HC Deb 09 June 1980 vol 986 cc99-141

' In section 7 of the National Health Service (Scotland) Act 1978 at the end of subsection (3) there shall be added : Provided that no scheme shall be approved by the Secretary of State under this subsection which changes the boundary of a local health council or reduces the number of local health councils in the area of a Health Board except by an order to that effect by the Secretary of State, and no such order shall be made unless a draft thereof has been laid before Parliament and approved by a resolution of each House of Parliament." '—[Mr. George Robertson.]

Brought up, and read the First time.

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Mr. George Robertson (Hamilton)

I beg to move, That the clause be read a Second Time.

Mr. Deputy Speaker (Mr. Richard Crawshaw)

With this we may discuss new clause 18—Health Board Districts.

Mr. Robertson

This selection of new clauses gives us a welcome opportunity to discuss for the first time in this House some of the proposals put forward by the Government in the document entitled "Structure and Management of the National Health Service in Scotland". The purpose of the Opposition in tabling new clauses 17 and 18 was to put down a marker for the future conduct of the Government in the way in which they might deal with the proposals that they put forward in their document.

The main recommendation in the document "Structure and Management of the National Health Service in Scotland" was for the abolition of the districts—a level of administration below the health boards. That is an administrative possibility that could be embarked upon by the Government without coming back to Parliament, and as that is a far-reaching development of some considerable significance to the future of the Health Service in Scotland, the Opposition believe that no such decision should be made without reference to Parliament. The effect of clause 18 would be to lay a mandatory charge on Ministers to bring forward an order to the House of Commons before any change could be made.

New clause 17 is designed to do precisely the same for the local health councils, the other area outlined by the Government for administrative change in their consultative document. New clause 17 is, indeed, the one about local health councils, but I should like to say a few words in introducing the debate on new clause 18 in so far as it relates to the districts within the existing National Health Service structure.

When the National Health Service was last reorganised in Scotland, the district level of organisation was one that was left very much to the health boards themselves to determine. The Secretary of State retained for himself only the opportunity to veto the changes that were put forward by the health boards to his Department. At the moment, only 10 out of the 15 health boards in Scotland even use a district level.

The consultative document, in a brief introduction to what can only be described as a very brief and rudimentary paper, starts by saying : The Secretary of State considers, and the views of the Royal Commission confirm this, that no further substantial reorganisation is required in Scotland. I am sure that most hon. Members on both sides of the House would concur with that conclusion.

What we can conclude from that statement is that there should be no change in the structure of the National Health Service in Scotland simply for the sake of change. That would be a conclusion that would be too easy to derive from the Government's consultative document, because it goes on to recommend, two pages later, a major—indeed, one might say a fundamental—change in the structure of the Health Service and the way in which it is organised in Scotland. The document states that boards should now be organised so that there is to be no multidistrict structure below the area board level. Indeed, paragraph 12 states that the Secretary of State therefore considers that all boards should work on the basis that the normal structure should be a single district area. The consultative document is poor—not to say empty—on the real rationale behind the Government's conclusion that they should eliminate the multi-district level that exists in only 10 of the Scottish health board areas. It is quite clear, from discussing this matter with people who are involved in the Health Service in Scotland—whether at health board, area or sub-health board level—that there is no clear reason in their minds why the Government should have concluded that in Scotland anyway there should be a reorganisation proposed of this type that would, at one fell swoop, eliminate a complete district that exists and works quite effectively in health boards throughout Scotland.

Indeed, the proposal for yet another generalised reform of the Health Service appears to be in flat contradiction of the conclusions that were arrived at by the Royal Commission on the National Health Service, when it talked about a flexible structure and the need to get away from simple one-off solutions for the whole of the National Health Service.

Paragraph 20.48 of the Royal Commission's report said : The NHS is not a tidy construction and it still bears the mark of the haphazard growth of health services before 1948. Arrangements which will suit one part of the United Kingdom will be wholly unsuited to another. At the same time as the Royal Commission says that about the Health Service in the United Kingdom as a whole, the Government take one of the Commission's other conclusions, that relating principally to the organisation of the Health Service in England and Wales, and are about to introduce it in the National Health Service in Scotland.

Perhaps this evening we shall have an opportunity to hear from the Under-Secretary of State for Scotland precisely why the Government at this stage are taking one conclusion of the Royal Commission and pitting it against the overwhelming conclusion relating to the geography, the proven need and the flexibility of structure that exists within the rest of the Royal Commission's recommendations.

