NATIONAL HEALTH SERVICE (ENGLAND) (Hansard, 23 July 1980)

§ The Secretary of State for Social Services (Mr. Patrick Jenkin)
With permission, Mr. Speaker, I shall make a statement on changes in the organisation and management of the National Health Service in England. My right hon. Friend the Secretary of State for Wales is announcing his proposals for Wales today, and my right hon. Friend the Secretary of State for Scotland will be announcing his proposals next week. My Department—[Interruption.]

§ Mr. William Hamilton
On a point of order, Mr. Speaker. Can it be made clear at the outset that there will be a separate statement on the Floor of the House from a Minister representing Scotland? The Health Service in Scotland is an entirely different organisation from that in England and Wales.

§ Mr. Speaker
The only request that I have received is for the statement that is about to be made.

§ Mr. Hamilton
It is an outrage.

§ Mr. Jenkin
The hon. Gentleman may not have heard what I said because of the noise that was being made by many of his hon. Friends. My right hon. Friend the Secretary of State for Scotland will be announcing his proposals next week.

§ Mr. Hamilton
In the House?

§ Mr. Speaker
Order. There will be time for questions after the Secretary of State's statement.

§ Mr. Orme
On a point of order, Mr. Speaker. I wish to ask the Secretary of State whether—[Interruption.]

§ Mr. Speaker
Order. The right hon. Gentleman must address his point of order to me.

§ Mr. Orme
On a point of order, Mr. Speaker. Will the statements regarding Scotland and Wales be made as oral statements in the House—Wales today and Scotland next week?

§ Mr. Speaker
I cannot answer that point of order. The Secretary of State will be subject to questioning at the end of his statement.

§ Mr,. Jenkin
Perhaps I may respond to the right hon. Gentleman's point. My right hon. Friend the Chancellor of the Duchy of Lancaster has taken note of what he said, but that is a matter for next week.

§ Mr. Rowlands
Will you advise us, Mr. Speaker? The Secretary of State said that the Secretary of State for Wales will be making a statement today. If he is not to make it orally, and as the statement that has just started is described as being about England and not about Wales, are we to understand that the Secretary of State for Wales may simply issue a press release, or something like that, and not make a statement in the House and be subjected to the same interrogation and questioning as the Secretary of State for Social Services?

§ Mr. Speaker
The House must understand that I cannot order any Minister to make a statement in the House. I have to deal with the statement that the Secretary of State for Social Services is making. I cannot advise the hon. Member for Merthyr Tydfil (Mr. Rowlands), except to say that I have received no request for a statement about Wales.

§ Mr. Rowlands
Will you tell us, Mr Speaker, whether it will be in order for us, on this statement, to question the Secretary of State for Social Services on what is to happen in Wales?

§ Mr. English
On a point of order, Mr. Speaker. Is it not correct that it is only by courtesy that the House hears a ministerial statement? Would it not be a good idea if we refused to hear the statement until the Government have got themselves in order?

§ Mr. Speaker
Order. I think that I should call on the Secretary of State make his statement.

§ Mr. Speaker
Order. Mr. Michael Foot.

§ Mr. Foot
Obviously, Mr. Speaker, the House is in a considerable state of confusion. The right hon. Gentleman proposes to make a statement that refers only to England, and he suggests that there is to be a statement next week about Scotland, but in the meantime 501 we are not at all sure what is to happen about Wales. It would appear, therefore, that Welsh Members are to be deprived of the opportunity of putting any questions on what is to happen about Wales, as the statement is to be made not in this House but elsewhere.
I suggest that that is not the right way to treat the House and that the best course for the Government would be not to make the statement today but to consider the matter and tomorrow ask the leave of the House to make a proper statement. If such a course is not followed, Welsh Members will be deprived of their rights. I know that Conservative Members may not worry about that, but it worries Opposition Members. In view of the confusion in which the Government have placed us, I suggest that they should not proceed with the statement now but should make it tomorrow, when they have sorted the matter out.

§ Mr. Arthur Lewis
On a point of order, Mr. Speaker. Is it not the case that you have the sole right to decide whether to grant permission for a statement to be made, although invariably you grant that permission? We know that it is done in order that the House may be advised and informed of certain matters. In view of the fact that a full report of the statement has obviously been leaked by the Minister and appears in today's Daily Telegraph, I suggest that no harm would be done if you were to withdraw permission for the statement to be made, as my right hon. Friend the Member for Ebbw Vale (Mr. Foot) suggested. Then we could all read the statement in The Daily Telegraph and come back tomorrow well prepared to put our supplementary questions to the Minister.

§ Mr. English
Will you allow me, Mr. Speaker, to move that the leave of the House be not given for this ministerial statement?

§ Mr. Cryer
I will second that.

§ Mr. Pavitt
On a point of order, Mr. Speaker. Is it not the custom that before a statement is made Opposition spokesmen are issued with copies of it, so that they may give some prior consideration to it? Are you able to tell us whether in this case the Opposition spokesmen for Scotland and Wales have been issued with statements, so that they may be in 502 a position to deal with the problems that will face them?

§ Mr. Onslow
On a point of order, Mr. Speaker. I understood you to have called my right hon. Friend to make a statement, and I do not see how you can, so to speak, "uncall" him. Would it not be a great deal more orderly if he were to be allowed to make his statement? Hon. Members who found some deficiency in it could jump up and down afterwards.

