. I hope that the Minister will be able to reassure current employees of area health authorities on that point. Clearly, the best management must be employed, but that may not always be from among those currently holding the jobs.
I have long held the view that advisory committees, of whatever variety, have a limited useful life. If district health authorities are established, I believe that community health councils can be abolished. If there is centralisation at area level, it may be worth retaining community health councils, but only on the basis of the appointment of a representative from each community health council to the authority at area level. The longer the community health councils are left standing shouting on the sidelines, the less attention the players—the medical staff and administrators—will pay to them. At present, community health councils have no real power or responsibility. If they are to continue to exist, they must be given a small measure of both. If they are abolished and district health authorities are formed, the knowledge of many existing community health council members can be put to good use on district health authorities.
Some of my remarks may have sounded a little harsh. I realise that in any Health Service organisation the Secretary of State deals with many matters on which the conclusions are often contradictory. Nevertheless, I hope that during the passage of the Bill through the House, and as he sets about the subse- 683 quent reorganisation of the Health Service, he will not forget my comments. Should he forget, above all, the need for flexibility and variety of organisation, the taxpayer and the user of the Health Service—not the Secretary of State, because he will have moved on by then—will live to regret it.
§ 6.9 pm
§ Mr. David Ennals (Norwich, North)
I am sorry that the Secretary of State has left the Chamber. When I was Secretary of State for Social Services, he made some harsh remarks about me. I did not object to that. I start with a harsh remark about the right hon. Gentleman, and I am sorry that he is not in the Chamber to hear it. In the seven months during which he has been Secretary of State, he has done his job as if he were still a Treasury Minister. He has not shown the compassion which must inspire anyone with responsibility for a Department which is concerned with the sick, the disabled, the infirm and the weak in our society. He fulfils his function as if he were still a Treasury Minister.
The right hon. Gentleman proved that in a letter he wrote to the director of MIND, in which he said thatwhere we differ from previous governments is not in our policies for the mentally ill and for the mentally handicapped but in our overriding determination to secure substantial retrenchment in public expenditure…I…accept that this retrenchment will have an adverse effect on progress towards the new patterns of services which we would all like to see.I emphasise the phraseoverriding determination to secure substantial retrenchment in public expenditure.That is the objective set by the Secretary of State, and I believe that it is an unworthy objective. He shows an excessive concern—as he did when he was on the Opposition Benches—for the private sector of medicine at the expense of the National Health Service.
I have three main points to make. I want first to speak about the private sector and the pay beds issue; secondly, about local democracy; and, thirdly, about the financing of health authorities.
In looking, first, at the private sector, it is important for us to realise what a very small sector we are talking about. It can be seen from the Royal Com- 684 mission's report, page 289, paragraph 18.22, thatThe overall scale of private practice in relation to the NHS is small. In England about 2 per cent. of all acute hospital beds and 6 per cent. of all hospital beds are in private hospitals and nursing homesAs the report states,The private sector accounted for about 3 per cent. of total expenditure on health care in the United Kingdom in that year.".That was 1976. So we are talking of a very small sector of health provision. Of course there are advantages in a private sector. Those who can afford it, and think it ethical, can jump the queue.
I was very interested to hear the assurances that have been given by the medical profession to the Secretary of State. I should like to analyse them and to look at one or two of the qualifying terms, to see whether the assurances really mean anything at all. I hope that they do. I hope that they are built on the foundations that I tried to lay for common waiting lists. The private sector provides a supplementary income to those consultants who work in the NHS and also in private practice. On average, as the Royal Commission reports, there is about £6,000 per year in additional income for those who work in the NHS and who are also in private practice.
On the other hand, the private sector acts as a drain on the NHS in many ways. First, it lives off the NHS. My right hon. Friend the Member for Salford, West (Mr. Orme) mentioned earlier that the private sector does not incur the expense of training its own doctors, nurses or other staff, and the Secretary of State quite rightly recognised this.
Secondly, in some areas the private sector can suck into its orbit doctors and nurses who are needed by the NHS. This is why we established the Health Services Board. The Secretary of State has decided to expand the private sector, and I believe that this will take away doctors and nurses who are needed to run our National Health Service, which, of course, services the health needs of 98 per cent. of the nation.
Thirdly, there is a degree of subsidy, because the capital element is not always adequately covered. That is a criticism of myself, perhaps—that we did not set the figure for pay beds high enough.
685 When we look at what the Royal Commission recommended, we see that the Secretary of State is straying very far away from it. He drew upon the Royal Commission's report in a number of cases. The Royal Commission concludes on page 298, paragraph 18.43(b), thatthe capital element of pay beds charges should cover both the interest and depreciation costs of the capital investment in pay beds.More important still, it states thatthe Health Services Board should be given power"—that men as additional power—to control, and a responsibility to consider, the aggregate of beds in private hospitals and nursing homes when any new private development is considered in a locality".The Royal Commission's report mentions the strong emotion that is created by the pay beds issue among those who work within the National Health Service. As it states on page 294, in paragraph 18.40,Pay beds arouse strong emotions…health service workers, including some junior doctors, resent both the additional work they claim is imposed by private patients and what they see as the purchase of privilege by a small minority within a public service. When the controversy is raging, patients suffer.Not "Patients First", but "patients suffer".
Paragraph 18.42 states:From the point of view of the NHS the main importance of pay beds lies in the passions aroused and the consequential dislocation of work which then occurs. The establishment of the Health Services Board led to a welcome respite from discussion of this emotional subject.Why stir the trouble up again? That is the question I want to put to the Government. Why should they now, at a time when they and all people who care about the National Health Service want to see an improvement in industrial relations, hit the NHS on an issue which they know is wounding to so many who work within it?
I was involved in putting on the statute book the measure that the Bill seeks virtually to repeal. My aim was to try to cool troubled waters. Of course, the waters were not always cool, but in this sense they were. The great issue of private practice and pay beds was, in a sense, put before an independent board instead of being made the decision of the Secretary of State. The Secretary of State 686 has decided to take it back to himself. I believe that he is very wise in doing so.
The Health Services Board is to be abolished eventually. The phasing out of pay beds is to be put into reverse, and the control of private hospital development is to be decreased. This is quite wrong at a time when more and more doctors are needed in the NHS and when an increasing proportion of the doctors are opting to work full-time with the NHS. We ought to be encouraging that trend, not discouraging it.
We are not today discussing the details of "Patients First", although the hon. Member for Devizes (Mr. Morrison) referred to it in his speech. But the Bill gives powers to the Government to implement proposals contained in "Patients First". As has been recognised, at least the document acknowledges the mess that was made by the right hon. Member for Leeds, North-East (Sir K. Joseph) when he was Secretary of State. It broadly accepts the management recommendations of the Royal Commission and it gives the stamp of approval to my own work to create single district authorities.
It happened to be my decision, taken by me as Secretary of State, which led to the creation of a single district area. I hope that the Minister, when he replies, will give some details. Is it to be assumed that over five years £30 million has been wasted each year, making an accumulation of £150 million? Where does this figure come from? Was it just plucked from the air? Our experience was that the creation of a single district area produced a saving of about £100,000. I hope that we shall get some answers.
What about the consumers' interest? What is all this about "Patients First"? I said last week that it was a little cheeky of the Government to call the document "Patients First" when they were cutting down patients' services as a result of public expenditure cuts, and when they were putting up patients' charges as a result of their absolute determination—using the Secretary of State's own words—to reduce public expenditure.
Will the Government's proposal for more local health authorities lessen the bureaucracy? That question was also asked by the hon. Member for Devizes. I cannot see that it will. I agree with my right hon. Friend the Member for Salford, West. I believe that paragraph 687 26 of the consultation document spells out the death knell of the community health councils. Certainly it must have done when the Secretary of State approved it. It may be that he is now changing his opinion. It may be that pressure is being brought to bear upon him, that perhaps £4 million is not everything, and that perhaps the views of the public on the running of the National Health Service matter a little.
Community health councils took a few months—and in some cases a few years—to get under way, but they spoke up for the patient and for the community. It would be a tragedy if they were to be lost.
I agree also with my right hon. Friend's criticism of the reduction in the number of representatives of local authorities. I very much doubt whether, in the sort of structure that we have here, we shall find our new health authorities being more responsive to the consumer. There will be fewer local authority representatives. There will be no elected representatives of staff interests, to which the previous Government were committed and which play a vitally important part in industrial democracy. As my right hon. Friend has said, regional health authorities are given greatly increased powers. The watchdog role of the community health councils is in danger of being seriously stifled by the Government. The Government have abolished bodies that criticise them. They may want to abolish the community health councils because the councils sometimes speak out critically. The job of the councils is to be critical and to speak up for the people.
The Government have abolished the personal social services council largely, in my view, because it was critical of what is happening to the social services as a result of decisions taken by the Government.
Clause 4 would give powers to the new health authorities to raise their own money by appeals and collections. We have run through the list. The Secretary of State has given an assurance that the list will not include casinos. I do not know the reason for his decision. Are there to be regulations stipulating that no casinos will be allowed? The right hon. Gentleman has decided against lotteries. Why should lotteries be excluded? Lot- 688 teries are one of the best methods of raising money. My local Labour Party is doing marvellously in every way, but especially in raising money through lotteries.
What about jumble sales? Every time we put these suggestions to the right hon. Gentleman—it is a pity he is not present—he leaps up and says "We are not going to do that." The right hon. Gentleman is telling health authorities to raise their own money but not to raise it in ways that he, as Secretary of State, does not like. That seems to be arrogating to himself powers that no Secretary of State should seek to take.
§ Mrs. Kellett-Bowman rose—
§ Mr. Ennals
I have not given way. I may give way in a moment. I believe that the hon. Lady will try hard to catch Mr. Speaker's eye. I would not like to miss a word that she has to say.
I am not opposed to leagues of friends and efforts to raise money for television sets, curtains and other items for hospitals. I am fully in favour of the voluntary effort that goes into hospitals. As Secretary of State, I did more probably than any other Secretary of State to put money, resources and encouragement into the voluntary spirit. One aspect was the "Good neighbour" campaign which the Secretary of State decided to abolish by merely signing a letter without hearing the views of the advisory committee.
The work that can be done by leagues of friends is good. I am not opposed to local mayors setting up an appeal for a kidney machine or some equipment that the health authority does not possess. There are all sorts of voluntary activity. I believe that local people should be proud of their hospitals and should feel that they want to give. Some people, who know that their lives have been saved by the treatment they received in hospital, may want to make a donation.
The Secretary of State said that over £10 million was contributed to health authorities last year simply through the good will of people who said that they wanted to put something back personally. That is fine. But it is a different matter to make health authorities dependent, or even partly dependent, upon public fundraising. As my right hon. Friend said, that is wrong in principle in a service that, for a long time, has been, and, I 689 hope, will continue to be, basically a tax-financed service.
What is to stop some crafty Chancellor of the Exchequer or some Secretary of State with experience in the Treasury, simply because of the success of fund-raising, from reducing the public funds available? The right hon. Gentleman said that a clause in the Bill made this impossible. If there is such a clause, I have not seen it. I do not understand it. I doubt whether the Secretary of State understands it. I do not think it exists.
What happens in practice? In Southport, one can raise the money; in Stepney, one cannot. In Bournemouth, one can raise the money; in Brixton, it is much more difficult.
§ Mr. David Atkinson rose—
§ Mr. Atkinson
I wish to dispel once and for all the myth that Bournemouth is as rich as it is often made out to be.
§ Mr. Ennals
I gave way only because I knew that the hon. Gentleman would make the point for me. His right hon. Friend is saying that the new health authority responsible for Bournemouth will have the right and the opportunity to raise money itself in order to do its work without any assurance that Exchequer finance will not be reduced as a result of the generosity—or the meanness—of the population of Bournemouth. I am sure that the people of Bournemouth are generous. However, to put this responsibility on a health authority is wrong.
Those are my reasons—delivered, I fear, at remarkable speed; for I, like you, Mr. Speaker, do not believe in long speeches, and I hope to catch your eye again tomorrow—why I shall vote against the Bill and campaign against many of its proposals with great enthusiasm.
§ Mr. A. J. Beith (Berwick-upon-Tweed)
When I first came to this House in 1973, I made my maiden speech on the subject of the National Health Service. That speech was a plea that reorganisation should not go ahead. It was not a particularly original plea but at least it was 690 right. I believe that that was proved by events.
The first clause of the Bill demonstrates that the starting point of the Bill is the failure of the reorganisation that took place in 1974. The first clause gives the Secretary of State power to make changes in the local administration of the Health Service in England and Wales. Those structures proved a disaster. They were too extensive and too numerous. The administration proliferated. Jobs were created on a massive scale on the administrative side. There were ministerial appointments galore. A great many political appointments were made of a kind that the Conservative Party now seems to be questioning.
People felt increasingly remote from the organisations that had been created. The whole affair was a disaster. It is fascinating to see how the Conservative Party and the right hon. Member for Leeds, North-East (Sir K. Joseph) now view the matter. There is a certain honesty about their attitude. One should pay tribute to that. They admit that it was a disaster. What worries me is that when the right hon. Gentleman believes he is right, his eyes blaze and he goes into things with a clap of thunder. No one is allowed to criticise him. It is written on tablets of stone.
When he is wrong, the right hon. Gentleman is the frankest of all people in admitting it. That has been seen in practice. How are we to view the different pronouncements that the right hon. Gentleman is making as Secretary of State for Industry? This is not a subject that hon. Members can discuss today. But one worries about the situation.
The Government have recognised that they have to take action over what was created in 1974. I welcome their decision. There are too many tiers in many parts of the country. It is right to try to remove one of those tiers in such a way that power goes down and not up. That must be a guiding principle of a removal of a tier from the Service.
Many areas, including the county of Northumberland, part of which I represent, are single district areas. They have experienced the full extent of what this part of the Bill is likely to achieve, although not perhaps in identical form, for most areas. Where one tier has been removed, that has not proved enough. 691 Many of the problems that arose from reorganisation still exist.
It should not be supposed that simply by removing a tier we shall solve more than some of the problems. Many more will remain. Those trying to work in the Health Service, at local hospital level or in local general practice, however much they may favour removing one tier, will not be satisfied. The mere shuffling around of administrative responsibilities a long way up the line will not help them sufficiently in their day-to-day affairs. They want to be able to make decisions or get decisions taken within the local hospital or within the local area of general practice. They do not want to wait upon decisions made 50 miles or 200 miles away in order to get a ward painted or arrangements and facilities within a hospital altered. They want those decisions made locally. When they had the hospital management committee, they could get decisions made locally.
Most people in the Health Service whose memories go back to the hospital management committees are unanimous in their opinion that they could get decisions taken quickly and, on the basis of their own advice, much more readily in those days than they can now. Therefore, it is important that, as well as removing a tier from the Health Service, we pull power back to the level of the local communities and hospitals. That will not be done by taking out an administrative level. It requires a rethinking of the way that the Service is conducted at district level as well.
That brings me to the question of community health councils. There is no doubt that in the consultative document they are damned with faint praise. That is perhaps the kindest construction that one can put on that paragraph. We must keep the community health councils because they are the nearest we can get to a democratic element in the administration of the Health Service. The Health Service is severely deficient in this respect.
I should be happy to see the community health councils go in only one set of circumstances—namely, when we have a significant elected element in the running of the Health Service. In those circumstances a purely advisory health council may be less important, but, while the Health Service is dominated by 692 appointed members and is organised in such large areas, the community health council is essential. Indeed, many community health councils have demonstrated what a good job they do.
Although I am critical of private medicine and am in no way enthusiastic to see it grow again—it has grown under the legislation now being discussed—the Health Service could well do without another row about private medicine. I feel that the Government are making a wrong move in getting rid of the Health Services Board. The board has helped to take some of the party political steam out of the controversy. People hold genuinely different opinions about private medicine. However, I hope that we can establish agreement about the fundamental point that private medicine should not be allowed to impede the conduct of the Health Service or be used as a means of queue-jumping within it.
When we have covered that point, we enter a different area in which we can have a much more open difference of opinion. I hope that we do not disagree on that fundamental point. But let us not get involved in another massive row about it now. It is relatively marginal to the Health Service as a whole as regards the money involved and the number of points at which it impinges on the Health Service. Let us not allow this matter to take over the attention of Ministers and democratic bodies, such as Parliament, or lead to arguments within hospitals and to the souring of relations between management and unions in the way that it has done in the past. Whatever our individual views, that should be the dominant consideration.
The Government will arouse false expectations if they imply that many of the fundamental problems of the Health Service will be solved by the provisions in the Bill. Very few of those problems can be solved in an atmosphere of massive public expenditure cuts. Therefore, I wonder what will happen on some fronts. What can the National Health Service do about the closure of pharmacies and the lack of dental services in many areas? What will the NHS be able to do, in the atmosphere of cuts, about long waiting lists which still exist for some operations?
What can the NHS do about the disadvantage of travel that we find in many rural areas? For people in many parts 693 of my constituency to go for a regular check-up is an expensive business unless they happen to be on supplementary benefit. If that is the case, they can take advantage of schemes that help with travel expenses. But a low wage earner in a rural area, such as Northumberland, may have to pay £3 or £4 every time he goes for a monthly or quarterly checkup if he is suffering from a recurrent complaint. The Health Service has not yet solved that problem by any adequate means-tested benefit for people who have to travel long distances to hospital. We shall not be able to do anything about that problem if cuts continue to be the dominating factor in the Health Service. These matters are worrying to many people. If we can save money by simplifying the structure of the Health Service, let us do so and put it to uses such as that.
§ Dr. Brian Mawhinney (Peterborough)
I start by declaring the fact that I have no direct interest in the Bill, although perhaps an indirect one. As a part-time employee of one of the London teaching hospitals, I am under the University Grants Committee, not the DHSS. Of course, with my office in the hospital and as I teach medical students, I obviously have considerable interest in the Bill's provisions in addition to my interest as a constituency Member.
I welcome the first two clauses, which indicate that before long there will be a change in the structure of the NHS. As has been recognised on both sides of the House, reorganisation was not an unqualified success. The Opposition sought to lay the blame on my right hon. Friend the Member for Leeds, North-East (Sir K. Joseph), but the difference is that, while they recognised that it was not a success and did nothing about it, we are now trying to put it right.
§ Mr. Speaker
Order. The hon. Gentleman is apparently not giving way. Therefore, hon. Members must resume their seats.
§ Dr. Mawhinney
I recognise that administration per se is not bad. There is a tendency these days to blame administrators willy-nilly. That is not right. Administration is both too much and too remote. We shall want to know from the Secretary of State that any reorganisation means a slimmed-down administration, not for financial reasons but because the decision-making processes in the NHS have become bogged down. Doctors are spending too much time on committees, to the detriment of their patients.
The hon. Member for Berwick-upon-Tweed (Mr. Beith) said that morale in the NHS was rapidly going down because it took such a long time for decisions to be taken. They are not being taken locally. They are being referred up the system and back down the system. We simply cannot operate when decisions cannot be taken locally.