There are, of course, other problems that have been thrown up by the consultative document. The Government say that there should be no further substantial reorganisation in Scotland, but I am sure that the Minister will not deny that there has been a significant impact on health board morale as a result of the proposals put forward in his consultative document.

People in Scotland who felt that the structure was operating reasonably well, and who had no reason, through public comment, to doubt that the structure had been accepted by the bulk of the Scottish population, must have been surprised to learn that the Government were coming forward with such a far-reaching proposal for reform. There has undoubtedly been an effect on staff morale because of the uncertainty that exists, during the consultative period, about the whole organisation that will exist within health boards after the consultative document and its proposals are brought forward with a view to administrative change.

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If the Government were to go ahead with the proposal in their consultative document they would remove the districts from, principally, the large health boards in Scotland. In the largest of the health boards, in Greater Glasgow, in Lothian and in Lanarkshire, the districts are performing a function that has been sadly underestimated up to now. In my area, in Lanarkshire, the districts are responsible for populations in excess of 200,000 people. Indeed, these districts are larger than the area health boards in some parts of England. Therefore, what may be a solution to the English problem is not likely to be immediately translated into the Scottish environment.

If the districts are, willy-nilly, to be abolished in Scotland—districts which look after such large sections of the population—there will, as a consequence, be a gap between the area health boards and the unit and sector administrations in charge of the hospitals and the community facilities.

That gap will create problems for monitoring and for controlling the activities of the unit and sector level, as well as creating major problems in terms of training and the provision of a proper career structure for staff in the Health Service. In some of the health board areas in Scotland the gap would be far too wide, and the conclusion of the Royal Commission on the National Health Service that there should not be one simple solution or one sweeping reform is easily illustrated by the Government's resort to a solution that was genuinely and initially designed for the National Health Service in England.

The Government's proposed abolition of the district level of administration means that there is genuine concern that the hospital units will be strengthened at the expense of the community medical services. That intermediate tier has operated well and effectively in so many areas, and its demolition may concentrate power in a way that neither the Government nor the Opposition would want to see. On the basis of the consultative document it seems that the Government have given inadequate consideration to this matter. We shall be interested to hear from the Minister what is the Government's initial response.

I should like to say a brief word about the local health councils. I say "brief" not because I consider the matter unimportant, but because I know that many of my hon. Friends will raise the issue. If I catch the eye of the Chair later, I can perhaps pick up some of the points that they make about their own areas.

The fundamental question that must be asked about local health councils is whether they are necessary at all. That is a question which, apparently, the Government have not answered. The references to local health councils in the consultative document have left widespread uncertainty among local health councils throughout Scotland. Indeed, the weighty submission to the Secretary of State from the Association of Scottish Local Health Councils is explicit on this point. It says : The consultative paper for Scotland does not propose the abolition of local health councils but it is worded in such a way as to make it clear that their future is not assured. That is a widespread feeling among a large number of health councils.

The uncertainty created by the Government's inadequate treatment of this subject in the consultative document worries them considerably. The Opposition believe, as the previous Government did when they introduced this feature into the legislation, that the consumer's voice is necessary and integral within the NHS, and that by and large local health councils throughout Scotland have done an admirable job in reflecting the views of the health service consumer as well as the community at large, in 1relation to the problems thrown up in the day-to-day administration of the NHS.

Indeed, if there is any fault in the existing local health council structure, it is not that they are too strong, or that there are too many of them, but perhaps that they are too weak and that by statute we should have given them clearer and tougher guidelines within which to operate. I believe that they should have a statutory right to be involved in policy making at a level at which they can affect the eventual outcome of such decisions. I believe, too, that they should have access to NHS facts and figures and to the information that is necessary to make proper use of them. There is a good case to be made for allowing them to represent patients on the various tribunals and bodies to which patients can make complaints against health boards.

If reforms are necessary in the local health structure, and if it means a reduction in the number of health councils, we must ensure that mere is a strengthening of staffing, resources and powers of the local health councils so that the bodies that administer health in Scotland faithfully reflect the views of those in the community who use the NHS.

The NHS is not a luxury for the community, the country or for anyone, especially in Scotland with its own particular and special health problems. It is a necessity for the survival of the people. It should not be tinkered with, administratively or in any other way, simply to satisfy a lust for change which is unsubstantiated either by the facts or by experience. The NHS in Scotland deserves more than that, and we hope to hear a clarion call for its future from the Minister this evening.