§ Mr. Speaker
Order. The hon. Member for Woking (Mr. Onslow) is right. I have called on the Secretary of State to make his statement. I have been taking these points of order as a preliminary to the statement that the Secretary of State is likely to make.

§ Mr. Ennals
On a point of order, Mr. Speaker. At the time when you called the Secretary of State, presumably you did not know that the statement would not be dealing with Scotland and Wales, or that no announcement would be made about Scotland and Wales. May I, therefore, second the motion that has been put by my hon. Friend the Member for Nottingham, West (Mr. English), that permission be not granted for the statement to be made?

§ Mr. Speaker
I cannot accept such a motion at this stage. I have already called the right hon. Gentleman to make the statement.

§ Mr. Ioan Evans
When "Patients First" was issued, it was issued by the Welsh Office and by the Department of Health and Social Security. I understand that there is to be a statement about Scotland in the House next week [Interruption.] I thought that that was understood. That may happen. My point is that the present statement does not relate to Wales and that the announcement about Wales is apparently to be made somewhere else. We have not been told where it is to be made. Are not the Welsh Members being denied the opportunity to question the Secretary of State on what is contained in that statement?

§ Mr. Speaker
It is not my intention to confine questions to English Members—[Interruption.] I can do no more to help the House.

§ Mr. Foot
It is quite true, Mr. Speaker, as you have said, that you had called on the right hon. Gentleman to make his statement and that he had started to make it. Points of order have been made by several hon. Members, and certainly those from Wales have the larger grievance. Surely, in the light of what has occurred, it would be possible for the Leader of the House to say that he will make arrangements for a statement to be made tomorrow about England, as well as such statement as the Government may wish to make about Wales.
If the Leader of the House were to rise and make that suggestion, it would, I am sure, meet with the wishes of the House. It would get us out of the difficulty. Otherwise, there will be complete confusion about when a statement is to be made about Wales, when the Minister can be questioned, and how the rights of Welsh Members can be protected. I suggest to the Leader of the House that he is the person to rescue the House and the Government from the difficulty. It would be perfectly within the province of the Leader of the House to suggest that statements on both England and Wales should be made to the House tomorrow.

§ Mr. Speaker
Mr. Secretary Jenkin.

§ Mr. Speaker
Order. Points of order can be raised but they must relate to the rules of the House. I have tried to help the House as much as I can. I cannot do any more than call the Secretary of State, who has already started to make his statement. I suggest—[Interruption.] Order. I suggest that it is in the best interests of the House that we keep questions until after the statement has been heard.

§ Mr. Faulds
Further to that point of order, Mr. Speaker. There is, of course—[Hon. Members: "Speak up."] I think hon. Members will hear. There is another avenue of approach open to you, Sir. You could—it is within your powers—either on your own decision or at the request of the Chancellor of the Duchy of Lancaster, order a temporary suspension of the sitting of the House. That would give an opportunity—[Interruption.]

§ Mr. Speaker
Order. The hon. Gentleman must be allowed to make his point.

§ Mr. Faulds
Thank you, Sir, for your protection. That would give the Chancellor of the Duchy an opportunity to order his minions, the Secretaries of State for Scotland and Wales, to come here, where they should be, and make statements to the House rather than to issue press releases that are not open to immediate question by Members.

§ The Chancellor of the Duchy of Lancaster and Leader of the House of Commons (Mr. Norman St. John-Stevas)
Mr. Speaker, as far as I can see, the difficulty arises not over the statement being made on England but because a statement is not being made on Wales. We have had an indication that a separate statement is to be made on Wales. I suggest that while my right hon. Friend the Secretary of State for Social Services is making his statement on England I should pursue the matter to see whether the interests of other hon. Members can be met and consult my right hon. Friend the Secretary of State for Wales, who is here.

§ Mr. William Hamilton
On a point of order, Mr. Speaker. The Leader of the House could go much further than that. I think that Scottish and Welsh Members would be disinclined to accept that unless we got a specific guarantee that separate statements will be made on the Floor of the House next week, or some time soon. We must have that specific undertaking before we are prepared to consent to the statement being made by the Secretary of State for Social Services.

§ Mr. Rowlands
On a point of order, Mr. Speaker. I appreciate what the Leader of the House is trying to do, but without a clear assurance before the Secretary of State for Social Services makes his statement, many hon. Members will be in a dilemma. You have already said that you might not confine your calling of hon. Members to English Members. Unless we know that the Secretary of State for Wales is to make a separate statement this afternoon we shall not know whether to pursue our questions with the Secretary of State for Social Services. I hope that the Leader of the House will be able to state categorically that the Secretary of State for 505 Wales, who is present, will make a statement on the Welsh aspects of this problem now.

§ Mr. Robert C. Brown
On a point of order, Mr. Speaker. As a humble English Back Bencher, I should like to refer to the ruling that you gave a few minutes ago. I appreciate that you were trying to be extremely helpful to the House. You intimated that if the Secretary of State were to be allowed to make his statement you would not restrict questions to English Members. I am sure that you were trying to be very helpful, but it must be apparent that the moment the Secretary of State for Social Services is asked a question appertaining to Wales by a Welsh Member or a Scottish question from a Scottish Member, he will say that it does not fall within the purview of his responsibility. No matter how responsible and helpful you have tried to be, Mr. Speaker, the Secretary of State clearly will not be able to answer for Scotland or Wales. I feel that we are entitled to a further statement from the Leader of the House.