There is a decreased commitment on the part of all who work in the NHS because of the anonymity of the system. If no decision-making is available locally in respect of industrial disputes, for example, they are inclined to get out of hand because no one has the authority to say "Yea" or "Nay" or to negotiate meaningfully.
For all those reasons, I welcome clauses 1 and 2 and look forward to considerable advantages accruing as a result of the changes which should be made.
The hon. Member for Berwick-upon-Tweed was right when he said that the decisions must come much closer to the ground. For that reason, I welcome any proposal that will do away with the area health authorities. There is a need for an overall structure at regional level. Equally, there is a need for decisions to be made close to the ground, and that must be at district level.
I welcome the moves to retain private practice within the NHS. It has already been acknowledged that this right was part of the original Act. It may not have been the desire of all Opposition Members. Nevertheless, it was enshrined in the original Act, and it should remain, for a number of reasons.
The Royal Commission stated:The difference in scale of the private and public healthcare sector suggests that private practice could have at most a marginal and local effect on the National Health Service.695 Yet it has an important effect, for the Royal Commission also noted that just under half of all NHS consultants worked part-time. It is said that the majority do so in order to have a private practice. General practitioners are free to take private practice. The numbers in group private insurance schemes have been rising. There is obviously a desire on the part of those who practice and of those who benefit that there should be a private contribution.
There are three reasons why that should be so. First—and it is no good Labour Members pooh-poohing the idea—there is a desire for an element of freedom by both doctors and patients. That desire should not be allowed to undermine the structure of the NHS, as has been suggested from both sides of the House, but there should be an element of choice. That element is manifestly desired, and the Bill will preserve it.
Secondly, the Royal Commission says that the strongest argument in favour of retaining private practise within the NHS is the employment of the geographical whole-time or full-time consultant. It is nonsense to have parallel systems whereby those who practice privately in the NHS have sometimes to travel considerable distances between their two practices. This is disadvantageous, wastes time and money and cuts down the time available to doctors to practice their art. I declare an interest. Such a system adversely affects medical education, and if it continues it will have an increasingly detrimental effect.
I believe that it costs £40,000 to educate a medical student during the five years of his course, which involves exposure to the whole gamut of medicine. It is not in the interests of the student nor in the long-term interests of the patient if the student's experience is restricted because certain types of medicine are increasingly practised only in private clinics and hospitals which are not located near the teaching hospitals.
§ Dr. Roger Thomas (Carmarthen)
Is it not the practice on most medical rounds that when the consultant visits his private patients the medical students are excluded from that part of the round?
§ Dr. Mawhinney
The hon. Gentleman will have to ask the consultants about 696 that. There is a need for geographical full-time consultants rather than those who have to commute between two locations. The third reason why that is important—I make no apology for returning to the point—is underlined in the report of the Royal Commission in paragraph 18.27. The report says:we were told that private practice contributed towards the funds available for medical research. Academic staff holding honorary NHS contracts may not normally benefit personally from any private practice they undertake. The arrangement is that such fees are paid over to the university department and used for research purposes. The amounts involved are likely to be a small proportion of the total funds available for medical research, although they may be significant for some medical schools.It seems silly that funds for medical research, which will eventually benefit all of us, should be denied. It is unquestionably true that the amount of money which has been paid in private practice within the NHS—primarily to consultants—has been a bone of contention. I would like to see fees made available to all those who participate in the practice of private medicine within the NHS and not simply to the doctors.
I believe that the Royal Commission is right when it says that we should look carefully at local services in the private sector. We may well be able to learn of the deficiencies in the NHS which cause patients to turn to the private sector in those localities.
§ Mr. Ennals
The hon. Gentleman has quoted the Royal Commission several times. I take it that he does not doubt that the Royal Commission, having weighed up the advantages and disadvantages, reached the conclusion, in its wisdom, that the Health Services Board should be retained and that pay beds should continue to be phased out in the NHS.
§ Dr. Mawhinney
I will come to the Royal Commission's conclusion shortly. If the Opposition Front Bench spokesman was so opposed to the Secretary of State taking powers and abolishing the Health Services Board he might care to give a commitment to the House that, if and when a Labour Administration are next returned to power, they will repeal that legislation. I shall listen with interest to his views on that.
697 I remind the right hon. Member for Lewisham, East (Mr. Moyle) that private medicine within the NHS has tended to be an up-market activity; that is, it has tended to be for those who want specialist treatment. There is a genuine problem facing the National Health Service which is recognised on both sides of the House. There is a commitment to try to retain the cottage hospitals and emphasise their importance to the local communities. Nevertheless, it is also recognised that cottage hospitals are expensive to administer. Will my hon. Friend the Under-Secretary consider the possibility of introducing private beds at NHS cottage hospitals, so that these establishments can be preserved? Such a move might extend the commitment of local communities to their cottage hospitals and would be a useful and important step in safeguarding that which all of us believe to be important.
The Conservative Medical Society issued a statement yesterday in which it welcomed the retention of private practice within the NHS. It said:we call upon the Government to honour their Manifesto commitment to restore income tax relief on employer/employee medical insurance schemes.I shall be interested to hear the reaction of the Minister to that suggestion.
I turn to the point made by the hon. Member for Norwich, North (Mr. Ennals) and once more quote the Royal Commission report:There is no doubt that the private sector contributes to the health care of the nation, albeit on a small scale…It would be virtually impossible to establish how far health workers are diverted from employment in the NHS. We have reached no conclusions about the overall balance of advantage or disadvantage to the NHS of the existence of a private sector, therefore, but it is clear that whichever way it lies it is small as matters now stand.That gives the lie to the statement from the Opposition Front Bench that this is a thoroughly bad Bill. It is not. The Opposition cannot turn to the Royal Commission for support for their spurious claims. As has been said, this is a moderate, sensible and anti-doctrinaire proposal. It helps to preserve that which the majority of the people of this country would like and will benefit patients who support that view. For that reason, I am happy to support the Bill.
§ Mr. Laurie Pavitt (Brent, South)
I could not disagree more with 99.9 per cent. of what has been said by the hon. Member for Peterborough (Dr. Mawhinney). My hon. Friends and I will demolish most of his case in Committee, though I would like to take up one or two of his points. From the Conservative Benches there has been universal condemnation of the National Health Service Reorganisation Act 1973. However, no one seems to have condemned the right hon. Member for Leeds, North-East (Sir K. Joseph) for his part in it, nor for the £250,000 that was paid to American consultants for wrong advice. This Bill reflects very much the same thinking and philosophy.
The hon. Member for Peterborough should do more research before accusing the Labour Members of doing nothing about that abominable Act. The Act came into operation on 1 April 1974 and we won the election in the February. We voted against the Bill on Second Reading, in Committee, on Report and on Third Reading. When the Bill came into operation, we immediately made changes so that more local authority councillors could sit on the area committees. We strengthened the hands of the community health councils and established a national association.
The Bill is abominable and thoroughly bad. It is half-baked. It has come out of the wash without adequate thought. It displays an abysmal ignorance of the history and development of the National Health Service. Even more important, it is irrelevant to the real and urgent problems which the Health Service now faces. We require positive new steps, and many of us could advise the Government about what they should be. No such steps are contained in the Bill.
The Tory Government's economic policies are reminiscent of the 1930s. They are using the same type of remedies for unemployment. In their proposals for the Health service they are going back to 1911 and the Lloyd George Act. The Bill is so antiquated in its approach that I wonder whether the Conservates have learnt anything in the last 70 years.
The House is insulted by the way in which the Government have presented the Bill. It is a hotch-potch. We have been 699 unable to consider the Royal Commission's report, the consultative document, "Patients First", the annual reports from the Health Services Board and reports from the Health Services Council. Instead of debating those documents first and reaching conclusions from them, the Government have presented us with an enabling Bill which gives carte blanche permission for regional health authorities to do what they like. We shall oppose the Bill tooth and nail at all stages.
The move towards local administration would be a step in the right direction had it been better thought out and if it had provided a greater democratic element. Throughout the debates on the original reorganisation Act, hon. Members argued in favour of shedding a tier. If the area authorities go, the Minister estimates that there will be savings of £30 million. I predict that when that change takes place there will be no saving whatsoever in the administrative costs of running the Health Service.
I go further. We are talking about a Bill to alter the present provisions of the Health Service, which costs £9,000 million a year. Even if we concede the estimated saving of £30 million, this is only 0.33 per cent. of the total expenditure. That is what my right hon. Friend the Member for Huyton (Sir H. Wilson) called trying to collect the candle ends. That is typical of this Government's approach. The Government recently imposed some mean and Scrooge-like savings the like of which I have not seen in my 20 years in Parliament. In particular, the Government have increased by £5 the "season ticket" for medication needed by the chronic sick. In their attempt to cut public expenditure, the Government could not leave alone those who are permanently in need of medication, such as those who have had a coronary thrombosis.
The structure proposed is similar to the system which existed before reorganisation. Group hospital management committees will now have a new name. As my late right hon. Friend Dick Crossman said, business men and "self-perpetuation oligarchies" will be in charge, divorced from local pressures, especially if community health councils are to be abolished, as has been hinted.
Primary care is our main need. The switch from hospital to domiciliary care 700 is most urgent. However, the Bill consolidates the power base in the hospital service. It is nonsense not to take this opportunity to move towards a democratic structure. If the community health council watchdogs go, the Health Service will experience a period of unease, there will be problems with those employed and in sound organisation, especially at community level, and there will be problems in the relationship between the local authority social services and the Health Service.
In the care of the elderly and in mental health, there is a divorce between what is done in the locality and what is done in the Health Service. The Bill does nothing to bridge that gap.
I turn to the question of the dissolution of the Central Health Services Council in clause 6. Paragraph 11 of the 1978 report, headedPrevention of Handicap and Perinatal Mortality",states:One of the Council's members, Mrs. Peggy Jay, raised the subject of policies aimed at preventing handicap of perinatal origin, and referred to experience in France that financial investment in a prevention programme to reduce the number of children born with a handicap could be substantially less than the cost of providing continuing care for handicapped children.That is an important issue. For the sake of £127,000 the reports that we have had on this subject and, for example, on rubella and deafness will go by the board. That is an example of the Government's penny-pinching approach, for this council's work was a good source of advice and information for Back-Bench Members.
Under the Bill, dental consultants in hospitals may use pharmaceutical facilities outside hospital. That conceals the fact that pharmaceutical services in hospitals have been run down to such an extent that they can no longer provide a proper service. That is because of public expenditure cuts. As a result of that provision, prescriptions will cost more and that will lead to greater—not less—public expenditure. We shall pursue this matter in Committee.
The centrepiece of the Bill is that which deals with private practice. We started off at the time of the 1976 Act with 4,444 hospital pay beds out of a total of 500,000 in our hospitals. Now there are only 2,533. One of the Tory myths 701 is that the private sector can bring money into the Health Service. According to the figures, if the three major health insurance companies—BUPA, PPP and WPA—double their take-up of paying patients, the Health Service will gain by less than 1 per cent. of its total resources. The Bill is irrelevant to the problem.
The urgent need is to discover a practical way whereby, on the present basis of 84 per cent. of NHS total income coming from taxation, we can finance the Service properly and not by flag days and other peripheral methods contained in the Bill. Between 7.5 per cent. and 8 per cent. of the GNP should be devoted to the Health Service.
The Bill is a queue-jumper's charter. I shall bore the House with my own experience. There is no problem of waiting when the clinical need is urgent. I had a recent operation for cancer and there was no waiting; I went into hospital immediately. I am pleased to report to my hon. Friends that I am as fit as I am ever likely to be. My only health problems in future are likely to be in growing toe nails or corns. There is no waiting list for serious surgical necessities. However, there is a problem for non-urgent attention like gynaecology. A lady who is in acute discomfort but who will not die from it can be relieved of that discomfort under the Bill by jumping the queue and paying a consultant. That means that another case with the same clinical diagnosis goes to the rear of the queue.
Hon. Members will know that it is in treatment for hernias, varicose veins and gynaecological problems that the money is made by the private practice consultant, and there is a financial incentive to prolong waiting time.
I shall reserve for Committee my major arguments. I remind the House of what my late colleague Nye Bevan said when he resigned:Those who live their lives in mountainous and rugged countries are always afraid of avalanches, and they know that avalanches start with the movement of a very small stone. First, the stone starts on a ridge between two valleys—one valley desolate and the other valley populous. The pebble starts, but nobody bothers about the pebble until it gains way, and soon the whole valley is overwhelmed. That is how the avalanche starts, that is the logic of the present situation."—[Official Report, 23 April 1951: Vol. 487, c. 42.]That is the logic of the inroad made 30 years ago and is the logic that remains 702 true of this Bill. This is the start of the avalanche which will result, if it is allowed to continue, in the complete destruction of all that is best in our National Health Service. Nye Bevan was a great House of Commons man. He was right then to insist upon the retention of the humanitarian and compassionate reasons for the first National Health Service legislation.
I cay to the Government and to the financial insurance profiteers and to that small percentage of hospital consultants who put pay before patients that the next Labour Government will restore our Health Service. They will make it democratically responsible to the people whom it is supposed to serve. It is there for the patients, not for the doctors. A Labour Government will make the Service what it used to be, a system under which we shall be "Members one of another" and the healthy continue to take responsibility for caring for the sick and the disabled.
§ Mr. Deputy Speaker (Mr. Richard Crawshaw)
Order. Before I call the next speaker, I wish to indicate that the 10-minute rule will apply between now and 9 o'clock. I hope that hon. Members will limit their speeches, to save the Chain from having to intervene.
§ 7.2 pm
§ Mr. David Crouch (Canterbury)
I shall do my best. I hope that the hon. Member for Brent, South (Mr. Pavitt) realises that he was not so limited, although he voluntarily limited his speech. I was glad to hear him speaking with such vigour, as I know about the illness from which he suffered and to which he referred. It is a pleasure for the House to hear him speaking with vigour on a subject about which he is a considerable expert. For many years I have followed him in these debates on health matters in Committee and on the Floor of the House.
I have a dual interest in health, not only in keeping fit—and keeping the National Health Service fit and improving it—but as a director of a pharmaceutical company and a member of a regional authority.
Having fulfilled that little duty, I say this to the Opposition. They are working themselves up into a lather about the Bill. They have almost a synthetic indignation about the aims of the Bill. I 703 understand how they feel about pay beds. They go back to Nye Bevan on this question and they take notice of their consciences and feelings about the morality of pay beds. However, the Bill is not about that. It aims to improve the management of the Health Service. The guts of the Bill are designed to bring management closer to the patient. It is a move in the right direction.
As a member of a regional health authority, I am involved in the Health Service. I am glad that the area authorities, not the regional authorities, will go. I do not say that in my own interest. I would welcome not having to do additional work. The area health authorities are an unnecessary tier in the management structure. There was a mistake in the structure when those authorities were set up. They seemed to feel themselves primus inter pares with the regional health authorities. They felt that they had direct access to the Secretary of State and could go over the head of the regional authority. That has not made for successful management. In fact, it has impeded good management. It slowed management decisions and produced frustration.
I confess that I am happy to hear that pay beds are not now to go. I agree with the hon. Member for Berwick-upon-Tweed (Mr. Beith), who spoke for the Liberal Party. I hope that none of us in the House makes this the main issue on the Bill. It will only sour our discussion and consideration of the real issue.
It is worth trying to raise money by voluntary means. I see nothing wrong with that. It happens at the moment for the various cancer funds. Considerable amounts of money are raised. Such appeals are emotional. It is an emotional aspect of health. I believe that considerable amounts of money could be raised on a local, rather than a national, basis to support the Health Service and particular hospital needs.
The right hon. Member for Norwich, North (Mr. Ennals), a former Secretary of State, said that he would not mind money being raised for specialist equipment lacking in a hospital because it had not been provided from National Health Service funds.
704 I question the possible value, or advantage, of the voluntary recruitment of money as it might distort the best pattern of health service that we could produce. For example, it could be decided by a district health authority, under the new arrangements, to close a hospital—shall we say a small maternity hospital that was little more than a Victorian house with a dozen or 20 beds in it, which contained little equipment for modern maternity provision and care? Voluntary recruitment of money might distort the proper closure of such a place, as there could be an emotional appeal to keep that place open. When the money is raised, it might be used for something that could be against the best interests of good health care. I hope that my right hon. Friend will bear in mind that this move could produce the wrong result.
I now refer to the duties, as I see them, of members of health authorities. I have served on one for so long. There is a certain art about being a member of such a body. Officials propose and members decide. That is the structure of management. Members decide after discussion. The debate is always better when the members, or some of them, know what they are talking about, have looked into the problems, and have taken the trouble to find out what it is that they are being asked to consider. It is preferable when they know the medical, regional and local views, or the views of general practitioners, nurses, consultants, ancillary workers or radiographers, and understand what the patients and public think of the problems.
That is important for those who take part in the decision-making process. The members should know about those views. They should get about more and not concern themselves only with budget considerations. They must share among themselves the responsibility of finding things out, so that they may, as a team, cover the whole area of responsibility. It is here that the public interest can best be safeguarded. I want to see the public interest safeguarded in the management of the National Health Service.
Mention was made of the community health councils. I have always been an advocate of the CHC. Hansard records my willing acceptance and blessing of the introduction of the idea of CHCs. I have lectured on them at King's College. I have supported them through 705 thick and thin. When CHCs become politically motivated and directed—from whichever side of the political spectrum—they become a disaster and render a disservice to the interests of patients.
I refer next to the choice and selection of those who serve on health authorities. They should be health-motivated and health-interested persons rather than politically-motivated persons. It is a disaster for management when politics comes in and the political football is introduced. At this point, the professional men in NHS management become frustrated.
The community health councils have an important function as a focus for public inquiry and interest. However, I do not think that they should be used as a device to frustrate and slow up management. By all means there should be inquiry. Their members have a right to be present and to be heard when a case is being put, but they are not there to frustrate and delay.
I am sorry that there is no clause in the Bill to make a special case for London, for the 12 teaching hospitals. In some ways there should be a special case for all teaching hospitals, because I would like to insulate them from the problems of short-term patient care. I do not want to see them swamped by the general problems of the NHS that exist around them. This applies particularly in London, where there are 12 such hospitals. London's 12 teaching hospitals are like a special unit in the Army, a special corps that is kept slightly separate, with a separate management, related of course to the Health Service—not divorced from it in any way but completely related and integrated. They deserve special provisions in the general management.
The chairman of the Royal Commission, Sir Alec Merrison, said in the concluding part of that great report that there would be no blinding revelations in his report, and there are not. Neither does the Bill offer an immediate cure. But 1 would leave with the House the thought that, no matter how much we improve the management and the democracy, we shall still be deficient in one major element in producing better health care in this country—we shall not have enough money in the National Health 706 Service. One day—I pray it will be soon—we shall earn enough in this country again to feed the right amount of money from the State into the NHS, so as to deliver a much better health service in this country.