Mr. William Hamilton

The document on which the legislation for Scotland is based was a consultative document. But it was quite clear that the Government had virtually made up their minds about what they wanted to do. It is quite clear from the White Paper that the Government would like to see a diminution in the size or number, or both, of the local district councils and the health councils.

I hope that the Minister will take the opportunity to give us an extensive assessment of the negotiations. I do not know whether they have been completed, but they should have been. I hope that he will indicate which authorities are wholly or even partly in favour of the proposals contained in the consultative document. From the representations that I have received from throughout Scotland, it seems to me that the vast majority of informed opinion which knows about the Health Service, and has worked in it or for it or has engaged in some activity connected with it, is opposed in whole or in part, strongly or lukewarmly, to the Government's proposals.

I know, and I think all other hon. Members know, that the administration and management of the Health Service need changing. There has been constant criticism from all parts of the House, mainly from the Labour Benches, that the 1974 reorganisation was a disaster, that what was created was far too heavy on the administrative side and that it contained far too little democratic content.

As a Member of Parliament, I often have difficulty in pinpointing the area at which a complaint can be focused. Indeed, when new appointments are made at health board level, I invariably go along and say "I want to direct my complaints about the Health Service to you as the chairman of the health board". I do not know whether it is my bullying approach, but invariably it is agreed that that should be done. It is convenient for me to send letters of Health Service complaints to the chairman of the health board, because he or she can direct them to whichever part of the Health Service they apply. That is one of the problems with which any Government who are concerned with the effect of administration on the Health Service must be concerned.

Mr. Bill Walker (Perth and East Perthshire)

Does the hon. Gentleman agree that one of the problems is that ordinary members of the public do not know who runs the health boards and that those boards appear to the public to be very undemocratic? The people involved may be extremely dedicated and efficient, but because the boards appear to be undemocratic, or non-elected, the public have no idea to whom to go.

Mr. Hamilton

I shall deal with that point when I deal specifically with the local health councils.

There have been relatively few years in which those organisations could prove or disprove themselves, yet the Government are now virtually saying "We shall reduce their numbers or their functions, or both". But so far that has been the only effective way in which the consumer interest can be represented. It may be inadequate. I think that it is. I think that the publicity which the health councils have received has been wholly inadequate. That may be their own fault or the Government's fault in not providing the finance. Whatever the reason, they are not effective in representing the views of the consumer. If one asked the man in the street to name the members of his local council and to say what they did or were supposed to do, I believe that he would look blank and be unable to answer.

Mr. Robert Hughes (Aberdeen, North)

Does my hon. Friend agree that the difficulty is that health councils are specifically debarred by statute from taking up individual complaints about the Health Service?

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Mr. Hamilton

I must continue with my speech. I shall cover most of the points that are being raised by hon. Members, and if at the end of my speech hon. Members feel that I have omitted matters of importance they can then make their points.

I return to the question of the consultative document. It goes out of its way to state that the Royal Commission did not suggest any major changes in the Health Service because it did not feel that there was very much wrong with it, and, therefore, the Government would not make any substantial change. It states that there will be "no further substantial reorganisation", but that administration needs simplifying.

During the debate on a previous amendment, I pointed out that the English consultative document is entitled "Patients First". In the Scottish consultative document there is no mention of patients except on page 11. That page refers to "good patient care". In 11 or 12 pages of the document there is much jargon about hospital administrators, functional managers, unit administrators, sector administrators, line managers, functional hierarchies, clinical divisions and so on. But the Health Service exists for patients and no one else. Unless we keep that fact constantly in mind we shall not get the right answers to the administrative and management problems.

The changes that are proposed are substantial. Every organisation that has written to me, and to which I have written, agrees that the changes will be substantial at area, district, sector and unit level. Staffs at all those levels will be affected. It was not clear from the Minister's first speech that he was speaking on behalf of the United Kingdom. I hope that he will make clear in his reply that there will be maximum consultation with staff at all levels in the process of considerable friction that will undoubtedly be caused as a result of the implementation of the recommendations in the consultative document.