§ Mr. St. John-Stevas
Mr. Speaker, I have taken advantage of those exchanges to have a word with my right hon. Friend the Secretary of State for Wales. I hope that the House will be satisfied with this suggestion: with your permission, after my right hon. Friend the Secretary of State for Social Services has made his statement, the Secretary of State for Wales—[Interruption.] Just a minute; one thing at a time—the Secretary of State for Wales will make a statement, and the Secretary of State for Scotland will also make a statement on this subject, on a subsequent date, from this Dispatch Box. I think that we have done all that we can to be reasonable, even in July.

§ Mr. Jenkin
In response to the consultative document "Patients First", my Department received over 3,500 comments. I have had an analysis of these comments prepared and a copy has been placed in the Library. Further copies will be available in the Vote Office in a few days. There is considerable support for our proposal that the organisation of the National Health Service should be streamlined. Therefore, I am today issuing a circular to health authorities on the 506 changes to be made to achieve this. Copies of this and of my statement are in the Vote Office.
On structure, we have decided to remove a tier of administration. Instead of 90 area health authorities administering 199 districts, we will create a single tier of district health authorities. Each will serve a population of—generally—between 150,000 and 500,000. I have asked the regional health authorities to make recommendations to me on the boundaries of the new authorities by the end of next February after full consultation with interested bodies. I have told them that in order to minimise upheaval the new district health authorities should as far as possible follow the boundaries of existing health districts—including single district areas—because this should in most cases provide a satisfactory pattern.
I want the new authorities to enjoy considerable autonomy in managing their affairs. Greater freedom should encourage a greater sense of responsibility; and smaller authorities, closer to the communities they serve, should be more responsive to local needs.
With a view to enhancing local autonomy still further, I intend later on to review the role of regional health authorities. Regions' responsibilities for strategic planning, the allocation of finance to the districts and the maintenance of financial discipline will remain. Talks will be held between representatives of the doctors, my Department and the National Health Service on the future management of medical staff contracts with a view to seeking a way of reconciling my desire for more autonomy at the local level with the doctors' genuine concern that the benefits which have resulted from the existing arrangements should not be lost.
There is also strong support for our other main proposal—to strengthen management at the local level and remove the intermediate tier between the district and the local unit. Each district health authority, which will be served by a single management team, will therefore arrange the district's services into defined units, appoint senior people to manage them and give those people their own budgets. As far as possible, support services will be organised at that level. My objective is to get decision-making down to the 507 hospital and the community level. In order to give authorities greater flexibility on this, I am cancelling most of the existing instructions that require them to appoint specified officers to a substantial number of posts. District health authorities will decide for themselves what posts to create.
I attach high importance to effective collaboration between the National Health Service and local authorities. I propose, therefore, to retain the present statutory requirement for joint arrangements for collaboration. The creation of new district health authorities will, however, mean that in many parts of England health authorities and local authorities will no longer have common boundaries on a one-to-one basis. It is my hope that in most cases two or more district health authorities will make up one complete non-metropolitan county. I am proposing, in line with many views put to us, that health authorities should average around 16 members—significantly fewer than existing area health authorities. Within this total, I propose that local authorities should appoint four nominees.
There has been considerable support for community health councils; they will be retained in the new structure, with one CHC for each district. Later this year I shall issue a consultative paper seeking views on their membership, role and powers. When, after a few years, we have had experience of the working of the more locally-based district health authorities, I shall review the longer-term case for retaining these separate consumer bodies.
As foreshadowed in "Patients First", I intend to retain the structure of family practitioner committees, but I shall wish to study all the suggestions that have been made to improve collaboration with health authorities, especially in the planning of primary care.
I attach importance to close working between the National Health Service and universities with medical schools. I shall discuss with interested bodies the present arrangements for designating some health authorities as teaching authorities, taking account, for instance, of the extent to which medical students are now taught in hospitals run by non-teaching authorities.
The changes that I have announced imply no criticism of Health Service 508 managers. They have had to work in what turned out to be an unduly complicated structure. It is much to their credit that the Service has achieved what it has. However, staff at all levels will be affected by the changes, and there must be full consultation with staff interests on the ways in which change takes place. Staff must know that they are going to be treated fairly. We have put forward what I hope: are seen as fair proposals for the filling of posts in the new authorities, for staff protection and for early retirement and redundancy compensation. These proposals are being discussed with the staff sides and I hope that satisfactory agreements can be reached soon.
The 1974 reorganisation represented a major step forward in the integration of hospital and community health services, including primary care. It is the Government's policy, like that of our predecessors, that people should receive care in the community wherever possible. Further, the National Health Service is often criticised for neglect of prevention and of the more positive aspects of health promotion. The changes that I am announcing in structure and management will, by making the Health Service much more a local service serving local communities, reinforce this priority for community care, and should lead also to the closer involvement of the public with policies to promote good health. In this, the role of the relatively new medical speciality of community medicine will be of increasing importance.
The main purpose of the changes that I am announcing is to provide a Health Service that is better and more efficiently managed, and where local decisions can be taken more quickly by local people. At the same time, I am confident that it will be possible to make significant reductions in management costs, and I have told the Health Service that I expect these to be reduced, after a transitional period, by about 10 per cent., equivalent to about £ 30 million a year at present costs. This will release resources which could be used for patient care.
Management and structure, though important, will not solve all our problems. The Government have already embarked on a number of initiatives designed to get better value for money, improve links between the Health Service and local communities, and raise standards. In the 509 autumn I intend to issue a document outlining the Government's strategy and priorities for health. The proposals that I am announcing today will, when carried into effect, help to achieve what we all seek—a better service for our people.