§ Mrs. Gwyneth Dunwoody (Crewe)
The hon. Member for Canterbury (Mr. Crouch) said that the Bill was about improving the management of the National Health Service. Frankly, it is about nothing of the kind. It is about giving a specific boost to private practice and it is also specifically involved with the nostalgia and the dogma of the Tory Party. When we make that clear, we know what we are actually talking about. After all, how can it seriously be suggested that we intend to improve the National Health Service and the management structure of it if there are the kind of comments that have been made by the Minister of State? He has suggested—and this has already been revealed—that he believes he will save £30 million by these changes.
What the Minister does not say is how—if one tier is removed and, for example, we get lid of 30 area health authorities and create in their place 200 district hospital authorities—we improve the service. How shall we improve the structure? If we have different boundaries and retain existing private practitioner committees, and if they are operating on boundaries different from the district boundaries, how shall we improve the management structure in relation to primary health care? How shall we manage the district nurses and the associated health service workers? We cannot do so.
What we are talking about, as we have seen in so many Bills since this Government came to power, is an attempt to tinker cosmetically with the overall effect, not to do anything which will fundamentally change and improve the Service.
The NHS is desperately in need of improvement. particularly in the whole realm of industrial relations. What is so very depressing about the Bill is that there is not even any suggestion that there should be elected representatives of the staff working in the Health Service. That is actually ruled out of order. Last winter proved conclusively that we cannot treat 707 Health Service workers as if they are different from ordinary workers. We have to listen to their problems and try to find solutions. Most of them work at lower wage rates—and I am talking not about the medical profession but about the ordinary ancillary workers. The very fact that most of them work at lower wage rates than they could get elsewhere should be the reason for our being more aware of their industrial problems and more anxious to help them, not put them in a position where they are less advantaged than workers in other fields. The Bill does nothing to change that situation.
I am extremely sorry that the Minister of State is not here today because I should like to have said to him that I regard his remarks about a specific instance at Charing Cross as extremely unhelpful, coming from a Minister with responsibility for industrial relations. We really cannot have a situation where people ride their political hobby horses at the expense of the National Health Service, and that is what he was doing in no uncertain terms.
If, in the short time left to me, I say what I would like to have seen done in the Bill, it is because I believe the Conservative Government are not genuinely looking for the kind of changes that they say they want. I will give the Minister a little help. If he really wants to save the National Health Service a great deal of money, why does he not ask his Government to put a total ban on the advertising of cigarettes and tobacco products? Why does he not ask them to find time to discuss my Private Member's Bill? The amount of money spent by the National Health Service, not only on carcinoma and its treatment, and deaths from carcinoma, but on related diseases, is very much larger than the £30 million that he is suggesting he will save by these marginal changes in the Health Service.
There is the suggestion that we should change the method of raising money. If the Government are really serious about wanting the district health authorities to have the right to raise money, why not give them the same powers as are available to local authorities? We do not really raise the amount of money needed for health care by putting our nurses out on to the streets with collecting-boxes. There is no constructive way in a modern society, with a rising cost of health care, 708 by which we can possibly get enough money. All we do is pander to the nostalgia of those people who think that flag days are days when they are operating effectively. We are bringing the "lady of the manor" mentality into the Health Service.
I have no doubt in my mind that the timetable which is suggested, which is very vague, will make it impossible to consult all of the relevant parties in the NHS. There is no evidence that there will be a proper consultative procedure. That, after all, should be one of the things included in the Bill. There is already a very considerable planning blight inside the NHS, and the loss of morale is directly connected with this kind of shilly-shallying and change at Government level. There is the danger that we shall lose many of the best of our NHS staff. A further reorganisation will not affect health care at all.
The problems that we have in this country of an ageing population and of certain specialties which have become Cinderella specialties will not be altered at all by the Bill. People will go on getting older. We shall need more money spent on the NHS. It has become very obvious that we are one of the countries which spends even less money than many other comparable countries in the Community. This Bill is really a gesture, and a rather nasty gesture, in the direction of one aspect of health care—private practice.
When I was recently in Lesotho I noticed that in the hospitals there, which were very reminiscent of hospitals before the National Health Service was created, a very large and formidable black matron was going round and collecting sixpences from the patients as they sat up in bed. I am sorry to say that I believe that the Conservative Goverment are saying in the Bill that that is the situation they want to see created in this country once again.
§ Mr. Paul Dean (Somerset, North)
I welcome the Bill and, in particular, the intention to streamline the administrative structure of the NHS and the provisions to remove the shackles which the previous Administration placed on private practice and to encourage local fundraising. There is a sombre background 709 to this debate. First, there is the waiting list in National Health Service hospitals, which increased by no less than one-fourth during the period of the last Administration and now stands at the highest figure ever.
The right hon. Members for Norwich, North (Mr. Ennals) and for Salford, West (Mr. Orme), who were at the Department concerned, should be hanging their heads in shame at the waiting list which now exists. This Christmas there will be many more people than ever before who will be suffering the anxiety, inconvenience and pain of waiting for hospital treatment. Part of the responsibility was the appalling disruption in the health services that was carried out by a small militant minority of employees during last winter.
I congratulate my right hon. Friend the Secretary of State on the circular that he has issued, which gives guidance to local health authorities on dealing with disputes. But what a commentary that circular is on the failure of the previous Government to give a lead in maintaining discipline in the observance of contracts and in putting patients first. It is quite extraordinary that my right hon. Friend has had to remind health authorities that they will have his support in enforcing the basic conditions of work—namely, that strikers should not be paid and should not receive bonus or overtime payments that have not been earned, and that working to rule and blacking certain work are usually breaches of contract.
I hope that my right hon. Friend will go further and try to ensure that no-strike agreements are negotiated within the NHS. There is no place for strike action when caring for the sick. Using patients as hostages, as happened last year, is abhorrent to any fair-minded person. Indeed, it is wholly contrary to the calling of medicine and nursing.
§ Mr. Dean
I am sorry, but I shall not give way to the hon. Gentleman because of the limitation on time. I hope that he will forgive me.
Against that sober and sombre background, I wish to mention two particular points with regard to the Bill. The first concerns administration. At Question 710 Time the other day, my right hon. Friend hit the nail on the head when he told us of a comment that had been made to him by a head porter in the Health Service—that there was too much administration and not enough management. That, indeed, is the reform that we want to see. Above all, it means that decision-making must be as close to the patient as possible.
I share the doubts of my hon. Friend the Member for Devizes (Mr. Morrison) about whether getting rid of one tier of management will necessarily improve administration and bring it closer to the patient, which is what we desire. I hope that the Government will maintain flexibility in any proposals that they eventually bring forward. For example, what is right for the county of Avon, with its heavy concentration of teaching hospitals, is not necessarily right for Wiltshire or Somerset. I hope that we shall avoid getting into the position that occurred last time of imposing the same provision throughout the whole country when conditions vary considerably. I also query, as did my hon. Friend the Member for Devizes, whether it is right in every case to abolish the area health authorities.
The second point to which I shall refer briefly relates to the provisions in regard to private practice. Here I declare an interest in health insurance. I believe that the proposals as my right hon. Friend has described them constitute a sensible, moderate and balanced package. I welcome the restoration of the power to allow private practice in NHS hospitals. That will mean much-needed additional money going to the Service. It will facilitate what the medical profession calls the "geographically whole-time principle", which will enable consultants to work on the same premises and to be available constantly to meet the needs of all their patients, both NHS and private. However, I hope that my right hon. Friend will not attempt to unscramble the omelette and restore all the pay beds that were abolished by Labour. Let us start where we are now and try to ensure that in the future pay beds are available where there is a demand for them and where they can be used and staffed effectively.
I hope that my right hon. Friend will also take into account, as I am sure he will, that the attack on private practice by the previous Administration has given 711 a new lease of life to the independent sector. More people are now insuring than ever before, including many trade unionists. Much more independent hospital building is now taking place than ever before. In my view, we now need to forge new links in the light of the expansion of the independent sector between the NHS and private practice.
For example, BUPA has carried out some valuable pioneering work in diagnosis and preventive medicne. There has been a rapid development in that area. I hope that the NHS will be able to make use of the pioneering work that has been done in the private sector. That is one of many ways in which the growing private sector can help the NHS. There are ample opportunities for partnership between the two sectors. That partnership need not be limited to pay beds.
I also accept that Ministers are right—as, indeed, the Royal Commission recommended—to maintain some control over the private sector. It is sensible and practicable to have that reserve power. However, I share the concern of the independent hospital group about the likely effects of clause 10. That clause will allow independent hospitals of 119 beds to be built without the authority of the Secretary of State. That compares with the present figures of 100 beds in London and 75 elsewhere. That may appear to be an improvement on the present position. In practice, it could well prove to be more onerous because of the provisions in the clause relating to the aggregate number of beds in an area. In other words, the freedom of clause 10(1) could be neutralised by the restriction in subsection (2). Any figure is bound to be arbitrary, but I doubt whether it is right to have the same figure in London and for country areas. I believe that we need a more flexible criterion than is in the Bill at present, and I urge the Government to consider this matter again in the light of the representations that have been made by the private sector.
I am running out of time. I merely conclude by saying that I welcome the Bill as a sensible, practicable measure which I believe will be effective both in strengthening the NHS and in encouraging the private sector.
§ Mr. Andrew F. Bennett (Stockport, North)
The hon. Member for Somerset, North (Mr. Dean) began his speech by deploring the length of waiting lists. I agree with him that that is tragic. However, he ought to think carefully about how far those long waiting lists reflect a lack of resources within the Health Service and how far they reflect a policy by some consultants deliberately to make the waiting list long, either to boost private practice or merely as a matter of internal politicking within their own hospitals to improve and increase the resources that they receive. I have a suspicion that some consultants use the waiting lists as a means of boosting the whole concept of private health insurance. Therefore, we must be very careful about reading too much into the waiting lists.
The Bill is disappointing to all who use or work in the Health Service. The Service is looking for bold and imaginative leadership, yet all that the Bill does is to tinker and patch. It is even worse than that, because it reveals an attitude of despair in its approach to private medicine. Basically, the Government are saying that we cannot provide a good enough NHS to satisfy the rich and the vocal, so rather than improve the whole Service their aim is to buy off that criticism by giving privilege and preference to those who have the money to pay. We should throw out the Bill, but I suspect that the majority in the House will not do that, and there is therefore a strong necessity to modify the provisions regarding private medicine, which feeds like a parasite on the National Health Service.
If the extra provisions for private practice are enacted, any doctor, nurse or ancillary worker who has been trained in the Health Service and goes into private practice should have to make a contribution to the National Health Service from the money they earn to pay for the training that they have received. The Health Service should not continue to subsidise the private sector in that way. The provisions on private medicine make the Bill unacceptable, but it is also unacceptable because of an omission.
The Bill makes no mention of preventive medicine. Why will not the Government take on the question of ill health resulting from cigarette smoking? If the Minister really made an effort, far 713 greater savings could be made and more resources would be available to the Health Service than any of the administrative changes suggested would provide. Why do not the Government tackle the question of road accidents, which are, often an almost direct result of people driving when they have had too much to drink? That would make more resources available to the Health Service than will come from these administrative changes.
Why will not the Government tackle the problem of those children who are born with physical and mental handicaps because of the lack of perinatal care? Why does not the Minister improve screening services to ensure that those who suffer from an illness get early treatment at a lower cost? If the Minister wants to offer a lead to the country, he should make a major contribution to preventive medicine. We will get a far better return if we invest money in prevention rather than in cure.
The Bill does nothing to deal with the scandal of small private hotels that have a specialist clientele comprising the elderly. Those elderly people are often in exactly the same conditions as those who are in old people's homes or in psycho-geriatric wards of hospitals. However, some of those hotels manage to avoid all the regulations that apply to old people's homes. In many cases they exploit and damage those old people in an unacceptable manner. The Minister should legislate for that and should make sure that anyone who is responsible for looking after old people meets minimum standards.
There is an overwhelming case for making the Health Service responsible to a democratically appointed body. No such measure has been taken in the legislation. Indeed, we are going backwards because we are reducing the number of elected people involved at a local level. It places the chairman of an area health authority or the chairman of a regional health authority and many of his colleagues who are appointed by the Minister in an impossible position. If they kick up a fuss and demand extra resources, the chances are that they will not be reappointed. That is unacceptable.
Those authorities must have a mandate and be responsible to someone other than the Minister if they are to fight for and 714 demand extra resources. The Minister is going even further. Instead of giving democratic backing, he is saying that he will appoint officials. Bearing in mind the financial provisions of the Bill, the Minister will turn those officials into little more than rubber stamps. It is vital that everyone on the area health authority and on the regional health authority should be democratically elected and responsible to an electorate. That will give them power to say to the Minister that the Health Service must have more resources.
The Bill is a totally bad one, and I hope that it will make no further progress.
§ Mr. Robert Atkins (Preston, North)
I welcome the Bill, especially clauses 7, 8 and 9, which amend section 65 of the National Health Service Act 1977.
I wish to draw attention to an area of substantial abuse that has been un-quantified in terms of numbers or of cost. Much attention centred during the summer on the problems faced by unfortunate holidaymakers who suffer illness or accidents in foreign countries and do not receive the facilities available to them at home under the National Health Service. That publicity served to highlight the anomaly whereby nationals of those countries with which we do not have reciprocal arrangements for free treatment are not paying for treatment in the United Kingdom, although British citizens who go to their countries are required to foot any bills incurred.
We have reciprocal agreements only with the other eight EEC States, New Zealand and some of the Warsaw Pact countries, but anyone from another State can obtain free treatment under the NHS for accident or illness. The relevant instruction of the Department of Health and Society Security was outlined earlier this year before the general election. It stated that visitorsshould be allowed emergency treatment in accordance with the 'Good Samaritan' policyand thatan approach should be made to the appropriate Embassy for a guarantee of payment.From the correspondence that I have received, it is clear that that is something of a comic performance. In addition, no 715 treatment for a pre-existing condition should be given, exceptsufficient to enable them to return homeThe key point is thatonly hospitals which are authorised under Section 65 of the NHS Act 1977 may admit private patients".As a result of the Labour Government's policy, hospitals with the necessary pay beds have become few and far between. In practice, a great many emergency or casualty cases end up in hospital without section 65 sanction, and the ruling of the DHSS is quite clear:Neither the hospital nor the consultant who treated the patient would have any authority to charge the patient.It is especially ludicrous that foreign nationals have offered to pay the whole or part of the cost of their treatment, only to be refused under the ridiculous section 65. In addition, there is evidence to suggest that a small but consistent number of people arrive in the United Kingdom suffering from the early symptoms of communicable or infectious disease, such as polio or tuberculosis. Those people are taken to NHS hospitals, isolation or otherwise, for treatment. One does not know to what extent there is any danger of infection to those on board the aircraft or ship or to officials at the point of entry that would otherwise not be present or he present to a lesser degree.
What can be done about this clearly inequitable state of affairs? The former Minister, the right hon. Member for Lewisham, East (Mr. Moyle), wrote in a letter dated September 1978:I do not consider it likely, therefore, that the improper use of the NHS by foreign visitors is as large a problem as my correspondent believes or that there is abuse on a massive scale.However, according to a letter from the DHSS only a month later, in October 1978, the Department could notauthorise new pay beds…nor can it approve temporary additions to the number of pay beds already authorised.It refers to section 121, which embodies the substance of section 17 of the National Health Service (Amendment) Act 1948,empowering Ministers to make regulations whereby charges could be levied on persons not ordinarily resident in Great Britain…No such regulations however have been made.Powers exist under the Immigration Act 1971 to charge the carrier of a foreign 716 national who has been refused leave to enter the United Kingdom for expenses incurred in hospital care. That is particularly relevant if it is not possible for that person to be deported immediately because of his medical condition. How often are those provisions exercised? The guidance from the DHSS suggests that consideration was given to extending those powers but that it was never followed through. Accordingly,the only possible answer is to provide NHS treatment in these cases.A number of people have written to me—and the Minister will doubtless comment on these matters in his reply—with suggestions as to how the problem could be solved. Mention has been made of the medical levy whereby tourists coming into this country pay, say, £10 for six months' emergency cover and of various other schemes involving stamping of passports.
This problem was first brought to my attention purely coincidentally, when my 3-year-old daughter was in hospital, by a friend who was a practising hospital doctor. Since then I have received the most incredible amount of correspondence. I have a file full of letters from doctors, nurses and others working in the National Health Service, all of which draw attention to various abuses that have been brought to their attention. I shall briefly quote some of them.
For example, a doctor in Sheffield writes:I have, however, personal experience of a patient presenting himself at Heathrow from Hong Kong without having had a chest X-ray and was found on X-ray at Heathrow to have open tuberculosis. He was immediately admitted to an NHS hospital, and subsequently treated at great expense for the next two years.Another doctor says in reference to an American tourist:At a dinner party…a guest who loathed 'socialised medicine' did admit that when he crashed his car on the M1 his care at the Luton and Dunstable Hospital was 'great'—yet they never sent him a bill!Another doctor writes:I was closely connected to a situation where a Portuguese resident was brought to this district with serious leg trouble, which I believe was gangrene. He was admitted to the National Health Hospital, locally, had a leg amputation and a temporary artificial leg fitted and duly returned home. Some months later, again he visited this area on holiday and had a final artificial leg fitted, again under the National Health Service.717 Another doctor from Harley Street writes:Two years ago I wrote to the last Minister of Health, and pointed out that certain Language Schools advertised free medical treatment in their brochures, and that 'Tent City in South London told campers that we had a marvellous free health system here.They were therefore not to worry.
That doctor also comments that Britons travelling abroad are charged for treatment. Officially the money can be claimed back, using a form E111, but, as he said:It just isn't worth it. Firstly you only receive a percentage…and secondlyit takes longer than six months to get the money claimed.
I have here a letter from a consultant at the Hospital for Tropical Diseases who has made a great study of this problem. I shall not quote his detailed letter drawing attention to many examples of abuses of the system by tourists, but he says:It is far easier to stay in the U.K. as a sick immigrant than a healthy one. I will send you many case histories.The most incredible example I have is a quote from the Newcastle Morning Herald and Miners' Advocate of Newcastle, New South Wales, Australia. A gentleman who writes regularly in those columns draws attention to a man who had tooth trouble. It was suggested that he hopped on a flight to London, costing him $568, to have his tooth fixed under the National Health Service at an expenditure of some $50, leaving him at least $132 for accommodation and souvenirs from the $750 that he was quoted in Australia. The writer of the column says:That's a good one, eh? Terry, who has British citizenship, thought so too. He's booked himself into a hospital south of London to have the work done next month.Everywhere one looks, there is abuse of the health system. I have written to Ministers in various Departments, who had the grace to comment on a number of the points raised, and I have already mentioned the comments of the Under-Secretary. Many of the questions that I have raised are dealt with in clauses 7, 8 and 9 of the Bill, which amend section 65 of the National Health Service Act 1977.
However, the Bill does not go far enough. The cost is enormous, although it has not been quantified to the extent that I wish. I hope that in Committee 718 the Government will bring forward amendments to deal with these problems. There is need for early action to remedy the clearly unfavourable bias directed at Britons travelling abroad, not to mention the cost to the British taxpayer remaining at home. Greater attention than ever before is being paid to cuts in public expenditure, and in this area of the National Health Service careful scrutiny and fair charges could restore some measure of equity and save money.