Paragraph 25 of the consultative document admits that there will be : Considerable and wide-ranging implications for many members of staff. We tend to use many euphemisms for the phrase "putting people on the dole". We no longer use those words. We say that they are being made redundant, or that they are being retired prematurely. But they are out of a job. The basic purpose of this rearrangement is to save money and to cut back jobs. I am not saying that it is always necessary to retain every job, industry and social service for all time. But if there are to be redundancies, and if men and women are put out of work or if their career prospects are jeopardised, they must be fully consulted, and fully compensated, and there must be adequate machinery, in agreement with staff associations and trade unions, in order to effect those changes as smoothly as possible.

The Government say that in the reorganisation in Scotland the one statutory body that will not be affected will be the health board. Why do they say that? Do they think that the health boards are perfect and that all the other statutory bodies are deficient? The only other statutory bodies are the health councils.

I speak from local experience in Fife, and, although they may not thank me for saying so, I have the impression that there is a degree of friction between district councils and health boards because the health boards believe that the district councils are interfering with and are trying to take over some of their functions. My hon. Friend the Member for Hamilton (Mr. Robertson) pointed out that the functions of the district councils are ill defined as to where they begin and end, and about the overlap with the health boards. My hon. Friend the Member for Aberdeen, North (Mr. Hughes) said that the local health councils are not the machinery for individual complaints. But what or who is? It is not even the Ombudsman. Maladministration in the Health Service is a different matter, and it is narrowly defined. There is no clearly defined machinery through which individual complaints can be channelled. That is one of the great deficiencies of the Health Service that no Government have been able to tackle.

One of the health councils in my area has said that it should be able to have its own statutory panel through which individual complaints could be channelled. That is a desirable extension of the functions of the only bodies that represent the consumer within the Health Service. That would enable Members of Parliament and individual members of the community to know to whom to go to have their grievances redressed.

The council also makes the point that the health boards—this may be exaggerated—to a large extent represent the professionals in the Health Service, the doctors and people with professional qualifications, whereas they represent the layman, the consumer and the community. It is important to strengthen one against the other, because the views of the doctors can be different from, though not as closely in contact with the local community as, those of the health councils.

Far from being substantiated to get rid of or reduce the number of health councils, the argument is to retain them, to increase their functions and to define more clearly their functions. They have a great role to play which no other body that has yet been devised can play. The Association of Scottish Local Health Councils lists the activities in which it has been engaged, many of them educational. Many of them, on the principle that prevention is better than cure, try to educate the public in their areas on how to keep out of hospital. For instance, in Fife, the Kirkcaldy council established the Fife council for alcoholism to try to educate people on the dangers of excessive use or abuse of alcohol.

There are many examples, from the Borders to the Highlands, showing how the local health councils have tried to educate people. Where they have not been educating people, they have been making submissions to the health boards on particular problems—perhaps problems associated with the facilities for children's health, dental services or services for the elderly—and they have been able to make proposals. As a result, representations made to them and, through them, to the health board have resulted in additional facilities for individuals and sections of the community.

If the basic purpose of the Government's exercise is to save money, and I suspect that it is, that will be a false economy. All the representations I have received have said that the local health councils should be retained and strengthened and that their functions should be more clearly defined because they are the only bodies that remotely represent the wishes, desires, hopes and problems of the people who use the health services. To get rid of them or even to diminish them would be to diminish the quality of the service that people have a right to expect.

The same thing applies to the districts. Some of them cover a bigger area and represent bigger populations than do some of the health boards. The Government state blandly that the health boards are doing fine and that they should be left unchanged. However, they have given no convincing proof that that is the case. They have said that boundaries might be altered but they do not propose to amalgamate or abolish the boards. However, they virtually say that they intend going ahead with abolishing 19 or 20 districts, and they have given no reason for that.

The staff representations that I have received from various of these bodies indicate that they are extremely worried. The Government devote one paragraph out of 25 in the consultative document to the implications for staff. That is not good enough. The jobs and career prospects of thousands are involved. The unions will have a lot of harsh things to say about that. Unless the Government get this right, they will land themselves with a whole load of trouble.

I am not opposed to change in the Health Service ; on the contrary, I want it. The Service is top heavy with administration, but I am not sure that the present Government are the best to handle the problem. They have a record. In court a man's record is read out after the verdict is given. The Government's record on Health Service reorganisation is pretty miserable. I say "Keep your hands off it. You do not know what you are up to." I would prefer no change to the Tory Government changes proposed here particularly when I know that the Government's basic purpose is not immediately to destroy the Health Service but to transfer the burden, as they see it, from the taxpayer to the pocket of the individual. If they can save a few hundred thousand pounds by the proposals in the consultative document, they will be able to reduce the public sector borrowing requirement.