§ Mr. Orme
The Secretary of State for Industry should have been present on the Government Front Bench to witness the U-turn that the Government have made on the National Health Service and the correction that they are attempting to make to his disastrous reorganisation. We shall want to consider the statement in detail. It contains a great deal of information and far-reaching proposals.
The Secretary of State has spoken of making a statement later in the year on future proposals. I have before me a document that the right hon. Gentleman sent to the chairmen of regional area health authorities recommending the extension of private practice within the Health Service, to which we are totally opposed. Within that document he excludes certain areas for consultation. He states that certain areas cannot be taken as a basis for consultation.
I welcome the fact that the right hon. Gentleman is to retain community health councils despite the antipathy shown by him and other Ministers towards the councils when they came into office. Why does not the right hon. Gentleman concede defeat on this issue? Why does he not accept that the councils have a crucial part to play in representing patients within the NHS and allow them to play their full part?
I note what the right hon. Gentleman said about savings. It seems that the Government's proposals will lead to a reduction in managerial staff of about 10 per cent. leading to savings of about £ 45 million gross. It is my understanding that that will mean the loss of about 4,500 management jobs and a net saving to the NHS of about £ 30 million a year. We want to know exactly how that is to be achieved and how it will affect the morale of the staff within the NHS.
That leads me to the redundancy agreement that the right hon. Gentleman has failed to reach with the trade unions, not least with NALGO. He has failed to agree to a staff commission, which NHS members have correctly requested, so that 510 their position may be considered along with the issue of redundancies. Are there to be redundancies, or is there to be natural wastage and reorganisation?
Linked with redundancy is the issue raised by my hon. Friend the Member for Wood Green (Mr. Race), namely, consultations with the TUC and unions in the Health Service such as COHSE, NALGO and NUPE. Is the Secretary of State having consultations with those unions? If so, how are the consultations proceeding?

§ Mr. Michael Morris
What about the patients?

§ Mr. Orme
When we dealt with community health councils, we were dealing with the representatives of patients. It was the Conservative Party that wanted to get rid of that representation. We are concerned about patients. We did not hear very much about patients from the right hon. Gentleman.
I turn to the question of democracy within the Health Service. The Government are taking a backward step by reducing local government representation on the new district health authorities. To reduce that representation from one-third to one-quarter with a maximum of 16 members means that where there have been eight local government representatives in the past there will be only four in future. Local government representation, which is an indirect method of democracy, has, in effect, been removed.
My next concern is the size of districts. There seems to be a change in the statement and in the paper that the right hon. Gentleman has issued from that which was proposed in "Patients First". It applies to sizes and areas. I hope that the right hon. Gentleman will comment on that and will tell us the number of areas in which he envisages there will be more than one district. I had hoped that reorganisation would get rid of overlapping in the National Health Service.
Paragraph 33 of the Secretary of State's circular states: The disappearance of AHAs … will impose special strains which could lead to a serious breakdown … This must not be allowed to happen. What does the Secretary of State mean when he says that it should not be allowed to happen? 511 How will he prevent it? What action will he take?
Conservative Members should recognise that we are dealing with patients and with 1 million employees. This is an important subject. The Tory Government made such a hash of the previous reorganisation that we want to get it right this time. I notice that there is an appendix to the document, which deals with London. However, it does not deal completely with London, and there is an urgent need to hold a major inquiry.
The Secretary of State made his statement against a background of public expenditure cuts in the National Health Service. We are concerned about the maintenance and improvement of the National Health Service. We are also concerned about patients within the National Health Service, and about funding. While some of the proposals for reorganisation may be seen as a sign of progress, the proposals do not meet the problems of the National Health Service today.

§ Mr. Jenkin
Given that the Labour Party has always expressed itself broadly in favour of such streamlining, I think that that was a fairly uncharitable response from the right hon. Gentleman. The document is not concerned with private practice, although perhaps it is characteristic that the right hon. Gentleman should have made that his first question. I have never shown any antipathy towards community health councils. Over the next few years those bodies must be seen to justify their existence, because they cost money.
Most of the staff associations and unions that responded to the document "Patients First" expressed themselves broadly in support of the proposals for streamlining and decentralisation. The terms for protection and redundancy and the other issues that the right hon. Gentleman mentioned, are being negotiated by a special negotiating group, which is a sub-committee of the general Whitley council.
I consulted all the main unions involved in the National Health Service. Either my hon. Friend the Minister or I met the unions and discussed their representations. We agree with the Royal Commission that collaboration between health authorities and local authorities depends, 512 above all, on the will to collaborate. It does not depend on the number of local authority members on health authorities.
The right hon. Gentleman was right about the size of the district. In "Patients First" we leant towards the larger district. However, the representations that were made to us suggested overwhelmingly that the smaller district would be more in accordance with the wishes of those who run the National Health Service. That is why we made that shift.
I shall now turn to finance and the risks of breakdown mentioned in paragraph 33 of the circular. When the National Health Service was last reorganised, control over finance was not as good as it should have been during the change that took place after the election. We intend to take steps, through regional treasuries and, in particular, by setting firm manpower management cost limits on each health authority, to ensure that financial control remains intact.
I understand the right hon. Gentleman's wish for a more general inquiry into London. I have appointed an advisory committee, under the chairmanship of Sir John Habakkuk, to advise me on all the issues involved. The appendix gives advice on the reorganisation of London and it is one of the first pieces of work that the advisory committee has done. It is attached to the circular with my blessing. London has difficult problems. However, I do not believe that an open public inquiry, which would necessarily take a long time, would help towards their resolution.