I welcome the Bill, particularly clauses 7, 8 and 9. I hope that the Minister will comment on these abuses and the expenditure involved.
§ Mr. Frank Haynes (Ashfield)
Some hon. Members have had experience of the National Health Service. I have carefully read the Bill, and I agree with some measures contained in it.
Since the reorganisation of the National Health Service, I have been saying that we should get rid of area health authorities, which are costing the National Health Service a great deal of money, but the proposals in the Bill do not provide the right answers. Are the Government thinking of merely transferring bodies down to district level, which appears to be the case? I cannot see how else they can do it, unless they are taking a further step to increase unemployment, which has been growing since 3 May, when I became a Member of this House.
I compliment the previous Secretary of State for Social Services, who tried hard to reduce the cost of administering the National Health Service. I am an ex-chairman of a community health council and used regularly to attend the area health authority meetings. Those authorities said that they would see whether they could cut out waste, and the previous Secretary of State suggested about a 5 per cent. reduction over a period. The authority that I attended rejected the proposals entirely, and it was no wonder, because all its members were Conservatives. They rejected the suggestion of cutting out waste in the public sector that this Government are now pushing not only for the Health Service but in other areas. That authority made all sorts of excuses why it could not cut down on manning.
719 I believe that the great man from South Wales who created the National Health Service did so because there was a great need for it and it was necessary to be fair to all. As the years have passed, it has not been fair to all because of the private sector that has grown within the Health Service. I shall give some classic examples of private beds living off the National Health Service.
The original fairness has disappeared and we have inequalities. People have to wait at the end of a long list for service, but if they went to see the consultant privately they could have treatment the following day. I know of a gentleman aged 70 years in my area who needed to see an orthopaedic surgeon, and he waited 42 weeks. When he got there, the surgeon said that he needed an operation on both legs but that he would have to take his turn in a long list unless he was prepared to pay £200, when he could come in in a fortnight. That elderly gentleman knew of an empty bed on a ward and mentioned that fact. He was told by the consultant "I am sorry. We cannot afford to staff it and that is why it is empty." However, for £200 he could have taken that bed, and that is the immoral proposal that is continued in the Bill.
In the future, people will be able to buy their way into receiving medical treatment at the expense of those who cannot pay even more than they do now. Let us remember that not so long ago many people got a great deal of money from the Government at the expense of those who provided it. The same thing will apply. The poorer people will have to wait at the end of the queue for an NHS that is being run down. Make no mistake about it. Money will not be collected from the streets, as is being suggested. The policies of the Secretary of State for Industry have been mentioned a number of times during the debate. Not only will we be faced with raffles, bazaars and jumble sales but we shall need the begging bowl as well to run the NHS. It will be like the 1930s, when unemployed people begged on street corners.
I was on a radio programme last Friday afternoon. The programme received several telephone calls from listeners. One gentleman asked me to men- 720 tion his point if I was called to speak in the debate today. He told me that a consultant had taken out a second mortgage on his house to raise funds for equipment he needs—not a television or curtains, but equipment to provide proper services to patients.
I do not understand the Government's proposals. They will hit at the people who will really feel them—the people Conservative Goverments always hit, those without the necessary finance in their pockets. It is obvious that private beds exist for jumping the queue.
Another representation was made to me by a person who made inquiries about a private operation. He was quoted a figure but could afford to pay only part of the amount. The consultant said, "Okay, three days in the private unit and two days in an NHS bed". That is the sort of fiddle that goes on, and if the Bill passes matters will become a damned sight worse than that.
Reference has been made to the pharmaceutical industry. There is a real problem for the community in a lack of pharmacies. Most of them are private and they are closing down right, left and centre.
Where will the proposals in the Bill take us? The Bill is in the interests of a certain section of the nation and not of us all.
§ Mr. Richard Alexander (Newark)
We must be quite honest and say that the reorganisation of the NHS in 1974 was a disaster and that with hindsight no Government—neither Labour nor Conservative—would do the same again. The NHS became cumbersome and heavily administered, and its patient contact with those in need by those who made the decisions was exactly nil.
I was a member of an area health authority for some years. Without disrespect to my colleagues who worked with me there over the years, I can honestly say that, apart from the time that I spent on the regional economic planning council, my time on the AHA was the least useful that I have spent in several years of public life. Mounds of paper passed to and fro. Structure plans were expensively produced and chewed over while budgets were agonised over. Yet the positive decision-making where 721 patient care could be identified was rare. I hope that I do no injustice to my colleagues on the AHA when I say that.
The amount of paper that was generated was horrific. Few members read it thoroughly, and those who did were not much wiser at the end of the day. The amount of administrative time taken up in preparing the reports was considerable. Here I pay tribute to the work of the administrators in the NHS. It is fashionable to say that the NHS is over-administered—it is. Nevertheless, administrators are carrying out the job that the Government have asked them to do. Most of them spend long hours, often beyond the call of duty, in their thankless jobs. It is the committees and the passing of papers between the RHAs, the AHAs, the CHCs and the DHSS that take up the time of so many of these dedicated men and women.
The proposal to cut out one of the tiers will enable those people to administer more effectively. I hope that the new district health authorities will take over and complement the excellent work of the CHCs. I know of the working of only two CHCs—Bassetlaw and central Nottinghamshire CHCs. The outstanding benefit of the 1974 reorganisation was the formation of the CHCs. Nearly all the members are involved in closely monitoring local services. They do a valuable service by calling attention to the deficiencies that they discover. If, in their new guise as DHAs, we give them power to act as well as comment, we shall have gone a long way towards making patient contact with those who make decisions positive and effective.
The people who are best able to judge local needs will be able to do something about those needs. In addition, they must have the power and the authority to tackle and expose the actions of such militants as are employed in the Service. At the moment, however outrageous may be the actions or behaviour of the militants, the chain of command is so remote that nobody has the effective authority there and then to stand up to those people. Still building on the work of the CHCs, it is essential, when the DHAs are appointed, that the local authority members should be appointed by the local authorities and not by the State and my right hon. Friend the Secretary of State.
722 Fortunately, the old aldermanic system was got rid of in another reorganisation in 1974. In the old days, the hospital management committee was served largely by the most aged alderman—the one with the time to do the job. He was never thought fit to be replaced by a new change of blood. It was a self-perpetuating oligarchy that had little contact with the local community and patient needs. The 1974 reorganisation did away with that.
Above all, the Bill, when enacted, will bring management back into the hospitals. The existing area catering officers, area nursing officers, engineers, and treasurers, to whom any major decision must be referred, will go. The person with authority will be the person at hospital or, at the very least, district health authority level. It will be local control over local issues if the Bill goes through. Do we need regional health authorities? Could they not go while we are about it despite the excellent work done by my hon. Friend the Member for Canterbury (Mr. Crouch)? I have read the minutes of meetings of my regional health authority for some years, and I sometimes wonder whether the journey of those who attended was really necessary. Decisions involving money are made by the Department of Health and Social Security. There is virtually no democratic representation on regional health authorities, so the need for them on democratic grounds has not been made out. Those authorities are merely another tier for passing paper to and fro. Perhaps when the Bill goes to Standing Committee consideration may also be given to phasing out regional health authorities, too.
I make a plea for consideration to be given to the training of more ancillary specialists, who are so vital to the National Health Service. We are short of speech therapists, yet we are producing sociologists, economists and psychologists from our universities. People who want to train for these ancillary specialties find it difficult to get a place to train.
In all seriousness, I say to the House that nothing in the reorganisation of the National Health Service would please the nation and the nursing profession more than if we were to scrap the title "nursing officer" and once more call a hospital matron "matron". It would bring 723 back a human touch to our hospitals, which is what the Bill is all about. I give the Bill a warm welcome.
§ 8.2 pm
§ Dr. Roger Thomas (Carmarthen)
If one is a doctor and a prospective parliamentary candidate, one is lucky to get away at the end of a meeting without being asked for one's views on private medicine. There is no doubt that within the Labour Party, including the Parliamentary Labour Party, there is an emotive objection to, even an abhorrence of, private medicine. It is felt to be distasteful that money can buy preferential treatment. Sometimes money can buy treatment and care for which there are many disturbing delays within the National Health Service. The reaction, at all levels of the Labour Party, of wanting to ban private and independent medicine is a phenomenon that we as a party have to live with and tolerate.
If an individual wishes to spend his own money on the care and health welfare of his family, he should be allowed to do so. However, he should be restrained from pursuing that freedom unless the medical treatment has been provided totally by the private, independent sector and no State facilities have been impinged upon or used to the detriment of similar cases on NHS waiting lists.
As was emphasised during a similar debate in the autumn of 1976, private medicine has often used back-up facilities that were available only within the NHS. There is little evidence to show that such practices are not still as extensive as ever. It would be unfair to say that the majority of consultants are guilty of such practices. Only a minority is involved. However, undoubtedly pressure is used within NHS departments to manipulate waiting lists for essential pathological or radiological treatment. The original consultation is carried out on a strictly private basis, but from that moment things change and there is a fair amount of queue-jumping.
In the autumn of 1976, the present Secretary of State said that there was no support within the NHS unions for removing NHS hospital beds. He suggested that we should wait until the Royal Commission had reported on Health Service finance and manpower. We now know what precious little 724 attention the Minister and his team intend to give to the parts of the Royal Commission report that do not fit snugly into their own future plans for an emasculated NHS.
Major problems confront the NHS and many of the important decisions within it and the main hospitals cannot be remedied unless adequate finance is provided. When I qualified, I served at various hospitals. At the head of the hospital there was a medical person. It would be good for the NHS if a medical person was once again in charge of our district and general hospitals.
Hospital porters who notice consultant surgeons leaving much of the morning's surgical work to an able registrar immediately come to the conclusion that the consultant in question may have left to operate on a private patient elsewhere. I have heard that said often. The truth is that it is only a minority who indulge such dubious practices. However, it gives the whole profession an undeserved reputation.
Twenty-five years in family practice have taught me that, on the whole, the middle classes have received, and will continue to insist they should receive, better and more prompt medical care than the lower classes. It is sad but inevitable that the educated middle classes are often responsible for keeping the primary care team on their mettle. More and more people, when told of long waiting lists, ask why they should pay for private care when they have already paid into the NHS.
The cuts in 1976, which the present Secretary of State described as symptomatic of a system in despair, were not dissimilar to the cuts of 1979. They deserve the same vivid adjectives. I do not see in what subtle way ward closures under a Labour Government lead to low morale and callous unrest while financial restrictions under the Tories are expected to be accepted as part of a belt-tightening exercise that will help to bring us all to our senses.
During the debate on the Health Service in 1976, the term "medical apartheid" was coined. The originator of that phrase thought that the Bill then being debated would bring about dual standards. The hon. Member who used that phrase was three years ahead of his time. It is clauses 7, 8 and 9 of this Bill which 725 possess all the ingredients for bringing about dual standards in the National Health Service.
Even three years ago a vigorous, efficient and well-equipped private sector was being forecast. So was a growth in the methods of providing funds through costly insurance schemes. An increase was also forecast in the extras and perks which come with managerial and similar positions. But dual standards in medical care in this country, predicted three years ago, did not come about. The standards in the overwhelming majority of our hospitals, be they acute, general, community-oriented, chronic or geriatric, have been stoutly maintained and the better type of medical attendants, from consultants down to unqualified personnel, have not deserted the Health Service for the predicted greener and more lucrative pastures of private medicine.
The British Medical Association waited long and patiently for the return of the Tory Government. The gestation period has been only eight months and the end product has been an acute disappointment to the BMA. This month's "News Review" emphasises that the present draconian cuts do little to dispel anxiety. They are producing a lack of confidence and a feeling of fear among members of the general public.
In reality, the National Health Service has never been adequately financed, particularly in relation to building capital. But now cash limits are affecting the running costs, with the non-productive administrative sectors tending to run riot. Unfortunately, staff care is standing still.
For these reasons, I strongly oppose the Bill.
§ Mr. Allan Stewart (Renfrewshire, East)
I wish to make a general point about part I of the Bill and then comment on clause 10. On part I, it is recognised on all sides of the House that there is widespread dissatisfaction with the present administrative structure. It is costly, and there are criticisms about its bureaucracy and delays in decision-making. However, I do not believe that structural changes in themselves, such as the elimination of one tier—however desirable that may be—will solve the deep-seated problems of management and resource utilisa- 726 tion in the NHS. At present there is something of a crisis of morale among the front-line troops—nurses and the doctors—about the effect on them of the bureacracy.
I draw to the Minister's attention a recent series of articles and comments in the British Medical Journal. A consultant pathologist claims that there is too much so-called democracy in the National Health Service which is causing major problems. He says that hardly any decisions, even comparatively trivial ones, can be made without reference to the recommendations of umpteen committees. A nursing officer writes about carelessness, wastefulness and irresponsibility, all of which have increased. According to a consultant physician, every department in his hospital is overstaffed and he spends half his time on administrative work. His feelings have not been helped by the discovery about his cleaners. For many years he had one cleaner to clean his room. Now he has two, one for the windows and one for the doors. However, there is a demarcation dispute and no one actually cleans his window sills. His feelings were not helped either when he discovered that there was to be a training school for cleaners and that a room was to be set aside, filled with rows of unconnected lavatories and strips of different kinds of carpet. Teaching staff were to be allocated. The mind boggles at the thought of trainee cleaners pushing brushes up and down lavatory pans under skilled supervision. This is perhaps a trivial problem, but it exemplifies a serious crisis. There is a lot of qualitative evidence that resources are not being utilised effectively and that there is a serious crisis of morale among the frontline staff.
I comment briefly on clause 10. Opening the debate, the Secretary of State put both the philosophical and practical cases for the independent private sector. This has expanded enormously from 500,000 in the mid-1950s to 2.5 million now. I believe that it will continue to expand. Labour Members talk about the adequacy of resources for the NHS, but there is a fundamental problem that, in a service that is substantially one of zero price, demand will inevitably exceed supply. No Government, however sympathetic, will ever supply sufficient resources to meet all possible demands.
727 Also, the private sector is helpful as an indicator of patients' needs. As the Royal Commission said, the private sector probably responds much more directly to patients' demands for service than the NHS. Therefore, the private sector provided a useful pointer to areas in which the NHS was defective.
On the provisions in clause 10, there is a case in theory for asking why there should be any restrictions at all on the private sector. The point made by my hon. Friend the Member for Somerset, North (Mr. Dean) is important. On practical grounds, the magic figure of 120 may be insufficiently flexible. I hope that it can be looked at again, particularly as different considerations may apply in different parts of the country.
Of course the private sector has a limited role, but I hope that it will expand, not only in London but in the regions. We have some excellent facilities already in Scotland. I hope that eventually Labour Members and the TUC will recognise practical reality and realise that an increase in the demand for private medical services is inevitable and that the private sector has a small but important and effective part to play in the total provision of health services in this country.
§ Mr. William Hamilton (Fife, Central)
The hon. Member for Renfrewshire, East (Mr. Stewart) represents, as I do, a Scottish constituency. I hope that, with me, he will object to the way in which Scotland has been hooked into this Bill. The Scottish Health Service is differently organised—we have our own separate legislation and our own problems. We have very little private health provision in Scotland compared with England. As a result of this linking, we will be lucky to have more than one Scottish Labour Member on the Standing Committee on the Bill. In view of the fact that we took more than 40 seats out of 70 in Scotland in the election, this is an insult to the Scottish Labour movement generally and it will not be appreciated.
It is humbug for the Government to pretend that the purposes of the Bill are to benefit the patient. To link the Bill with the White Paper on patients, as it 728 the sole objective of the legislation was to benefit those patients exclusively, is utter nonsense. Indeed, the Bill hardly touches on the fundamental problems of the Health Service. Indeed, it will probably make them worse.
The Minister referred in a fairly superficial manner to the key clause in the Bill—clause 5, which deals with cash limits. It is clear that the Government will slow down the development of the Health Service. It has been slow in developing for long enough. In fact, the basic difficulty over the last few years has been the eroding effect of inflation and the very poor performance of the economy as a whole. The Bill does absolutely nothing to tackle the fundamental problems. The Health Service will suffer equally with, or to a greater extent than, the other social services from the public expenditure cuts imposed by the Government.
The main purposes of the Bill are, first, to undo the damage done to the administration machinery by the previous Tory Government. We welcome that as far as it goes, but it needs careful consideration in Committee. Secondly, it seeks to switch limited resources—personnel and finance—increasingly to the private sector of medicine. Thirdly, it proposes to freeze or reduce the resources available to the National Health Service from national taxation.
The detailed provisions of the Bill are properly dealt with in Committee. I shall make two or three general propositions that will not meet with the approval of the Government, but I believe that it is important to state them. First, medical facilities should be provided for all sections of the community on the exclusive basis of need and not greed. Secondly, the element of competitive rivalry is incompatible with health care. Above all, the law of the market place must not be allowed to govern the quality of the Health Service.
The main case against private medicine is fundamentally one of political morality. That was the basis on which Nye Bevan acted when the Health Service was introduced, and that basis has been steadily eroded by successive Governments. It is precisely because we still live in a predominantly capitalist society, in which the market place is sovereign, that we hold strongly that the Socialist oasis—that is 729 what the Health Service is—must be safeguarded from the ravages of cruel and heartless market forces.
We are told repeatedly that the role of the private sector in medical care is a minor one. Whenever there is a scandal, we are told to forget about it because the private sector is too small. The size and scope of the private sector in health provision is a threat to the egalitarian, humane nature of the Health Service. The greatest danger to our health comes from the intrusion of the market place and the profit motive—whether it be drugs or private medicine. The hon. Member for Preston, North (Mr. Atkins) spoke of those who came to Britain and filched services from the Health Service. That is grossly exaggerated. I hope that the Minister, either today or in Committee, will give details. It is a grossly exaggerated abuse. It is on a smaller scale than the scandals exposed in the report produced some years ago by my hon. Friend the Member for Wolverhampton, North-East (Mrs. Short) on the private sector of the Health Service, where evidence was given of consultants and surgeons taking on loan expensive equipment from the Health Service and forgetting to return it. If we are to talk of scandals and waste, that side of it must also be considered. It is also known that private patients are jumping the queues and refusing to pay their bills. Hundreds of thousands of pounds are outstanding in bad debts.
The Government gave hand-outs to the wealthy section of the community in the June Budget. They are finding now that they must retrieve that money through higher prescription charges and a reduced quality of service in the National Health Service. They say that people prefer to have money in their pockets to spend in their own way. If they wish to spend money on health, why should they not? They might spend more money on tins of pork, or whatever. That is the thinking that governs the Government's actions.
To reduce that to an absurdity, we have what I call the flag day and raffles clause. The mind boggles. The title of the clause is:Power of health authorities, etc. to raise money, etc., by appeals, collections, etc.That might mean that the nurses could make jam and sell it at the entrance to 730 the wards. When the visitors are round the beds, they might hand out raffle tickets. There is no reason why the nurses should not run a football pool.
That sort of behaviour is completely alien to the fundamental principles on which the National Health Service was built. It shows the contempt of the Tory Party for those principles. It believes that the market place can solve the problems of the National Health Service.
Some years ago, the present Secretary of State for Industry said that we should have two Health Services, one to deal with the mentally ill and the geriatrics and the other in the private sector dealing with the more sophisticated and romantic problems, such as heart transplants. The Tory Government stand for first and second-class citizens, and that is why we shall oppose the Bill tooth and nail in Committee.
§ Mr. David Atkinson (Bournemouth, East)
I welcome the Bill and believe that it is in the best interests of all who are concerned with the National Health Service, not least the patients, the professional staff and the taxpayer.
I refer to three aspects of the Bill. The first is the proposed structural reorganisation referred to in the consultative document. From the debate this evening there appears to exist a widespread acceptance of the elimination of the area tier. It has proved to be too remote and to have encouraged the practice of buck-passing between various tiers—district, area and regional—and in consequence an avoidance of responsibility.
The Bill suggests the emergence of a new, dynamic, powerful district authority with a membership reduced to around 20. It will have its work cut out if it wishes to be aware of and to satisfy local needs in the Health Service. It will mean full-time members, especially those who are already members of local authorities, and others with another job. I hope that they will be adequately compensated for loss of earnings. Perhaps my hon. Friend the Minister will refer to that aspect in his reply.
Paragraph 23 of the consultative document refers to four local authority members representing the district authority. I echo the remark of the right hon. Member for Salford, West (Mr. Orme) 731 when he asked "Is that enough?" I also pose that question. Considering that the new district health authorities will probably cover a number of district councils as well as the social service authority, which is the county council, will four local authority representatives be enough?
Paragraph 24 refers to retaining joint consultative committees. That is a reference to bringing together representatives of the social service authorities and the health authority. The terms of reference will prove to be all-important to the success or otherwise of the new joint consultative committees. The terms of reference should ensure the avoidance of talking shop committees, ivory towers, or semi-prestigious bodies for long-service worthies, as has often been the case in the past. They should be unique representative bodies concerned with health in the widest sense in the area with which they are concerned.
We should recognise—it is no secret—that doctors have resented the establishment of separate social service authorities following the Seebohm recommendations in the early 1970s. We must recognise that on the part of general practitioners there exists widespread suspicion and dissatisfaction with social service departments. They feel—I do not necessarily share their feelings—that there is too much talk in the social service departments, too much desk work, too many case conferences and not enough field work in support of patients. The new joint consultative committees should recognise that. They should work towards a closer relationship between the general practitioner and the social services department.
A suggestion that has been made on a number of occasions in the past is that each general practice should have attached to it its own social worker under the direction of the doctor.
Paragraph 26 of the consultative document refers to the future of the community councils. As a past member of a community health council, I believe that such bodies have a useful role to play in highlighting the shortcomings of the Health Service in the areas that they represent and in voicing the complaints of patients.
732 The Community Councils represent good value for the £4 million that is spent annually on their behalf. They should remain—at least for the time being—until the new district health authorities have gained experience, bearing in mind that they will include local authority councillors, who in due course may find that they can replace the community health councils by taking up the complaints of patients and voicing the views of the local community.
I turn to the part of the Bill that is concerned with the financing of the NHS. It is the part which is aimed at reversing the previous Government's policy of phasing out pay beds and private practice generally. We must recognise a number of factors. First, the NHS has suffered from a serious underfunding for a number of years. It will continue so to suffer. If the Government mean what they say and are determined that there have to be more public expenditure cuts, the NHS should not be excluded from these cuts. We cannot look to other countries to continue to pay for our National Health Service. We must look to the private sector to help to fund any expansion of the NHS if expansion is to take place.
We must also recognise that attitudes have changed towards the NHS. When the Beveridge proposals were first introduced, they were based on conditions in the 1930s. They were implemented by Bevan in the 1940s. They may not necessarily be what people want in the 1980s, nearly 50 years later. I understand that the Labour Party is to include in its new song book the song entitled "Times they are a-changing". That is a theme that we need to apply to the NHS.
The Government's annual publication "Social Trends" indicates that people are better clothed, better housed and better fed than they were 30 years ago. Real personal disposable income has doubled in that time. People want the right to choose between providing for the health needs of their family and spending their money on other things—holidays, a new television set, a new car, bingo, and so on.
§ Mr. Atkinson
I have not said that. They also want a choice between a "free" National Health Service, paid for by the taxpayers themselves, and a better service, for which they are prepared to pay extra, over and above the taxes they pay. That has been borne out—as my right hon. Friend the Secretary of State said in opening the debate—by successive opinion polls.
Recently, I conducted a poll of opinion in my constituency, using my local Young Conservative organisation. We polled 855 people whose views would apply nationally as well as locally. We put the question "Should the Government encourage people to supplement the National Health Service by providing health schemes?" Five hundred and ten people—approximately 60 per cent.—said "Yes."
Our National Health Service was once the best in the world. Now, as stated by the Royal Commission, it is no longer the envy of the world. In many ways we have been overtaken by other European 734 countries, which rely partly on private financing and partly on a system whereby a fee is paid.
I welcome the announcement of my right hon. Friend the Secretary of State that a feasibility study of a State health insurance system is to be set up. I hope that the Bill will herald the start of a greater contribution to the National Health Service from the private sector than ever before, by offering incentives—perhaps in the form of tax relief—for the acceptance of greater responsibility. In that way, everyone wins. People who insure against illness, the so-called private patients, will get what they pay for—a better service. The National Health Service patient will get a better deal, because he will benefit from a better-funded Service.
I turn, finally, to the matter of a better relationship—
§ Mr. Deputy Speaker (Mr. Bernard Weatherill)
I must tell the hon. Gentleman that he has had his 10 minutes.
§ Mr. Frank McElhone (Glasgow, Queen's Park)
I emulate my hon. Friend the Member for Fife, Central (Mr. Hamilton) in resenting that Scottish health legislation has been lumped into a United Kingdom Bill. The Secretary of State for Social Services is amending, among other Acts, the National Health Service (Scotland) Act 1978. The Government are following the same practice with the education, local government, and industry Bills. I am sure that that will be resented by National Health Service staff in Scotland.
I wish to comment on clauses 3, 4, 8 and 15. In the interests of other hon. Members, I shall be as brief as possible.
Clause 3 covers joint financing between Health Service and local authority social work departments. As I understand, that system is already operating in Scotland. I do not understand the reference to it in clause 3, where it is stated that the "joint financing" arrangements in England and Wales will be statutory. As I understand, that is the case in Scotland. If I am wrong, I hope that the Minister who replies to the debate will correct me. The previous Labour Government provided extra money for local authorities—especially in the Strathclyde region—to finance the building of 30 hospitals for the mentally handicapped. Will the Minister indicate that that will continue, either through increased aid through the Health Service, or through the joint financing experiments practised under the previous Government?
I endorse the resentment expressed by my hon. Friends, especially that of my right hon. Friend the Member for Salford, West (Mr. Orme) of the "flag day" society mentality reflected in clause 4. That will also be resented. I hope that the Bill will be amended to indicate that there will be no compulsion or undue persuasion on the staff—nurses or others—to ensure that they raise funds for health services.
Clause 15 deals with the power to make loans to general practitioners. In what way will this practice be amended? I tell the Minister that in the deprived areas, especially in large housing estates and in some rural parts of Scotland, it is extremely difficult at present to get general practitioners. The main reason is that these areas tend to be those from which 736 the young families have migrated to new towns, so that they are left with the chronically sick, the elderly and the unemployed—the people who most regularly visit the GP's surgery. I hope that the Minister will be able to say that clause 15 will not be amended in a way that will affect the provision of greatly improved facilities in such areas.
If there is any clause in the Bill which makes me feel very angry, it is clause 8, which seeks to amend the National Health Service (Scotland) Act 1978. That Act gave powers to the Secretary of State to allow the use of National Health Service accommodation and services for the treatment privately of patients. I tell the Minister that in my constituency, in the Victoria infirmary on the south side of Glasgow, and the related hospital in Mearnskirk, there has for a long time been a long waiting list, especially for orthopaedic surgery. Some old people in my constituency are suffering grievously from severe arthritis and rheumatic diseases. They are trapped in their homes. However, anyone who has the money can see certain consultants privately in their homes and surgeries, thereby jumping the queue. Clause 8 will be welcomed by that minority. I am second to none in my admiration of the doctors in the Victoria infirmary and in all other hospitals in Scotland, but a small minority of doctors are waxing rich, notwithstanding the misery of the poor people who cannot afford to pay substantial fees for private treatment.
This is a bad Bill. It is a re-enactment of Cronin's book "The Citadel" and all the misery that was endured in the 1930s by the poor and deprived people in my constituency and in the rest of Scotland. It will be opposed with all the force that the Opposition can command, and I hope that it will be rejected.
§ Mrs. Elaine Kellett-Bowman (Lancaster)
I have the honour to represent a city which has for centuries been the focal point of medical care for a very wide area of north Lancashire, spilling over into Cumbria. It is no exaggeration to call ours a hospital city, since the National Health Service is the largest employer of men and women alike, and service often goes on in an unbroken line from generation to generation. It may well be that it is for this reason that 737 industrial relations in our hospitals are extremely good.
We were fortunate in obtaining a new maternity unit three years ago. Within the money available, our structure is sound, and very old-fashioned mental and subnormality hospitals are being steadily brought up to date. Large wards are being subdivided, antiquated toilet and bath facilities are being updated, and facilities are being provided for the basic domestic and industrial training for the mentally subnormal who can, with such training, go out into the community. I was talking to a number of such people the other day. As low-dependency mentally subnormal patients, they are already going out to do part-time work.
But, like other health authorities, we could always do with more money. The planning of improvements is very carefully phased, but clearly, if more money were available, modernisation plans would be speeded up. We desperately need a new theatre suite at the Royal Lancaster infirmary. Proposals for this were agreed two years ago, but the money has not been available, and the work is not now expected to be completed until 1987. Clearly, if more money were available, that date could be brought forward or temporary improvements effected.
That is why I welcome the provisions in the Bill to enable local health authorities to raise their own funds and to put them to whatever purposes they choose. I am not suggesting that they could raise enough money for the full scheme, but they might very well raise enough to provide temporary facilities which would tide us over until the full scheme is completed.
I also welcome the reversal of the Labour Government's determination to get rid of pay beds in National Health Service hospitals. My constituency is by no means a wealthy area. There will never be a demand for private beds comparable with that in the South-East. But, even in Lancaster, the phasing out of pay beds will cost about £60,000.
The question of private medicine goes beyond that issue. On a national basis, no less than £30 million comes from pay 738 bed revenue. We in the North-West have long complained that the amount spent on health care has been consistently lower than that spent in the South-East. Every pound that is spent on private health care in the wealthier South-East reduces the demands on the National Health Service funds and leaves more for less wealthy areas such as the North-West.
There is clear and growing demand for private medical treatment. There has been an increase in the number in private health insurance from 500,000 in 1955 to nearly 2.5 million in 1978. The number is going up at an accelerating rate all the time. It is a demand that is not by any means confined, as Opposition Members would like to imply, to the rich. Trade unions are increasingly including private health treatment in their pay bargaining. Shop stewards, members of the Transport and General Workers Union, negotiated private medical treatment for their 1,300 members at Bass Mitchell's, while 40,000 members of the Electrical, Electronic, Telecommunication and Plumbing Union, under the enlightened and modern leadership of Mr. Chapple, did likewise.
Private medical treatment provides easily the biggest potential input of funds to health care and the best way of reducing waiting lists. I agree with my hon. Friend the Member for Peterborough (Dr. Mawhinney) that putting beds into cottage hospitals may save some of these popular places from closure, as could the raising of funds by people who wish to keep open a small hospital, as suggested by the Secretary of State in his speech.
It is an interesting fact that the most consistently Socialist state in the Western world, Sweden, forbids private beds outside public hospitals so that doctors do not waste time travelling from one hospital to another.
It is absurd for the hon. Member for Brent, South (Mr. Pavitt) to describe the Bill as a queue-jumpers' charter. National Health hospital waiting lists will continue to be common. But encouragement of the growth of private hospitals, particularly as they have agreed to play their part in nurse training, will take potential patients off the waiting lists, which grew by 250,000 under Labour, the largest 739 increase in our history. This is, indeed, cruel and heartless, to quote the hon. Member for Fife, Central (Mr. Hamilton).
§ Mr. D. N. Campbell-Savours (Workington)
On a point of order, Mr. Deputy Speaker. Is it in order for an hon. Member to read speeches to the House?
§ Mr. Deputy Speaker
Order. I am dealing with a point of order. It is not in order for hon. Members to read speeches. It is in order for hon. Members to make liberal use of notes but not to read absolutely from them.
§ Mrs. Kellett-Bowman
This is the only way in which hon. Members can keep within the time allotted. I am seeking to do that for the benefit of Opposition Members, some of whom rarely join in debates, particularly those affecting their own areas.
It is cruel and heartless that waiting lists should have gone up by 250,000, or no less than 50 per cent., under Labour.
Clauses 1 and 2 confer on the Secretary of State the power to make changes in the structure of the National Health Service. But the Secretary of State has stated categorically that this will not prejudge consultation on the consultative document "Patients First", an excellent document which I trust all hon. Members have read. The document emphasises that people, not organisations, should be responsible for the care and cure of patients. There is no rigid blueprint that will serve for all time. Flexibility is vital, nowhere more so than in that part of the world from which I come, where patient flows cross county boundaries.
That is an argument for another day. For the present, I welcome the Bill. It will expedite decision-taking and give back the degree of flexibility to the Health Service that it lacks.
§ Mr. Alfred Dubs (Battersea South)
The Bill will do nothing about the main weakness affecting the National Health Service, because successive Governments have starved it of funds. We are getting a National Heatlh Service on the cheap. From the Royal Commission's report we see that, whether looked at in terms of 740 expenditure per head or as a percentage of gross domestic product, we are near the bottom of the league. We are endeavouring to get too much out of too small a pot. The Government's suggestion that devices that I remember from my childhood, such as a hospital Saturday fund, will help to correct the problem is completely misconceived.
I regret that the debate on the Royal Commission's report and on "Patients First" is to be held in the new year. It would seem logical to debate those two documents before the Second Reading of the Bill.
I turn briefly to the question of democracy in the Health Service, because it is fundamental to those two documents and to the Bill. I was for some time a local council member of an area health authority. In "Patients First" the Government talk about the balance of district health authority members appointed by regional health authorities for the individual contributions that they can make. I question whether it is valid to have the NHS run by people who make only individual contributions. In my experience, almost all decisions that were taken on the area health authority on which I served had to reconcile conflicting interests and pressures. People representing different areas—be they local councillors, doctors or nurses—were accountable to some group within the area health authority. But individual members accountable to no one had no place there, because they could take no sensible part in decisions and in trying to balance conflicting interests. They were not accountable to anybody in the sense that, as a councillor, I always felt that I was answerable to my constituents for the decisions that I made on the area health authority.
If our National Health Service is to be improved, the key decision is one of democracy and accountability, not a matter of reducing the democratic element by cutting down the numbers of councillors and talking only of members who serve as individuals.
I wonder about the motives of those who want to go into private practice and of those who argue for these clauses in the Bill. The motive, first and foremost, seems to be money. Doctors want more money and the institutions that provide the basic services for private practice are also after money.
741 What are the patients after? I suggest that the majority want quicker treatment or to have treatment when it suits them, never mind others who are waiting for NHS treatment.
Those motives are reprehensible and damaging to what the NHS was set up to achieve and is about. Thus, the Opposition reject them utterly.
Several hon. Members referred to public opinion polls as evidence that people want private practice. It depends on how the question is phrased. If one asks "Do you think that more private medical care would not be a bad thing?" most people will probably say "Yes". If the question is put in real terms "Do you think that an expansion of private practice is desirable, even if it means, as inevitably it will, damaging the National Health Service?" I suggest that most people will say "No". That is the only honest way to put the question.
About 60 per cent. of NHS expenditure goes on children, the elderly, the mentally ill and the handicapped. Not many private health schemes cover those groups. The private schemes take the fashionable, the easy, acute illnesses, and seek to leave to the NHS those groups of people who are most vulnerable and in need of real help. Therefore, those who argue for an expansion of private practice must do so in the knowledge that they are advocating double standards and do not mind how much damage they do to the basic National Health Service.
The NHS is a compromise in the sense that, when it was started, we had to have some private practice. It is accepted that some private practice exists. The question is to what extent it will expand before it does serious damage to the principle of the NHS. This Bill encourages that sort of damage.
Though some parts of the Bill are unwelcome, the suggestion for a simplified management structure is welcome. But, even when these changes are made, major problems will remain, especially in the London area where the problems of NHS organisation are more complex than elsewhere. What will happen to the postgraduate teaching hospitals? Will they become part of the main system or remain separate so that decisions on medical services will not take their particular activities into account?
742 Will anything be done to compensate for the wrongs done to the undergraduate teaching hospitals which are being deprived of their just share of resources? No formula yet worked out compensates them for the cost of treating the large number of patients taken from areas outside London.
In their consultative document the Government say that they do not intend to change the boundaries of the Thames regional authorities. I regret that. Change there might have made NHS organisational problems in London more manageable.
Various Government documents refer to the difficult problem of links with local authorities. I do not suggest that relations are totally bad or that they do not work at all, but the relationship between the local authorities and the NHS is a particularly difficult one and more thought is required in order to establish better relationships than in the past.
With the exception of the provision for changes in management structures, this is a bad Bill. The Bill's bad features outweigh the good. It represents a backward step for the NHS.
§ Mr. A. P. Costain (Folkestone and Hythe)
I have seldom heard a more inane argument advanced against a Bill than that put forward by the hon. Member for Battersea, South (Mr. Dubs). He seems to object to the fact that money needs to be raised for hospitals. He sees the raising of money as nurses rattling tin cans on street corners. I wish that he would come to my constituency, to Etchinghill hospital. Each year 3,000 local people turn out to support that hospital. It is the event of the year. If I were to say that we were against raising money in this way, local children would be completely disgusted. The annual fund raising for the hospital is an event to which the whole village looks forward. It is looked on as a good afternoon's entertainment and we raise about £3,000.
We made an appeal for the Royal Victoria hospital at Folkestone. One of the nursing sisters there thought that the hospital should have special apparatus to help people suffering from heart disease. Within two days £3,000 was raised.
An hon. Member indicated that money for hospitals could be raised only in rich 743 areas. Let me tell him that the apparatus to which I referred and which cost £4,000 was paid for in two days because the hospital sister went round two of the local establishments, one of which was Dungeness power station. She raised £1,000 in two hours because people like to be associated with raising money for hospitals.
The difference in approach to this question since the Government took office has created a new attitude in the medical profession. Doctors now look forward to co-operating with the Department of Health and Social Security and helping to carry matters forward. They do not look backwards. Opposition Members have not admitted that the hospital service was not up to proper standards when they were in power.