§ Mr. Beith
Will the Secretary of State note that we certainly support any attempt to undo the damage done by the Secretary of State for Industry when he wished such a ridiculous structure on the National Health Service? Does the right hon. Gentleman recognise that getting decision-making down to the local hospital and local community level is at least as important as removing a tier from the administration? Will he continue to emphasise that point? Does he accept that community health councils will remain essential unless there is more democracy in the National Health Service and unless Ministers appoint fewer people, not more? Are there not too many jobs for the boys in the appointment of such bodies?

§ Mr. Jenkin
I support the hon. Gentleman's remarks about the need to make decisions at the community and hospital level. In "Patients First" we said that that was the most important feature of reorganisation. We want to make it work effectively. As long as almost all finance comes from central Government and from my Department in the form of cash allocations to the National Health Service the Department is accountable. I or the regions, therefore, must, appoint the members of health authorities. As the hon. Gentleman knows, we are examining alternative methods of financing the National Health Service. By getting greater decentralisation by means of an insurance system, local health authorities may become more accountable to local communities.

§ Mr. Crouch
I am glad that my right hon. Friend and his colleagues on the Front Bench have responded to the genuine demand for three separate statements. There are three separate health organisations and that is, therefore, appropriate. I am grateful to my right hon. Friend. I am delighted that he has taken note of the desire to retain community health councils. They provide an element of democracy for the community and for the patient. They cost the small sum of about £ 4 million a year. If the number of elected local government representatives on the new district health authorities is to diminish, my right hon. Friend should consider whether the amount of money provided should be increased and whether it is possible for such representatives to put in the proper amount of time.
I am concerned about democracy in this essential aspect of our social services. My right hon. Friend said that local decisions, taken more quicky by local people, was his aim. I have heard nothing this afternoon from my right hon. Friend to suggest that decisions about disputes among the 1 million employees will be taken at a local level. If they were taken at a local level and not referred all the way to the Secretary of State, we might eliminate the disputes that must arise when people are employed by an employer who is also a Secretary of State.

§ Mr. Jenkin
I thank my hon. Friend for his support. The community health councils and those who spoke for them 514 have made their case. One of the arguments that weighed with me was that community health councils have many members from voluntary bodies. They are often best placed to speak on behalf of the Cinderella services, such as the services for the mentally ill, the mentally handicapped and the very old. Such people might otherwise not receive the priority treatment that successive Ministers have desired to give them. We shall be issuing a consultative paper on community health councils later in the year.
As I said in answer to the hon. Member for Berwick-upon-Tweed (Mr. Beith), local decision-making is a crucial part of the reorganisation. We intend to ensure that the people who run the show in the hospitals and in the communities have seniority and experience, and their own budgets, so that they can take decisions on the spot. Such people will include the administrator and senior nurse who might be called the director of nursing services. They will have the authority.
I am surprised at what my hon. Friend said about disputes. We brought to fruition the initiative taken by the right hon. Member for Norwich, North (Mr. Ennals) for establishing local disputes procedure. Since I have been in office no industrial dispute has been decided by any Minister in this Government.

§ Mr. Speaker
Order. I remind the House that there is to be a statement by the Secretary of State for Wales. If questions are succinct I shall be able to call more hon. Members.

§ Mr. Ennals
Does the Secretary of State recognise that most people in the country and in the Health Service will welcome the decision to put right most of the gross errors committed by the present Secretary of State for Industry? Is he aware that most people will also welcome the decision to retain the community health councils? We welcome the tribute that he paid to the administrators, who have done a difficult job.
The Secretary of State referred to decisions being taken at a local level. I agree with the spirit of that. May we have an assurance that the Service will continue to be a National Health Service, with national standards? Many 515 of the criticisms of "Patients First" implied that the Secretary of State was looking too much towards a hospital-based service as opposed to a community-based service. Will he comment on that criticism, since such a proposition would be a backward step?

§ Mr. Jenkin
I thank the right hon. Gentleman for his welcome for the main thrust of our proposals. Of course, we have a National Health Service and we shall progressively work towards achieving more national standards through the resources allocation process. The speed at which we can do that depends on the money available. The view that "Patients First" was hospital-orientated was partly due to inadequate drafting and partly due to a misunderstanding by the readers. There was never any intention that it should be so.
If the right hon. Gentleman studies the circular he will discover that it fully endorses what I say. For example, a unit can be a mental illness hospital, the psychiatric community services, and the psychiatric services in a district general hospital. I believe that a more local service will reinforce the general proposition that as many patients as possible should be cared for in the community.

§ Mr. Paul Dean
Will my right hon. Friend confirm that the essential element in his statement is that we can now welcome back the hospital matron and that management decisions will be made in the local hospital and in other places where health care is given? Will my right hon. Friend keep an open mind about having exactly the same pattern of administration throughout the country? Does he accept that in some compact counties, such as Avon, savings on administration and co-operation with a university and with the social services of the county council might be best achieved by having one tier of administration rather than several based on the districts?