§ Mr. Costain
That is an unfair comment. I have listened to much of the debate. I have been doing other work in the House but I have listened to most hon. Members.
My time is up. I welcome the Bill and look forward to its quick passage through the House.
§ 9 pm
§ Mr. Roland Moyle (Lewisham, East)
I must tell my hon. Friend the Member for Battersea, South (Mr. Dubs) that we accept the Royal Commission's recommendation that there should be an inquiry into the London health service. I hope that the Secretary of State will convey our condolences to the Minister for Health, who has been a vigorous contributor to our debates on the Health Service for many years. We miss him. We wish that he were here tonight, if only to answer for some of his misdeeds. I hope that he will be back with us soon.
The Bill is like the curate's egg—good in parts. Anybody who has ever tried to eat the good parts of a bad egg and leave the bad parts will know that it cannot be done. For that reason we reject the Bill and we shall vote against it.
744 Clause 1 deals with administrative changes in the Health Service. We welcome the opportunities in that clause. Accord between the two sides of the House is greatest on that part of the Bill. I congratulate the Government on their obvious repentance in view of the damage which the right hon. Member for Leeds, North-East (Sir K. Joseph) did to the NHS when he was Secretary of State between 1970 and 1974. We are pleased to see that the Government intend to avoid using management consultants. I congratulate the Government on following the Royal Commission's recommendations on advice.
I note in passing that the right hon. Member for Leeds, North-East plans to bring to the leadership of Rolls-Royce the personal qualities that he brought to the leadership of the National Health Service. As an ex-Health Minister I wish Rolls-Royce the best of British luck.
I commend the Royal Commission's report to the Secretary of State almost in its entirety. That view will emerge even more strongly when we debate the report. I urge the Secretary of State to follow that report wherever possible. If he does that, he will not go far wrong. However, clause 1 does not reorganise the National Health Service. It merely provides the opportunity to reorganise it. The administrative principles set out in "Patients First" appear to be sound, and the idea of substituting district health authorities for a general tier of area health authorities is sound. However, we shall watch the way in which the Secretary of State carries out the reorganisation because his party's track record on reorganisations, particularly of water, local authorities and health services, is not particularly good.
The hon. Member for Devizes (Mr. Morrison) and Newark (Mr. Alexander) made a number of helpful suggestions about the way in which the reorganisation might be carried out and the problems that must be faced. Those suggestions should be considered. My right hon. and hon. Friends will fight hard for the retention of the community health councils. I was glad to see that many Tory Members supported that view.
I wish to make one or two comments on the reorganisation. The Minister for Health thinks that reorganisation will save the Health Service £30 million over 745 two years. That is the original figure. My hon. Friend the Member for Brent, South (Mr. Pavitt) is too generous in saying that it will save 0.3 per cent. of the Health Service budget in each of those years. It will save only 0.15 per cent. of the budget. In times past the record of Conservative Governments has been that their reorganisations have cost money—not saved it.
§ Mr. Patrick Jenkin
May I make clear what is the figure of £30 million? This is a target saving that represents approximately 10 per cent. of the present administrative costs of the National Health Service. We have set ourselves that target. Subject to consultation and acceptance of the proposals, we shall seek to enforce it on the Health Service—but not over two years. It is difficult to put a time scale on it. We hope that that will be achieved when the simplification of the structure and the tightening of the management have been completed and given a chance to work.
§ Mr. Moyle
In that case even my estimate of 0.15 per cent. of the health budget saved per year will be a gross overestimate of the savings.
The argument for reorganising the Health Service is based on the introduction of flexibility, simplicity and decentralisation. At the end of the day, I doubt very much whether anyone in the National Health Service will notice any financial saving.
On the subject of the family practitioners committees, the Secretary of State, having started by accepting the recommendations of the Royal Commission on the National Health Service, has now tended to backtrack. However, I am pleased that everything in the consultative document is up for discussion and possible decision thereafter, as the Minister makes a pretty strong case for those committees. That is in direct contrast to what the Royal Commission said. At paragraph 20.57, page 327, it said:We recommend the abolition of FPCs in England and Wales and the assumption of their functions by health authorities as a step towards integration.It thought that family practitioner committees were an obstacle to health authorities from the point of view of influencing the distribution and quality of surgeries, achieving a balance between 746 hospital and community care, moving staff across institutional boundaries. It noted that family practitioner committees were superflous in Scotland and Northern Ireland. As a Minister who held some responsibility for Northern Ireland, I found that in no way were the family practitioner services there inferior to those in England and Wales.
We oppose the Bill and the consultative document that strengthens it. With the benefit of only six months' office, and without public discussion, the Government are giving the impression of supinely deciding to nail their colours to the family practitioner committee mast. I am glad that this afternoon the Secretary of State was able to resile a little from that.
I should like to know why joint finance is being made legal under clause 3. We never felt the need to do that. The Royal Commission never recommended it. It seems to be a bit superfluous.
I should very much like to know why the General Practice Finance Corporation is being given powers to lease premises. I am worried that that may lead to an even greater weakening of control by health authorities over the family practitioner services. I should like that query cleared up.
We shall raise other issues in Committee. We shall probe them, so I shall not mention them here. I pass on to some of the more contentious clauses. Clause 4 is certainly one of those.
My right hon. Friend the Member for Salford, West (Mr. Orme), along with many of my hon. Friends, has given voice to the deep sense of moral indignation over the idea of a Government trying to ensure that a substantial portion of Health Service money is raised in these haphazard fashions. It is a very badly conceived clause. We are not talking about extra money for the Health Service raised by voluntary local effort, as I understand it, but about a substantial contribution to the funding of the National Health Service, because the appropriate provisions already exist for the kind of thing that the hon. Member for Folkestone and Hythe (Mr. Costain) was talking about; that is an irrelevance.
The only assumption that we can make is that Tory Members are thinking that a large portion of the NHS budget will 747 come into the National Health Service by these various nefarious means. Quite simply, it means first, that the richer the area, the more money it will raise and the poorer the area, the less money it will raise. In London they will be going down to their friends in the City and raising their £250,000 without any trouble, to add to the substantial, well-equipped teaching and postgraduate hospitals that already exist there. In Sandwell they will have nurses standing on the street corners hoping with a bit of luck to be able to raise £500. That is not good enough.
This provision will increase the geographical distortion which is already one of the major problems of the Health Service. It will lead to the public going, as is always the practice, for the glamorous acute medicine sector of the NHS, the kidney machines, the EMI-scanners and things of that kind which will attract the money, but not enough to meet the running costs of those things. That will not be glamorous enough. One cannot very easily organise an appeal on that. It will be the geriatrics, the mentally handicapped and others of that kind who will be neglected.
Finally, the object of this clause is presented as a way of raising more money for the National Health Service. My right hon. Friend the Member for Norwich, North (Mr. Ennals) hit that firmly on the head, because, as the right hon. Gentleman should know better than anybody, the moment that the Treasury realises that substantial sums of money are being raised for the Health Service by these means, at that stage not just a sharp Chancellor of the Exchequer but any Chancellor of the Exchequer will start cutting the central subvention to the NHS. That will be the position. There is no way in which this clause will raise more money for the NHS. All it will do will be to raise the money in a more haphazard, more erratic and less just manner than that in which it is raised now.
We turn to the clause on statutory cash limits—because that is what it deals with. It seems to me to be a ridiculous clause. It converts an administrative tool into a centralised, legal, rigid despotism. The Secretary of State, during all the time he was in Opposition, during the General Election and in his early months in 748 office, stood before the public and the House talking of the need to decentralise decision-making. What he does is come to the House on joint financing and cash limits and impose rigid shackles from the centre on every health authority in the country. That strikes me as being a direct contradiction of all things that he said in Opposition and in his earlier week in office. My right hon. Friend the Member for Norwich, North and myself managed to run the system even under the ramshackle regime of the right hon. Member for Leeds, North-East without the assistance of these draconian measures and I see no need for anything of this kind.
Now we turn to what the right hon. Gentleman has made the central part of his Bill. Others may think that he might have made reorganisation the central part. There are far more benefits to be obtained from that course than from that upon which he is embarked; but it was a press statement from the right hon. Gentleman's own Department when the Bill was published which started it. The statement said:Health Services Bill fulfils pledge on private practice".That is supposed to be the central feature of this Bill. Therefore, the right hon. Gentleman must not complain if that is where we mount our greatest opposition to the Bill. We on this side of the House have a totally different moral approach to the Health Service from that of Tory Members.
If ever we want a clear, pristine comment on the philosophy of the Conservative Party, without any shilly-shallying and with great integrity, we can always rely upon the hon. and learned Member for Beaconsfield (Mr. Bell), who during the debate in 1976 said about our Bill:The Bill circumscribes how people may offer their services and how other people may buy them."—[Official Report, 27 April 1976; Vol. 910, c. 260.]I commend that as a clear statement of the philosophy of the Government and their supporters in these matters. It puts the consultant who offers his services to cure human bodies in exactly the same position as the auctioneer who offers his services to buy and sell cattle in the market place. There is no difference at all. I could reduce it even from that to colour television 749 sets, bingo, champagne bottles and the rest. It is the philosophy of the market place.
Many of my hon. Friends, including my hon. Friends the Members for Fife, Central (Mr. Hamilton), Carmarthen (Dr. Thomas) and Brent, South, referred to that moral difference. We believe that it is not right for a person's medical care to be at the mercy of the fees that he pays. Neither should a person have his medical care postponed because another person pays for his. Broadly speaking, that is the position that we take.
Most of the consultants in the hospitals declare that they treat their NHS patients in exactly the same manner as they treat their private patients. I personally believe that. If one wants privacy on the NHS, one can get it by going to an amenity bed. Therefore, the only justification for the private bed is that of queue-jumping. That problem will not be solved by the six principles enunciated by the right hon. Gentleman this afternoon.
One of the significant omissions from those six principles was the recommendation of the Health Services Board that social factors should be taken into account in compiling the common waiting lists. Nowhere was that mentioned in any of the six principles. The inclusion of the word "significant" in the first principle was a worrying introduction from our point of view.
§ Mr. Patrick Jenkin
I am surprised that the right hon. Gentleman should say that, because it is taken exactly and precisely from the legislation that was put on the statute book in the previous Parliament.
§ Mr. Moyle
There was no legislation on common waiting lists in the previous Parliament. There was a provision that the Health Services Board should report on the introduction of such matters, and we started discussions. The conclusion of those discussions was left to the right hon. Gentleman, and unless closer examination reveals something that I have missed, he has not produced a solution this afternoon.
§ Mr. Patrick Jenkin
The right hon. Gentleman cannot get away with that. If he says that the word "significant" is the thing that causes him the greatest anxiety, he must know that section 62 of the 750 National Health Services Act 1977 contains the phrase:will not to a significant extent interfere with the performance by him of any duty imposed on him by this Act to provide accommodation or services of any kind".
§ Mr. Moyle
That is in a totally different context from the six principles that the right hon. Gentleman enunciated this afternoon. The inclusion of the word "significant" in the first principle renders null and void all the other principles. For that reason, we do not think that that is a solution.
What has happened is that the right hon. Gentleman has resurrected a dead controversy. There has been peace—
§ Mr. Ennals
If the purport of the six principles is to ensure that there is no difference whatever between the private patient and the public patient, no one would ever again need to go private. Therefore, does not my hon. Friend agree that there must be some snag, be it the word that he chose or some other word?
§ Mr. Moyle
I think that we can leave this matter at that point and press on.
I agree with my right hon. Friend the Member for Norwich, North that there has been peace on this issue ever since the 1976 Act was placed on the statute book, in spite of the fact that 2,000 private beds have disappeared from the Health Service during that time. Together with the hon. Member for Berwick-upon-Tweed we are worried about what will happen now that the Health Services Board has gone. I pay tribute to the board and its work. That board combined some disparate elements but produced good team work and presided with judicious balance over the phasing out of more than 2,000private beds—1,000 beds under the Act and 1,000 beforehand.
It is unusual for a member of one party to pay tribute to a politician of another party, but I pay tribute to Lord Wigoder, the chairman of the Health Services Board, for making such a contribution to the exercise. Of course, he is a Liberal Whip in another place, but he made an outstanding contribution. Who will now stand between private hospital development and the interests of the National Health Service? There is no doubt that a top limit of 125 beds in the NHS is more likely to cause damage to the 751 interests of the National Health Service than the limit imposed in our Bill.
The first port of call when a private project is recommended is the area health authority. The area health authority is the one body that resists the development of private practice and private hospitals more than anything else. Therefore, the private sector will not regard area health authorities as impartial. But appeal will lie to the Secretary of State.
By introducing this Bill, which allows for greater expansion of private medicine, particularly in the NHS, the Secretary of State will have deprived himself of any right to say that he is impartial. The introduction of the Bill removes that possibility. What happened to all the practical arguments that Conservative Members used against the introduction of our Bill in 1976? I have been studying some of the speeches that were made at that time. In that debate the present Secretary of State said:This absurd policy will cost £40 million to £50 million".Of course, it has cost nothing like that. We are now in possession of the figures, and it has cost a loss of only £5.8 million in charges. If the Secretary of State looks at the answers given by his hon. Friend the Minister for Health he will see that that figure must be reduced by the redeployment of the resources from the private sector into the National Health Service. That is an offsetting factor that is difficult to calculate. Therefore, the Secretary of State was wrong.
§ Mr. Patrick Jenkin
The right hon. Member is playing with words and figures. If his policy had been as successful as he tried to pretend to his hon. Friends, and if all the beds that were supposed to go had gone, there would have been a further loss of £30 million. If he phased out the pay beds, he would lose that.
§ Mr. Moyle
The Minister for Health has said that the figure was £31 million and that must be reduced by the reallocation of resources from the private sector into the National Health Service. Therefore, the right hon. Gentleman's calculations in 1976 were wildly out. During the 1976 debate, the right hon. Gentleman went on to say:if pay beds go and the consultants who wish to continue to take advantage of the private practice undertaking are forced to divide their 752 time between two locations, some of the most distinguished will leave the NHS altogether and cease to be available for NHS patients.However, on 30 September 1975 there were 30,503 doctors employed in hospitals in England and Wales. Last 30 September that figure was 33,275. There has been an increase of medical input into the National Health Service.
During that debate the Secretary of State also said:Not only patients but medical education will be affected".I sought aid from the Under-Secretary of State for Education and Science, the hon. Member for Brent, North (Dr. Boyson), who has some responsibility for these matters these days. He told me that in 1975–76 there were only 3,786 full-time academic staff in our medical schools. In 1977–78, two years after the passage of the Bill, that figure had risen to 4,240, an increase approaching 500. Medical education was not affected either.
I said that I was sorry that the Minister for Health was not with us. He envisaged a flight of the swallows—a departure of everybody to the rest of the Common Market after the Bill had been passed. He said:In a year or two when we get the figures, we shall be wringing our hands in distress.We now have those figures. In 1977, 117 doctors applied for authorisation to practise in Europe and in 1978 the figure was 134, which is approximately one-third of 1 per cent. of all the doctors in hospitals in England and Wales. However, even if they were authorised to go, it does not mean that they went, and even if they went it does not mean that they did not come back. We are therefore talking about the largest possible figure.
The right hon. Gentleman, in his 1976 speech, added: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.The first thing that he does, however, when he gets the initiative is to compound the passion, time and effort by introducing a Bill that forces us to go back over the same ground.
That is strange, and it is even stranger because his plea was:I am saying that we should withdraw the Bill and refer the matter to the Royal Commission."—[Official Report, 27 April 1976; Vol. 109, c. 218–319.]753 The Royal Commission's advice is now available, and it says:From the point of view of the National Health Service the main importance of pay beds lies in the passions aroused and the consequential dislocation of work which then occurs. The establishment of a Health Services Board led to a welcome respite from discussions on this emotional subject.The Royal Commission concedes one part of our case, and that is the advice that the right hon. Gentleman wanted to see. Why, then, is he introducing the Bill at this stage? We are beginning to realise that it is a first step on a long road taken by the right hon. Gentleman and his right hon. Friends.
§ Dr. Mawhinney rose—
§ Mr. Moyle
The hon. Gentleman would not give way to me and I shall not give way to him.
Ten days ago, the right hon. Gentleman was extensively reported in the press as saying that he wanted an insurance-based National Health Service with doctors paid on item of service. In other words he wants to destroy the National Health Service as we have known it since 1948, and this Bill is a step towards so doing.
First, he is trying to introduce item of service payments for doctors. Colloquially translated, that means putting consultants on piecework. Many of the most distinguished in the profession will oppose that idea and we shall support them.
The most damaging part of the Bill is the idea of an insurance-based scheme, which destroys the moral basis of the National Health Service as we know it. It will no longer be an organisation primarily for aiding the sick. People will have to pay for what they get and will get what they pay for. The inference in an insurance-based scheme is that the poor will get less and the rich will get more. We shall have two health services, which is what the right hon. Member for Leeds, North-East called for during the previous Administration. It will be a workhouse service for the great mass of the population and a Harley Street service for the small section who can afford to pay.
What are we letting ourselves in for? On 4 December there was a letter in The Times sayingI joined…Private Patients' Plan when in my thirties shortly after the war. I regarded 754 my membership, which has continued without interruption, as a protection against the likely illnesses which would probably increase as my wife and I got older.I assumed that PPP by receiving subscriptions from healthy young people would be able to fund the advertised benefits for members as they became older. I was therefore rather shocked a few years ago when PPP informed me that as I had reached a certain age the rate of my subscription would have to be increased solely because of my age.That is what we shall let ourselves in for under an insurance-based Health Service.
The scheme is well launched. There are to be 70p prescription charges, road accident charges have been increased by substantial amounts and growth in the Health Service has been limited to 0.8 per cent. next year. As the right hon. Gentleman well knows, unless the Health Service has a growth rate of 1 per cent., it stands still. There has been no increase in cash limits despite—
§ Mr. Moyle
Yes. But we did not double VAT in the Budget, we did not put up the health costs of the NHS by substantial amounts and we did not create an inflation rate of 17 per cent. and refuse to increase cash limits. We shall now have the retention of pay beds in the National Health Service and the funding of private hospitals. Now is the time when we shall start to fight back. The people of this country must get rid of the Government before their schemes for the NHS come to fruition.
§ The Under-Secretary of State for Health and Social Security (Sir George Young)
The debate has been wide-ranging. It has covered not just the specific points in the Bill but the related issues raised in our consultative document "Patients First".
As my right hon. Friend the Secretary of State explained when he opened the debate, there will be another occasion in the new year for a debate on the consultative document. I hope that the House will understand if I leave until then some of the points raised on the future structure and concentrate on specific issues that are raised by the Bill.
Clauses 1 and 2, which deal with the structure, do not commit us to a particular structure. No decision will be taken 755 until consultation is complete. The right hon. Member for Salford, West (Mr. Orme) opened the attack on behalf of the Opposition. I should like to deal with his remarks on clause 4. Opposition Members have totally misunderstood the object of clause 4. It deals with the power of health authorities to raise money by appeals and collections. It is a permissive clause. Our objective is to enable hospitals to play a more positive role in local fund raising. While authorities can now accept voluntary contributions and donations, they cannot be engaged in fund-raising activities themselves. As a result of that, some hospitals have been lumbered with expensive equipment which has not been a priority for the local health service. Clause 4 will partly overcome that problem by enabling the local health authority to initiate and participate in local fund-raising and to steer it in the right direction.