§ Mr. Jenkin
I am grateful for my hon. Friend's welcome. If a health authority decides, with the consent of the staff, that the senior nurse in a hospital should be called a matron, I shall have no objection. Of course, it is not an appropriate title for a male nurse. I believe that there will be wide support for the proposition that there should be a senior 516 authoritative chief nursing officer in each hospital to reassert authority.
My whole instinct leans towards the pattern of district health authorities that I outlined in my statement. The over-whelming thrust of representations reinforce that view. Bodies and organisations running the health services on the ground are in favour of that pattern of reorganisation. It will be for the regions to put forward proposals for the structuring in their regions. My hon. Friend and others who have views should put them with all the force that they wish to the regional health authorities so that they can be taken into account.

§ Mr. Pavitt
The Secretary of State has made a wide-ranging and comprehensive statement, which will affect the whole of the National Health Service. It is the prelude to a number of statutory instruments arising from the Bill that will reach the statute book shortly. May we have an undertaking that the Secretary of State will consult the Leader of the House so that immediately after the recess we may have a full-scale debate on the matters which are too complex for a question-and-answer session?
The regional health authorities are to advise the Secretary of State on the boundaries for the new district health authorities. What is the position of Members of Parliament? Do we make our representations about boundaries to the regional health authorities? Will we have the opportunity, through a Select Committee, for example, to discuss that matter?
Will the Secretary of State say more about coterminosity with the social services departments? The Secretary of State has made a hospital-oriented statement. What will happen to the family practitioner committees? Will they be split up and become part of the district health authorities? In what way will the general practitioner be integrated with the new work? Will there be a further tier at hospital level comprising a committee governing the district general hospital, for example?

§ Mr. Jenkin
I am grateful for the hon. Gentleman's welcome of the proposals. He will know that it was agreed earlier in the year that there should be a full day's debate at some stage which could be linked with the statutory instruments 517 which carry into effect the first stage of the reorganisation. The precise date is a matter for the Leader of the House.
In the first instance the regions will recommend boundaries after consultation. In the end I shall decide in any case over which there is a dispute.
"Patients First" makes it clear that it would be ideal if it were possible to have a viable district health authority coterminus with its local social services authority. There is wide-spread recognition that in 1974 the principle of coterminosity was elevated to the point where it operated to the detriment of the management of the Health Service.
The question of family practitioner committees will have to be considered when we know the district structures and to what extent it is necessary to make use of the powers in the Bill being considered in another place, which reorganises the family practitioner committees.

§ Mr. McCrindle
Is my right hon. Friend satisfied that the welcome moves that he has announced really will lead to a reduction in bureaucracy within the Health Service? Is he aware of the widespread fear that the staffs of the area health authorities will be queueing up to join the newly formed district authorities? Is he aware of the fear that the district authorities might start operating more highly staffed than is strictly necessary? When my right hon. Friend considers the composition of the community health councils, will he take into account the possibility of voluntary bodies being more prominently represented?

§ Mr. Jenkin
I am grateful for my hon. Friend's support. Our settled determination is to reduce the amount of bureaucracy in the National Health Service. We shall impose strict management cost limits and it will not be open to health authorities to overstaff their structures. There is widespread support for the view that voluntary bodies should be more fully represented on CHCs. That is one of the matters on which we shall consult interested bodies later in the year.

§ Mr. Arthur Lewis
I am the only hon. Member present who had the pleasure of voting for the Health Service, against the Tories, when it was introduced, and I was 518 overlooked by you, Mr. Speaker. May I therefore congratulate the Secretary of State on retaining community health councils—a decision that gives my constituents and myself great pleasure? The right hon. Gentleman avoided the question of the hon. Member for Berwick-upon-Tweed (Mr. Beith) on costs. How many thousands of millions of pounds has "Joseph's folly" cost the Exchequer and the taxpayer? The Government wish to cut expenditure, and perhaps the right hon. Gentleman can later give us a figure for the cost of "Joseph's folly".

§ Mr. Jenkin
The hon. Gentleman will recognise that his second question, by its nature, is impossible of answer. There is widespread recognition that the structure is over-elaborate and cumbersome, which has hampered decision-making. Some very unkind remarks have been made about my right hon. Friend the Secretary of State for Industry, but at the same time Labour Members have been swift to praise community health councils. He invented them.

§ Mr. Hordern
Does my right hon. Friend recollect that when area health authorities were formed during the previous reorganisation of the Health Service the number of administrators increased by about 20,000, which was 25 per cent., in what my right hon. Friend describes as an unduly complicated structure, which the Labour Government did nothing to correct? As area health authorities are to be abolished, may we expect a commensurate reduction in administrators?

§ Mr. Jenkin
Although in Health Service terms people are called administrators, the great majority are managers. Competent and effective management is essential to manage £ 8 billion or £ 9 billion. We want to make sure that that management works within a structure in which it is possible to manage effectively. I believe that that will mean fewer administrators, which will in no sense reduce the enormous importance to be attached to the administrative function of managing the National Health Service.

§ Mr. Joseph Dean
As an ex-local authority member of an area health board, may I tell the Secretary of State that his proposals to reduce the number of local authority places from over 30 per cent. to 25 per cent. will be greeted 519 with dismay? Bearing in mind my recent experience, of which the right hon. Gentleman is aware, does he really believe that his proposals will democratise the Health Service? When I wrote to the right hon. Gentleman on 2 July I pointed out that the chairman of the Yorkshire regional health authority had refused point-blank to let me have, as a Member of Parliament for a Leeds constituency, the proposals that area health authorities were making in response to "Patients First". Sir William Tweddle is answerable to no one, and apart from the refusal I have received only an acknowledgment card. May we be assured that we shall be given more consideration over these proposals?