We are talking about the better use of voluntary fund-raising and about building up a more effective link between the health authority and local fund-raising activities. I cannot see how anybody can sensibly object to that. Let me make absolutely clear that any money that is raised in this way will be in addition to the allocations made by my right hon. Friend the Secretary of State. There is no question of clawback. We will maintain next year's expenditure on the NHS budget at the level set by our predecessors. That will fully compensate for the inflation that has taken place this year.
§ Sir G. Young
Yes, there will be full compensation next year for this year's inflation. There will be no disbenefit to the Health Service from the implementation of clause 4. I hope that the hysteria that has been expressed about clause 4 will subside. Indeed, for the hon. Member for Crewe (Mrs. Dunwoody) to say that we shall go back to the position that exists in Lesotho with large black matrons extracting sixpences from patients is a credit to her imagination and nothing else.
The right hon. Member for Salford, West found himself in some difficulty when my hon. Friend the Member for Lancaster (Mrs. Kellett-Bowman) asked him whether the £1.75 million that was raised in the North-West by Pat Seed was 756 obscene. He was forced to admit that his Government should have found that money. In my constituency, Age Concern raised £500,000 for a geriatric day centre based at the Central Middlesex hospital. Should the right hon. Gentleman's Government have found the money for that as well? Was that obscene? Where do we stop? It is impossible for for the NHS to meet every need and there will always be a role for local fundraising. What we are trying to do is to ensure that the institutions that benefit from fund-raising will be associated with the activity from the outset.
§ Mr. Beith
I share the Minister's enthusiasm for local fund-raising, but his right hon. Friend specifically referred to a clause in the Bill which would prevent any clawing back by the Treasury of the equivalent in money raised locally. Has the Minister been able to identify that clause, because I have not?
§ Sir G. Young
I apologise to the hon. Member for Berwick-upon-Tweed (Mr. Beith). So far I have been unable to identify that clause. Perhaps it is something that we can explore further in Committee. The right hon. Member for Salford, West said that we were strengthening regional health authorities. There is nothing in the Bill about regional health authorities and our consultative document leaves the question of the future role of those authorities wide open.
We have a genuinely open mind on community health councils. We have come to no pre-judgment on their role and we shall welcome an informed debate on that and on whether they are the best or right way to secure consumer representation.
The right hon. Member for Salford, West accused my right hon. Friend of reducing accountability. One of the main objectives of the Bill is to abolish the Health Services Board and to restore the powers held by that board to the Secretary of State, who is answerable in this House. The right hon. Gentleman's accusation about reducing accountability is, therefore, totally without foundation. He admitted that in principle he would like to see a Health Service with no private sector whatever. He must recognise that that suggestion goes against a commitment given by the previous Administration of which he was a member. On Third Reading of the previous 757 Health Services Bill I think that it was said that it was not the policy of the Labour Administration to do away entirely with private practice. At some point Opposition Members must come clean and tell the country exactly where they stand on private medicine.
My hon. Friend the Member for Devizes (Mr. Morrison) criticised the 1974 reorganisation. He was not alone in that. He asked how we proposed to secure economies if we moved from area health authorities to smaller districts. It is true that there may be more authorities, but the cost lies not with the authority itself, but with the management structure underlying it, based on the staff.
For example, in Wiltshire there is one area health authority and three health districts. In effect, therefore, there are four management teams. If we proceed on the lines that we have outlined, we hope to reduce that number to two or three. That is where the potential saving lies. There will naturally be consequences for the staff. This is conceded in paragraph 13 of the consultative document. We accept that there will have to be negotiations.
The right hon. Member for Norwich, North (Mr. Ennals) had the effrontery to give us a lecture on the National Health Service. He managed to do that without once mentioning the events of last winter. He clearly suffers from a distressing illness—selective amnesia. He told us that strong emotions would be aroused by our Bill because it threatened industrial relations in the hospitals, with the consequence that patients would suffer. He did not mention the chaos over which he presided last winter.
§ Mr. Ennals rose—
§ Sir G. Young
I shall give way in a moment. When my right hon. Friend needs advice on industrial relations in the National Health Service one of the last places he will call for that advice will be Norwich, North.
§ Mr. Ennals
I was not expressing an opinion; I was simply quoting from the Royal Commission's report. If the Minister is saying that his right hon. Friend does not need the advice of the Royal Commission on industrial relations, that is a very serious statement.
§ Sir C. Young
Throughout the debate on his Bill the right hon. Gentleman made it quite clear that if the pay beds problem could be solved, that was the key to better industrial relations. The history of events since that time has shown that he was absolutely wrong. Pay beds were irrelevant to the problems over which he presided last winter.
We recognise the strong feelings that are held in the NHS. For that reason, my right hon. Friend announced earlier in the debate the six principles, which I believe are valuable and which will go some way to reassuring people about our policies. In addition, my right hon. Friend has retained specific safeguards to look after the interests of the NHS, and I shall return to that.
§ Dr. Mawhinney
Bearing in mind that my hon. Friend told the House that a majority of people in the country, including trade unionists and Labour Party members, as well as a majority in this House, wanted private medicine to continue in the National Health Service, will he agree that if there is any fury arising from the Bill it will be the responsibility of Labour Members to tell their radical friends that they must obey the democratic wishes of Parliament?
§ Sir G. Young
My hon. Friend is quite right. However, I hope that our proposals will be accepted by all those who work in the Health Service and that no attempt will be made by Labour Members to stir things up.
The right hon. Member for Norwich, North asked about administrative savings resulting from reorganisation. It is envisaged that these will accrue to the Health Service. I said earlier that I was unable to locate the specific clause of the Bill which dealt with preventing the Treasury's clawing back. The provision is on page 14 of the Bill in subsection (5)—sums shall be disregarded for the purposes of this section".Therefore, the assurance that the right hon. Member seeks is in the Bill. This is a matter for Committee where we can explore further the issue of safeguarding the NHS.
It has been alleged throughout the debate that we are embarked on a fundamental attack on the principles of the Health Service. We have been accused 759 of going back to the 1930s, and even to 1911. When this Bill is on the statute book, the NHS will have greater protection against possible adverse effects from private practice than it had from 1964 to 1970. My right hon. Friend will have safeguards that were not thought necessary by the two Labour Administrations of that time.
The hon. Member for Berwick-upon-Tweed asked about the General Practice Finance Corporation. Clauses 15 and 16 refer to this. The corporation has power to borrow money and to lend it to doctors to buy, improve or build surgery premises. Without doubt the corporation has been a great help to GPs over the years. It has now committed the full £25 million that it was entitled to borrow under the 1966 Act. Clause 16 raises the borrowing limit to £40 million, with power to increase it, by order, to £100 million.
Clause 15 contains a new power which allows the corporation to buy premises and lease them to GPs for their surgeries. Both the corporation and the profession believe that this will help doctors, particularly in the inner cities where high building costs and high rents make it extremely difficult for practices to find suitable premises. Some doctors are still unwilling to practise in health centres, and leasing from the corporation may be attractive to them. This power will be operated in accordance with the scheme to be approved by Ministers. Therefore, there will be proper control.
The hon. Member for Berwick-on-Tweed asked a number of specific questions. Perhaps I could write to him about some of them. I emphasise to him that the Health Services Board is still in existence. How it proceeds is a matter for the board. It may take the view that on the Second Reading of this Bill it is not worth proceeding with further proposals for phasing out pay beds.
The hon. Member also spoke about cuts in the future. Next year's planned expenditure will be 3 per cent. higher in real terms than the likely expenditure this year. We have honoured our predecessors' expenditure commitments on the Health Service for next year.
My hon. Friend the Member for Peterborough (Dr. Mawhinney) made a positive and thoughtful contribution based 760 on his knowledge of the Health Service. Under the Bill it will be possible to have pay beds in cottage hospitals if there is sufficient demand for them.
The hon. Member for Brent, South (Mr. Pavitt) on two occasions described savings of £30 million as being "candle ends". This expansive approach is not one that the country needs at the moment.
My hon. Friend the Member for Canterbury (Mr. Crouch) made a knowledgeable speech based on his service on the regional health authority. He made a forceful point about London, and, as a London Member, I understand what he says about the dominance of teaching hospitals here. I hope he will accept that paragraph 41 of our consultation document deals with the special role of London.
The hon. Member for Crewe was not at her best today. She implied that no restructuring was necessary, thus destroying what had been up to then a happy consensus.
My hon. Friend the Member for Somerset, North (Mr. Dean), as did my hon. Friend the Member for Devizes, stressed the need for flexibility in reorganisation. They are both right. My hon. Friend the Member for Somerset, North asked whether all the pay beds that had been phased out would be restored. It is unlikely that that would happen because so many of the beds were not used. He spoke of the need for partnership between the public and private sectors of medicine, and I hope to return to that later. He raised a specific point about clause 10 and the number of beds needed before the matter could be referred. That is something we could usefully consider in Committee.
The hon. Member for Stockport, North (Mr. Bennett) and other Opposition Members spoke of the private sector feeding like a parasite on the National Health Service. Opposition Members are totally unable to accept that there could be a relationship between these two sectors that could be to the advantage of both. I hope to return to that theme later.
§ Mr. Pavitt rose—
§ Sir G. Young
I am sorry, but I cannot give way. My hon. Friend the Member for Preston, North (Mr. Atkins) 761 raised the issue of the abuse of the hospitality of the National Health Service by visitors from overseas, sometimes referred to as gate-crashers. We have that matter under review. The right approach would be to persuade other countries to be as hospitable to our tourists as we are to theirs. We are making progress in that direction.
The hon. Member for Ashfield (Mr. Haynes) made a somewhat hysterical speech. Nothing that anyone could say to him could ever shake his conviction that private medicine is an organised conspiracy to rob the taxpayer. I am not going to attempt to persuade him now. However, I ask him to consider the six principles enunciated by my right hon. Friend in his opening speech, and perhaps to concede that they are steps in the right direction.
Much of the concern expressed in the debate related to allegations of queue-jumping, and I wish to make our position absolutely clear. It is totally unacceptable that the treatment of an NHS patient who is seriously ill or in need of urgent medical care should be pre-judiced because priority had been given to a private patient in less need. It is equally unacceptable that a patient who has had a private consultation should, as a result, be given a higher degree of priority for treatment under the NHS than would have been available to any other patient whose medical needs are the same.
The general principles that have been agreed with the medical profession unequivocally outlaw that sort of thing. Indeed, they go substantially further than any other arrangements made in the past towards ensuring that private practice in the NHS is conducted properly and fairly.
§ Mr. Pavitt
Will the Under-Secretary of State tell me whether the six principles that he has enunciated also cover the priority queue-jumping that takes place in out-patients departments? He will know that the present practice, when a patient goes for diagnosis, is that there are two forms, one that is marked PP and another that is marked NHS. Those with forms that are marked PP go straight in and those with forms marked NHS have to wait two or three hours. Will the six principles affect that?
§ Sir G. Young
That was covered by the second principle mentioned by my right hon. Friend in his opening remarks.
Clause 3 makes statutory the present informal arrangements for joint financing under which health authorities contribute to personal social services projects run by local authorities. Joint financing was started by the previous Government and is being carried on by the present Government. It has been successful in many areas in fostering collaborative planning between health and local authorities. It is contributing to a more rational economic use of available health and social service facilities.
Hitherto, authority for joint financing has rested with the approval of the Treasury on the Estimates and on the confirming appropriation Acts. Joint financing is now an established feature of health and social services, and it is right that it should become statutory. The House should know that in the plan for NHS spending next year we are providing around £50 million for jointly financed projects—a 16 per cent. increase in real terms over the current year's allocation.
A number of points raised dealt with the position of staff on reorganisation. While the consultative paper clearly points to cut-backs in bureaucracy and reduction in management costs, it recognises the need to treat the staff of the NHS, at whatever level they are working, both fairly and openly. The programme of implementing the changes proposed in the consultative paper has been framed with a view to limiting disruption and minimising the impact of change on staff. With the disappearance of both the area and sector levels of management, some staff will be affected, although it is not possible to estimate how many at this stage. We hope that most of the necessary staff reductions can be handled through natural wastage. That is one of the reasons why we are proposing a fairly lengthy time scale for both restructuring and for the review of management arrangements, though there may have to be some redundancies. In deciding what arrangements will need to be made for filling posts in the new service and for treating fairly those who may be displaced, we shall be taking into account the views of both NHS management and staff interests.
763 We attach great importance to proper consultation with staff interests throughout the process of reorganisation. We shall be starting consultations at national level as early as possible.
There were one or two defects in the arguments deployed by the right hon. Member for Salford, West. Happily, pay beds have not been totally phased out. For that reason the forecasts that my right hon. Friend the Secretary of State made during the passage of the previous legislation have not been fulfilled. The Government consider that to be a matter for rejoicing.
The main debate has been about the relationship between the National Health Service and the private sector. It seems that there are four options open to any Government on policy for the National Health Service. Two options are extreme and the other two occupy the middle ground. One extreme is the State monopoly, with the total abolition of all private practice. The second extreme is a free-for-all for anyone who wishes to enter the market. In the middle are two other options that have been adopted by Government. One involves the existence of a private sector that is separate from the NHS. That is what the Labour Government practised. The second involves not merely the existence of the private sector but a co-existence with the National Health Service.
First, I shall deal with the more extreme arguments. Some Labour Members object on ideological grounds to private medicine for the same reason that leads them to object to private education, private ownership of the means of production, and private ownership of wealth. The type of society that they envisage, in which there is no alternative to a State-provided service, is not one in which most people wish to live.
Even if the National Health Service were perfect, and even if it could meet all the demands made on it, I still think that it would be right for there to be an alternative, so that someone would be able to say "Thank you very much. I know that there is a National Health Service and that I am entitled to use it, but I wish to go elsewhere." That in no way invalidates the concept of a National Health Service, any more than the existence of owner-occupiers threatens the 764 existence of council tenants. There is no case in a free society for the establishment of a monopoly in the supply of health services.
The second extreme option is what might loosely be called a free-for-all, with free entry into the health market for anyone who wishes to invest in it. My right hon. Friend has explained that we are retaining some controls on private sector development. He explained why such controls are necessary and why there should be controls that can be exercised where there is a threat to the National Health Service.
This is not a control on the size of the private sector. It is merely a safeguard where there is a possible threat in any locality. Health care resources, both public and private, are too valuable to be wasted, and where there would be prejudice there will be powers of control.
I mentioned the two options between the two extremes that have been adopted by Government. Both presuppose the existence of a private sector alongside the National Health Service, with some controls over it. There is a difference in the relationship between the two. The first option was the Labour Government's policy—the private sector was there and they did not like it although their legislation presupposed it so that they could ensure that pay beds would be phased out. The theme was no co-operation and no communication. The phasing out of pay beds was the severing of the institutional link between the two sectors, the link provided by the "geographical whole-time consultant"—the consultant who did some private work within National Health Service hospitals rather than, as would have happened under present legislation, miles away at a private hospital.
The fourth option, which is our option, is positive, and not negative, co-existence. We want the two sectors to co-operate to make the best use of resources. The two sectors can and should complement each other. The National Health Service already makes use of private sector facilities. It did so even under the Labour Administration. That is a sensible system. There are about 4,000 beds in non-NHS institutions that are used by the NHS on a contractual basis. That more than outnumbers the present number of pay beds. We shall encourage authorities to make greater use of spare capacity in 765 the private sector where this rather than direct NHS provision is a sensible use of resources.
It has always seemed to be a total nonsense that Labour Members say to the public "You may spend your money on any activity that you like—motor cars, holidays overseas and bingo—but on no account are you to make a voluntary deduction from your own income to make provision for yourself when you are ill." That is Socialism at its worst. These are important issues about the freedom of the individual.
Part of our message is that the individual must assume greater responsibility for his health. The National Health Service does not have a "pill for every ill". The major improvement in the nation's health will come from people voluntarily deciding to adopt healthier life styles. There is no difference of opinion between Labour and Conservative Members on that point. It is entirely consistent with our philosophy of individual responsibility that we shall encourage each individual to make provision for himself privately. That provision having been made, the resources which are accumulated should be put to the most effective use.
I quote from an article in the News of the World by Frank Chapple. [Interruption.] Labour Members spend much time quoting the advice of trade union leaders to us. I should like to return the compliment.
The article is entitledA severe case of hypocrisy".Mr. Chapple writes:There is a great deal of hypocrisy in the trade union movement. And it was spelt out loud and clear at Blackpool when holier-than-thou union leaders attacked the private health treatment deal negotiated by 40,000 of my members. I make no bones about defending it. Whatever was said, then or in the future, will not affect the deal. It will stand because it makes good sense.…It could be justifiably argued that private health care could ease the strain on the NHS. What the largely ill-informed critics of the scheme have so far failed to prove is how the cover offered in our private scheme can possibly weaken the NHS…Hypocrisy taints all these accusations that it is my deal which is badly injuring the NHS. There is no condemnation when Liverpool women accepted the offer of open heart surgery in a private hospital because they could not get in it on the NHS. There is no condemnation when industrial disputes 766 delay the building of new hospitals and so deprive the public of medical services.I am still quoting the remarks of Frank Chapple. He adds:Those who condemn our agreements conveniently overlook the fact that many leading policitians and trade union leaders have received private treatment. The outcry seems to have arisen simply because the rank and file are now being offered the same facilities.…What it boils down to is that blue-collar workers are about to get the preferential treatment that has long been available to white collar and managerial working groups.…It is sheer hypocrisy on the part of NUPE and COHSE. They have added to the NHS problems through their industrial disputes for higher wages. Now they have the cheek to assert that it is my agreement that will undermine the service.Those views expressed by Frank Chapple on behalf of his union members are shared by many other trade union members—for example, the National Union of Seamen.
My right hon. and hon. Friends are convinced that the relationship between the public and private sectors of medicine should be one of partnership. The policy of separate development embarked on by the previous Government was misguided. The private sector is not a threat to the National Health Service to be distanced from it but a potential ally to be brought closer.
If the Opposition are concerned about the development of a two-tier Health Service—one tier for the rich, and another for the poor—their policy of separation would inevitably have brought that about. The enforced phasing out of pay beds and their hostility to the private sector would have led to a greater surge of interest in private medicine from people in all walks of life and from all income levels.
Our policies are designed to ensure that the National Health Service and the private sector co-operate. We want to ensure that the best use is made of our health resources, from wherever they come. Labour Members want to drive a wedge between the two, whereas we wish to build a bridge. If we can get the relationship right, it will be to the benefit of the National Health Service. The Health Service will lose if Labour Members turn their backs on the private sector.
I invite all hon. Members who care about health services as a whole to give the Bill a Second Reading.
§ Question put, That the Bill be now read a Second time: —768
§ The House divided: Ayes 320, Noes 250.771
|Division No. 129]||AYES||[10pm]|
|Adley, Robert||Edwards, Rt Hon N. (Pembroke)||Knox, David|
|Alexander, Richard||Eggar, Timothy||Lang, Ian|
|Alton, David||Emery, Peter||Langtord-Holt, Sir John|
|Amery, Rt Hon Julian||Eyre, Reginald||Latham, Michael|
|Ancram, Michael||Fairbairn, Nicholas||Lawrence, Ivan|
|Arnold, Tom||Fairgrieve, Russell||Lawson, Nigel|
|Aspinwall, Jack||Faith, Mrs Sheila||Lee, John|
|Atkins, Rt Hon H. (Spelthorne)||Farr, John||Lennox-Boyd, Hon Mark|
|Atkins, Robert (Preston North)||Fell, Anthony||Lester, Jim (Beeston)|
|Baker, Kenneth (St. Marylebone)||Fenner, Mrs Peggy||Lewis, Kenneth (Rutland)|
|Baker, Nicholas (North Dorset)||Finsberg, Geoffrey||Lloyd, Ian (Havant & Waterloo)|
|Banks, Robert||Fisher, Sir Nigel||Lloyd, Peter (Fareham)|
|Beaumont-Dark, Anthony||Fletcher, Alexander (Edinburgh N)||Loveridge, John|
|Beith, A. J.||Fletcher-Cooke, Charles||Luce, Richard|
|Bell, Ronald||Fookes, Miss Janet||Lyell, Nicholas|
|Bendell, Vivian||Forman, Nigel||McAdden, Sir Stephen|
|Benyon, Thomas (Abingdon)||Fowler, Rt Hon Norman||McCrindle, Robert|
|Benyon, W. (Buckingham)||Fox, Marcus||Macfarlane, Neil|
|Best, Keith||Fraser, Rt Hon H. (Stafford & St)||MacGregor, John|
|Bevan, David Gilroy||Fraser, Peter (South Angus)||MacKay, John (Argyll)|
|Biffen, Rt Hon John||Fry, Peter||Macmillan, Rt Hon M. (Farnham)|
|Biggs-Davison, John||Galbraith, Hon T. G. D.||McNair-Wilson, Michael (Newbury)|
|Blackburn, John||Gardiner, George (Reigate)||McNair-Wilson, Patrick (New Forest)|
|Blaker, Peter||Gardner, Edward (South Fylde)||McQuarrie, Albert|
|Body, Richard||Garel-Jones, Tristan||Madel, David|
|Bonsor, Sir Nicholas||Gilmour, Rt Hon Sir Ian||Major, John|
|Boscawen, Hon Robert||Glyn, Dr Alan||Marland, Paul|
|Bottomley, Peter (Woolwich West)||Goodhew, Victor||Marlow, Tony|
|Bowden, Andrew||Goodlad, Alastair||Marshall, Michael (Arundel)|
|Boyson, Dr Rhodes||Gorst, John||Marten, Neil (Banbury)|
|Bradford, Rev. R.||Gow, Ian||Mates, Michael|
|Braine, Sir Bernard||Gower, Sir Raymond||Mather, Carol|
|Bright, Graham||Grant, Anthony (Harrow C)||Maude, Rt Hon Angus|
|Brinton, Tim||Gray, Hamish||Mawby, Ray|
|Brittan, Leon||Greenway, Harry||Mawhinney, Dr Brian|
|Brocklebank-Fowler, Christopher||Grieve, Percy||Maxwell-Hyslop, Robin|
|Brooke, Hon Peter||Griffiths, Eldon (Bury St Edmunds)||Mayhew, Patrick|
|Brotherton, Michael||Griffiths, Peter (Portsmouth N)||Mellor, David|
|Brown, Michael (Brigg & Sc'thorpe)||Grist, Ian||Meyer, Sir Anthony|
|Browne, John (Winchester)||Grylls, Michael||Miller, Hal (Bromsgrove & Redditch)|
|Bruce-Gardyne, John||Gummer, John Selwyn||Mills, Iain (Meriden)|
|Bryan, Sir Paul||Hamilton, Michael (Salisbury)||Mills, Peter (West Devon)|
|Buchanan-Smith, Hon Alick||Hampson, Dr Keith||Miscampbell, Norman|
|Buck, Antony||Hannam John||Mitchell, David (Basingstoke)|
|Budgen, Nick||Haselhurst, Alan||Moate, Roger|
|Bulmer, Esmond||Hastings, Stephen||Molyneaux, James|
|Burden, F. A.||Havers, Rt Hon Sir Michael||Monro, Hector|
|Butcher, John||Hawksley, Warren||Montgomery, Fergus|
|Butler, Hon Adam||Hayhoe, Barney||Moore, John|
|Cadbury, Jocelyn||Heath, Rt Hon Edward||Morris, Michael (Northampton, Sth)|
|Carlisle, John (Luton West)||Heddle John||Morrison, Hon Charles (Devizes)|
|Carlisle, Kenneth (Lincoln)||Henderson Barry||Morrison, Hon Peter (City of Chester)|
|Carlisle, Rt Hon Mark (Runcorn)||Heseltine, Rt Hon Michael||Mudd, David|
|Chalker, Mrs. Lynda||Hicks, Robert||Murphy, Christopher|
|Channon, Paul||Higgins, Rt Hon Terence L.||Myles, David|
|Chapman, Sydney||Hill, James||Needham, Richard|
|Churchill, W. S.||Hogg, Hon Douglas (Grantham)||Nelson, Anthony|
|Clark, Hon Alan (Plymouth, Sutton)||Holland, Philip (Carlton)||Neubert, Michael|
|Clark, Dr William (Croydon South)||Hooson, Tom||Newton, Tony|
|Clarke, Kenneth (Rushcliffe)||Hordern, Peter||Normanton, Tom|
|Clegg, Walter||Howe, Rt Hon Sir Geoffrey||Nott, Rt Hon John|
|Cockeram, Eric||Howell, Rt Hon David (Guildford)||Oppenheim, Rt Hon Mrs Sally|
|Colvin, Michael||Howells, Geraint||Osborn, John|
|Cope, John||Hunt, David (Wirral)||Page, Rt Hon R. Graham (Crosby)|
|Cormack, Patrick||Hunt, John (Ravensbourne)||Page, Richard (SW Hertfordshire)|
|Costain, A. P.||Hurd, Hon Douglas||Parkinson, Cecil|
|Cranborne, Viscount||Irving, Charles (Cheltenham)||Parris, Matthew|
|Critchley, Julian||Jenkin, Rt Hon Patrick||Patten, John (Oxford)|
|Crouch, David||Johnson Smith, Geoffrey||Pattie, Geoffrey|
|Dean, Paul (North Somerset)||Johnston, Russell (Inverness)||Pawsey, James|
|Dickens, Geoffrey||Jopling, Rt Hon Michael||Penhaligon, David|
|Dorrell, Stephen||Joseph, Rt Hon Sir Keith||Percival, Sir Ian|
|Douglas-Hamilton, Lord James||Kaberry, Sir Donald||Peyton, Rt Hon John|
|Dover, Denshore||Kellett-Bowman, Mrs Elaine||Pink, R. Bonner|
|du Cann, Rt Hon Edward||Kershaw, Anthony||Pollock, Alexander|
|Dunn, Robert (Dartford)||Kilfedder, James A.||Porter, George|
|Durant, Tony||Kimball, Marcus||Prentice, Rt Hon Reg|
|Dykes, Hugh||King, Rt Hon Tom||Price, David (Eastleigh)|
|Eden, Rt Hon Sir John||Kitson, Sir Timothy||Prior, Rt Hon James|
|Knight, Mrs Jill|
|Proctor, K. Harvey||Sims, Roger||van Straubenzee, W. R.|
|Pym, Rt Hon Francis||Skeet, T. H. H.||Viggers, Peter|
|Raison, Timothy||Smith, Dudley (War, and Leam'ton)||Waddington, David|
|Rathbone, Tim||Speller, Tony||Wakeham, John|
|Rees, Peter (Dover and Deal)||Spence, John||Waldegrave, Hon William|
|Rees-Davies, W. R.||Spicer, Jim (West Dorset)||Walker, Rt Hon Peter (Worcester)|
|Renton, Tim||Sproat, Iain||Walker, Bill (Perth & E Perthshire)|
|Rhodes James, Robert||Squire, Robin||Waller, Gary|
|Rhys Williams, Sir Brandon||Stanbrook, Ivor||Walters, Dennis|
|Ridley, Hon Nicholas||Stanley, John||Ward, John|
|Ridsdale, Julian||Steen, Anthony||Watson, John|
|Rifkind, Malcolm||Stevens, Mar In||Wells, John (Maidstone)|
|Rippon, Rt Hon Geoffrey||Stewart, Ian (Hitchin)||Wells, Bowen (Hert'rd & Stev'nage)|
|Roberts, Michael (Cardiff NW)||Stewart, John (East Renfrewshire)||Wheeler, John|
|Roberts, Wyn (Conway)||Stokes, John||Whitelaw, Rt Hon William|
|Ross, Wm. (Londonderry)||Stradling Thomas, J.||Whitney, Raymond|
|Rossi, Hugh||Tapsell, Peter||Wickenden, Keith|
|Rost, Peter||Taylor, Robert (Croydon NW)||Wiggin, Jerry|
|Royle, Sir Anthony||Tebbit, Norman||Wilkinson, John|
|Sainsbury, Hon Timothy||Temple-Morris, Peter||Williams, Delwyn (Montgomery)|
|St. John-Stevas, Rt Hon Norman||Thatcher, Rt Hon Mrs Margaret||Winterton, Nicholas|
|Scott, Nicholas||Thompson, Donald||Wolfson, Mark|
|Shaw, Michael (Scarborough)||Thorns, Neil (Ilford South)||Young, Sir George (Acton)|
|Shelton, William (Streatham)||Thornton, Malcolm||Younger, Rt Hon George|
|Shepherd, Colin (Hereford)||Townend, John (Bridlington)|
|Shepherd, Richard (Aldridge-Br'hills)||Townsend, Cyril D. (Bexleyheath)||TELLERS FOR THE AYES:|
|Shersby, Michael||Trippler, David||Mr. Spencer Le Marchant and|
|Silvester, Fred||Trotter, Neville||Mr. Anthony Berry.|
|Abse, Leo||Dempsey, James||Homewood, William|
|Adams, Allen||Dewar, Donald||Hooley, Frank|
|Allaun, Frank||Dixon, Donald||Horam, John|
|Anderson, Donald||Dobson, Frank||Howell, Rt Hon Denis (B'ham, Sm H)|
|Archer, Rt Hon Peter||Dormand, Jack||Huckfleld, Les|
|Armstrong, Rt Hon Ernest||Douglas, Dick||Hudson Davies, Gwilym Ednyfed|
|Ashton, Joe||Douglas-Mann, Bruce||Hughes, Mark (Durham)|
|Atkinson, Norman (H'gey, Tott'ham)||Dubs, Alfred||Hughes, Robert (Aberdeen North)|
|Bagier, Gordon A. T.||Duffy, A. E. P.||Hughes, Roy (Newport)|
|Barnett, Guy (Greenwich)||Dunn, James A. (Liverpool, Kirkdale)||Janner, Hon Greville|
|Barnett, Rt Hon Joel (Heywood)||Dunwoody, Mrs Gwyneth||Jay, Rt Hon Douglas|
|Benn, Rt Hon Anthony Wedgwood||Eadie, Alex||John, Brynmor|
|Bennett, Andrew (Stockport N)||Eastham, Ken||Johnson, James (Hull West)|
|Bidwell, Sydney||Edwards, Robert (Wolv SE)||Johnson, Walter (Derby South)|
|Booth, Rt Hon Albert||Ellis, Raymond (NE Derbyshire)||Jones, Rt Hon Alec (Rhondda)|
|Boothroyd, Miss Betty||Ellis, Tom (Wrexham)||Jones, Barry (East Flint)|
|Bottomley, Rt Hon Arthur (M'brough)||English, Michael||Jones, Dan (Burnley)|
|Bradley, Tom||Ennals, Rt Hon David||Kaufman, Rt Hon Gerald|
|Bray, Dr Jeremy||Evans, Ioan (Aberdare)||Kerr, Russell|
|Brown, Hugh D. (Provan)||Evans, John (Newton)||Kilroy-Silk, Robert|
|Brown, Robert C. (Newcastle W)||Ewing, Harry||Kinnock, Neil|
|Brown, Ronald W. (Hackney S)||Faulds, Andrew||Lambie, David|
|Brown, Ron (Edinburgh, Leith)||Field, Frank||Lamborn, Harry|
|Buchan, Norman||Fitch, Alan||Lamond, James|
|Callaghan, Rt Hon J. (Cardiff SE)||Flannery, Martin||Leadbitter, Ted|
|Callaghan, Jim (Middleton & P)||Fletcher, L. R. (Ilkeston)||Leighton, Ronald|
|Campbell, Ian||Fletcher, Ted (Darlington)||Lestor, Miss Joan (Eton & Slough)|
|Campbell-Savours, Dale||Foot, Rt Hon Michael||Lewis, Ron (Carlisle)|
|Canavan, Dennis||Ford, Ben||Litherland, Robert|
|Cant, R. B.||Forrester, John||Lofthouse, Geoffrey|
|Carmichael, Neil||Foulkes, George||Lyon, Alexander (York)|
|Carter-Jones, Lewis||Fraser, John (Lambeth, Norwood)||Lyons, Edward (Bradford West)|
|Cartwright, John||Freeson, Rt Hon Reginald||Mabon, Rt Hon Dr J. Dickson|
|Clark, Dr David (South Shields)||Garrett, John (Norwich S)||McCartney, Hugh|
|Cocks, Rt Hon Michael (Bristol S)||Garrett, W. E. (Wallsend)||McDonald, Dr Oonagh|
|Cohen, Stanley||George, Bruce||McElhone, Frank|
|Coleman, Donald||Gilbert, Rt Hon Dr John||McKay, Allen (Penistone)|
|Concannon, Rt Hon J. D.||Ginsburg, David||McKelvey, William|
|Conlan, Bernard||Golding, John||MacKenzie, Rt Hon Gregor|
|Cook, Robin F.||Gourlay, Harry||Maclennan, Robert|
|Cowans, Harry||Graham, Ted||McMahon, Andrew|
|Craigen, J. M. (Glasgow, Maryhlll)||Grant, George (Morpeth)||McMillan, Tom (Glasgow, Central)|
|Crowther, J. S.||Grant, John (Islington C)||McNally, Thomas|
|Cryer, Bob||Hamilton, James (Bothwell)||McWilliam, John|
|Cunliffe, Lawrence||Hamilton, W. W. (Central Fife)||Magee, Bryan|
|Cunningham, George (Islington S)||Harrison, Rt Hon Walter||Marks, Kenneth|
|Cunningham, Dr John (Whitehaven)||Hart, Rt Hon Dame Judith||Marshall, David (Gl'sgow,Shettles'n)|
|Dalyell, Tam||Hattersley, Rt Hon Roy||Marshall, Dr Edmund (Goole)|
|Davidson, Arthur||Haynes, Frank||Marshall, Jim (Lelcester South)|
|Davies, Rt Hon Denzil (Llanelli)||Healey, Rt Hon Denis||Martin, Michael (Gl'gow, Springb'rn)|
|Davles, Ifor (Gower)||Heffer, Eric S.||Maxton, John|
|Davis, Terry (B'rm'ham, Stechford)||Hogg, Norman (E Dunbartonshire)||Meacher, Michael|
|Deakins, Eric||Holland, Stuart (L'beth, Vauxhall)||Mellish, Rt Hon Robert|
|Dean, Joseph (Leeds West)||Home Robertson, John||Mikardo, Ian|
|Millan, Rt Hon Bruce||Roberts, Gwilym (Cannock)||Thomas, Mike (Newcastle East)|
|Mitchell, Austin (Grimsby)||Robertson, George||Thomas, Dr Roger (Carmarthen)|
|Mitchell, R. C. (Soton, Itchen)||Robinson, Geoffrey (Coventry NW)||Thome, Stan (Preston South)|
|Morris, Rt Hon Alfred (Wythenshawe)||Rodgers, Rt Hon William||Tilley, John|
|Morris, Rt Hon Charles (Openshaw)||Rooker, J. W.||Torney, Tom|
|Morris, Rt Hon John (Aberavon)||Roper, John||Urwin, Rt Hon Tom|
|Moyle, Rt Hon Roland||Ross, Ernest (Dundee West)||Varley, Rt Hon Eric G.|
|Mulley, Rt Hon Frederick||Rowlands, Ted||Wainwright, Edwin (Dearne Valley)|
|Newens, Stanley||Sandelson, Neville||Walker, Rt Hon Harold (Doncaster)|
|Oakes, Rt Hon Gordon||Sever, John||Watkins, David|
|Ogden, Eric||Sheldon, Rt Hon Robert (A'ton-u-L)||Weetch, Ken|
|O'Halloran, Michael||Shore, Rt Hon Peter (Step and Pop)||Wellbeloved, James|
|O'Neill, Martin||Short, Mrs Renée||Welsh, Michael|
|Orme, Rt Hon Stanley||Silkin, Rt Hon John (Deptford)||Whitehead, Phillip|
|Owen, Rt Hon Dr David||Silkin, Rt Hon S. C. (Dulwich)||Whitlock, William|
|Palmer, Arthur||Silverman, Julius||Wigley, Dafydd|
|Park, George||Skinner, Dennis||Willey, Rt Hon Frederick|
|Parker, John||Smith, Rt Hon J. (North Lanarkshire)||Williams, Rt Hon Alan (Swansea W)|
|Parry, Robert||Snape, Peter||Wilson, Gordon (Dundee East)|
|Pavitt, Laurie||Soley, Clive||Wilson, Rt Hon Sir Harold (Huyton)|
|Pendry, Tom||Spearing, Nigel||Wilson, William (Coventry SE)|
|Powell, Raymond (Ogmore)||Spriggs, Leslie||Winnick, David|
|Prescott, John||Stallard, A. W.||Woodall, Alec|
|Price, Christopher (Lewisham West)||Stewart, Rt Hon Donald (W Isles)||Woolmer, Kenneth|
|Race, Reg||Stott, Roger||Wrigglesworth, Ian|
|Radice, Giles||Strang, Gavin||Young, David (Bolton East)|
|Rees, Rt Hon Merlyn (Leeds South)||Straw, Jack|
|Richardson, Jo||Summerskill, Hon Dr Shirley||TELLERS FOR THE NOES:|
|Roberts, Albert (Normanton)||Taylor, Mrs Ann (Bolton West)||Mr. James Tinn and|
|Roberts, Allan (Bootle)||Thomas, Dafydd (Merioneth)||Mr. George Morton.|
|Roberts, Ernest (Hackney North)||Thomas, Jeffrey (Abertillery)|
§ Question accordingly agreed to.
§ Bill read a Second time.
§ Bill committed to a Standing Committee pursuant to Standing Order No. 40 (Committal of Bills.)