§ Mr. Jenkin
There is not universal support for reducing the number of local authority members. However, apart from local authority associations, which wanted a measure of retention or increase, virtually everyone concerned primarily with the Health Service argued for much smaller health authorities and smaller local authority representation. That is the view that we accepted.

§ Mr. Race
How many?

§ Mr. Jenkin
The hon. Gentleman will be able to look at the summary of the responses to "Patients First" and make a judgment. Without wishing to comment on the issue raised by the hon. Member for Leeds, West (Mr. Dean), in the light of the consultations, regions have been taking informal soundings in their areas on how they might respond once they saw which way the wind was blowing. Those soundings are informal, purely to inform the administrators at regional level what may come forward. The formal consultations required by the circular that I am issuing today will take place on a wide and public basis, and Members of Parliament are included among those who will have to be consulted.

§ Mr. Kershaw
May I welcome my right hon. Friend's retention of community health councils, which is a prudent insurance? Will the greater independence that it is proposed to give to local bodies include the possibility of their collaboration with the private sector in medicine, if that seems to them to be a good idea?

§ Mr. Jenkin
We are consulting the Health Service on how best to bring forward collaboration with the private sector. It is not in the best interest of patients and people generally to maintain the medical apartheid that our predecessors invented. We wish to encourage collaboration in every way possible. I hope that the new local health authorities will be able effectively to carry that forward.

§ Mr. Speaker
Order. I propose to call the three Conservative Members who have been standing and four Labour Members.

§ Mr. Faulds
Has the right hon. Gentleman requested a letter of apology, regret and contrition from his right hon. Friend for having created the chaos, which he has a genius for doing with whatever he touches, by his original reorganisation of the NHS, from which the right hon. Gentleman is now trying to extricate us? If not, should he not?

§ Mr. Jenkin
The hon. Gentleman should recognise that one of the main purposes of my right hon. Friend's reorganisation six years ago was the much closer integration of hospital services, community services and primary care. That has been substantially achieved, and we are building on that achievement.

§ Dr. Mawhinney
May I congratulate my hon. Friend on his most welcome statement, which is not only moderate and sensible but puts patient care first? Does he plan to say anything about the ambulance service in the near future?

§ Mr. Jenkin
When my hon. Friend studies the circular he will see that there is a paragraph about services that are currently carried on at area or other levels. It will be for health authorities to make recommendations and to consult on how best those services can be carried on in the new structure. A whole range of options are open to them.

§ Mr. Race
Will the Secretary of State assure us that when the consultative document on community health councils is issued later this year there will be no proposal to reduce the statutory power of a CHC to refer a hospital closure to the Minister? Will he also assure us that there will be no attempt to reduce the proportion of local authority representatives on 521 community health councils? Can he confirm that regional health authorities will also be asked to make a 10 per cent. reduction in management costs, notwithstanding the amount of management expenditure that they incur at present?

§ Mr. Jenkin
With regard to the hon. Gentleman's question about the consultative paper on CHCs, I am sure that he will agree that both the points that he raises are matters on which it would be wise to consult a wide range of people before we determine the matter. It will be for the regions to decide in relation to each of the health authorities for which the management cost limit is imposed, what is the appropriate limit. It would be impossible for me to do that centrally.

§ Mr. Latham
Since the county of Leicestershire, with 800,000 people, which currently has one area and three district health authorities, will presumably have two or even three district health authorities under the proposals, will my right hon. Friend assure us that he will not allow bureaucratic co-ordinating committees to be set up to deal with the lack of coterminosity?

§ Mr. Jenkin
The word "flexibility" has shone through a great many of the representations that have been made. We have been asked to leave the maximum flexibility for local health authorities to decide on their own structure. The only statutory requirement will be to have a team of officers at district level and senior managers at hospital and community level, and to have a joint consultative committee. Apart from that, it will be for local health authorities to determine how best to organise their management structure, which will include the matter mentioned by my hon. Friend.

§ Mr. Hardy
Is it not clear that, whatever changes are made, the areas that receive an inadequate share of NHS resources will continue to experience severe need? South Yorkshire patients come second. In carrying out the changes, will the Secretary of State guarantee the improvement in provision without which no administrative change can be successful?

§ Mr. Jenkin
I am not sure that that arises out of the statement, but I refer the hon. Gentleman to the public expen- 522 diture White Paper, which proposes an increase in resources nationally of nearly 2 per cent. a year up to 1984.

§ Mr. Michael Morris
Is my right hon. Friend aware that the extent of his consultations on "Patients First" is widely welcomed? What safeguards are there for the district health authorities that disagree with the apportionment they receive from the regional health authority, as happens now, certainly in the Oxford region?

§ Mr. Jenkin
I have not detected that district health authorities are slow to bring their grievances to the attention of Ministers, either directly or through their Members, and that channel will remain open. In the end, the allocation by the regions must be a matter for them, because otherwise there would be an enormous mass of centralised decision making in my Department.

§ Mr. McNally
Where do health centres fit in to the right hon. Gentleman's general philosophy on primary care? Will he give an assurance that when an area authority is convinced that, because of low income or social stress, a health centre is needed in a particular area, there will be no attempt by the Government to dissuade it from going ahead?

§ Mr. Jenkin
Two factors that must dominate in deciding whether a health centre is built are whether there is a demand for it and whether it will be used effectively. If those criteria are satisfied and the resources are available, a health centre may be built. But too many health centres have stood empty or been used for other purposes. That is why we are taking a more cautious view on the building of health centres.

§ Mr. Moyle
No doubt the Secretary of State will agree that, apart from looking after patients first, one of the major arguments for reorganising the NHS is to improve staff morale. A series of officers of health authorities—laundry officers, catering officers, works officers and those in personnel and medical records, together with some nurses—are being organised on a functional basis, which is to be swept away. They will be placed in district health authorities without a structured organisation underneath them. What action does the right hon. 523 Gentleman intend to take to protect those groups?
The right hon. Gentleman did not answer a question put by my right hon. Friend the Member for Salford, West (Mr. Orme). Will he institute a staff commission to look after the staff? After all, we calculate—and I should like the right hon. Gentleman's confirmation—that about 4,500 management jobs in the NHS in England are likely to go.
The right hon. Gentleman's proposal to subject community health councils to continual review will be regarded in the country as a rather clumsy attempt, which will fail, to emasculate bodies that should be essentially independent if they are to do their job. Does the right hon. Gentleman realise that his fragmented approach to the future planning of health services in London is not carrying the people of London and that that will lay up trouble for the future?
Will the right hon. Gentleman look again at the problems of community and social service planning? The organisation that he has introduced has made that much more difficult by moving away from coterminosity, reducing the number of local authority representatives on health authorities and making the institution of joint planning machinery between the two groups much more difficult. Is he aware that some district health authorities, covering populations of 150,000, will be too small to do their job?

§ Mr. Jenkin
The action to protect the groups to which the right hon. Gentleman referred is the subject of negotiation in the special negotiating group to which I referred. The question of a staff commission has been raised with me by the unions, but I am extremely loth to go for the sort of cumbersome, bureaucratic staff commission that was set up under the 1973 Act. I am certainly prepared to consider a national appeals procedure for the few cases that cannot be resolved through the regional appeals machinery.
There will not be a continuous review of CHCs. I said that it would be right to look at them again after some years. The councils can plan for the next few years on the basis that they have a clear function to perform.
We have been over the ground on the provision of health services in London, 524 and I disagree with the right hon. Gentleman's views. I want to see reorganisation in London taking place, if possible, within the same time scale that applies to the rest of the country. The massive public inquiry that the Labour Party is advocating would make that impossible.
As for planning with social services, the logic of the right hon. Gentleman's question is that, if we are to keep a whole number of one-to-one coterminosity arrangements with every local authority, the NHS will retain its existing over-cumbersome, bureaucratic structure. The right hon. Gentleman cannot have it both ways.

§ Dr. M. S. Miller
On a point of order, Mr. Speaker. May I ask you whether, when future statements affecting England are made and we are promised by the Leader of the House that later statements will be made for Wales and Scotland, you will make that clear to us beforehand so that those of us who represent Scottish constituencies will know where we stand? Even those of us who represent Scottish constituencies have general interests affecting the NHS and we should like to have been brought into the debate.

§ Mr. Speaker
I understand the hon. Gentleman's feelings. I made the offer to the House earlier that I would call hon. Members from all parts of the United Kingdom. It was brushed aside and the demand for another statement continued. Another statement is about to be made, and the House has been given an assurance that there will be a statement on Scotland next week. I felt that I had better confine myself to calling those who represent English constituencies, and even so many English Members have not been called.

§ Mr. Cryer
On a point of order, Mr. Speaker. I wish to raise a point that I have raised on a number of previous occasions. I thank you if you have used your influence in getting the statement of the Secretary of State for Social Services deposited in the Vote Office today. You have demonstrated your sympathetic support for statements to be deposited in the Vote Office when they are made by a Minister to the House.
It was of assistance to have today's statement put in the Vote Office. The process was relatively painless for the 525 Government—at least as regards the depositing of the statement—and was helpful to Back Benchers. If you used your influence, Mr. Speaker, I urge you to continue to use it with other Ministries so that, as a matter of routine, most major statements are put in the Vote Office when they are made. It is a step forward and should be marked as such.

§ Mr. Speaker
I should tell the hon. Gentleman and the House that the virtue that he attributes to me belongs to the Leader of the House, because the statement was not deposited in the Vote Office as a result of pressure from me.

§ Mr. Kenneth Lewis
On a point of order, Mr. Speaker. As a mere Englishman I am sorry to prolong the proceedings, but we are setting an unfortunate precedent if, when a statement is made by a United Kingdom Minister, statements on similar lines have to be made by the Secretaries of State for Scotland and Wales. I object to that. It is not in conformity with the best traditions of Parliament, and I hope that it will not happen again.

§ Mr. Speaker
With the name that the hon. Gentleman has the privilege of enjoying, he might have claimed to be Welsh.

§ Mr. Parry
On a point of order, Mr. Speaker. Would it be possible for you to call Members from the regions? We on Merseyside have hospitals being closed at a rate exceeded only by the rate of unemployment in Liverpool.

§ Mr. Speaker
Order. It will be intolerable if I am to be told that I must go into almost every constituency. The hon. Gentleman is not being fair to me. I have to think of the rest of the House. I called an hon. Member from Lancashire, as the hon. Member for Liverpool, Scotland Exchange (Mr. Parry) will see if he looks at the list.