That is the main purpose of all these activities, whether in health, education, housing or social security. Their general theme is "We do not like publicly provided services." The consultative document and the Bill fit into the picture, and that is why we, the unions and the general public have a right to be suspicious. The Bill is concerned not only with structure but with handing round the hat as a means of financing the Health Service. There will be flag days, striptease artists, bingo and all the rest. To that extent, we deeply suspect the Government's motives. Equally, the public have a right to suspect and fear what the Government will do to the Health Service in the next three or four years if they get the chance.

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Mr. Jim Craigen (Glasgow, Maryhill)

I agree with my hon. Friend the Member for Fife, Central (Mr. Hamilton). I should have thought that today's Ministers would be hesitant about involving themselves in another round of reorganisation since we are here dealing with the structure of which the Conservatives were the architects. I speak in that way not so much because I regard the present set-up as perfect, but because there is a genuine feeling throughout the Health Service which says "For goodness sake, do not let us become involved in yet another reorganisation which ultimately does not benefit the patients, the staff or the general public."

The Government's consultative document showed clearly that they were more intent on reorganising the structure in England and Wales. The Scottish consultative document was a rather shadowy document. I wonder just what will be the cost to public funds of all the consultation and time-consuming effort in the document. With my hon. Friends I have been involved in many meetings on the White Paper. I dare say that a great deal of staff time has been spent in the area health boards and even at St. Andrew's House.

The problems of the National Health Service in Scotland are ones of resource—finance and staffing—not problems of structure. I hope, therefore, that we will not spend a great deal of time in the near future on seeking an administrative reshuffle of health provision in Scotland.

I turn next to the local health councils. I do not know why my hon. Friends are surprised that the Government should be seeking to reduce the element of consumer voice in the Health Service. They are doing it in a variety of other areas. However, we need the health councils because the Ombudsman and individual Members of Parliament alone cannot adequately represent consumer need in dealing with constituents' cases.

I turn now to what is happening in Glasgow. My hon. Friend the Member for Dunbartonshire, East (Mr. Hogg) and I recently met the chairman of the northern area of the Greater Glasgow area health council. The council was concerned lest it should disappear. However, it was equally concerned that there should be no telescoping of the five local health councils in the Greater Glasgow area. There comes a point when, if we are seeking to reduce the number of local health councils from five to four, or even to three, as has been mooted, we might as well have only one.

Frankly, Glasgow would be far too big an area to have only one local health council. It could not provide the intimate knowledge that is required to deal with the cases that come before a local health council. The view was pointedly expressed that area health boards should consult local health councils more than they do. Being a cynic, I know that sometimes area health boards feel that local health councils would come up with answers that they did not want. That has been the case in the recent discussion document put out by the Greater Glasgow health board regarding the future level of bed provision and other facilities for patients and staffing levels in the city. I hope that the Government will not seek to destroy the work of the local health councils. They have not had a long period in which to build up their services or to become well known to the general public. These factors have to be taken into account.

I understand that the Greater Glasgow health board intends to recommend the retention of the five health councils within the city. That is desirable because many of the 48 health councils in Scotland are infinitely smaller than any one of the five local health councils in Glasgow.

I turn now to the new clause dealing with the organisation of the Service. The Minister will have received a letter from me and also from the Ruchill hospital medical staff association on this matter. The association's decided view is that the Government should leave the existing district management structure within the city. That also coincides with the local health council's boundaries.

Of greater concern than any swiftness of hand in altering the structure is the available resources in the Greater Glasgow area. Recently, the Greater Glasgow health board put out a discussion document proposing the closure of several hospitals and a reduction in the number of beds in many other hospitals in the city. I accept that that was in part due to the forecast reduction in the population within the Greater Glasgow area. But as I have made clear to the chairman and secretary of the Greater Glasgow health board, population predictions can easily go awry. New pressures are building up within the Health Service in Greater Glasgow, not least deficiencies in provision for geriatrics, especially psycho-geriatrics. Moreover, the Baird Street clinic for rheumatic diseases, which is in my constituency, was at one point intended to go into the new Royal infirmary. But, as the Minister will be aware, the chairman of the health board not so long ago expressed concern that sections of this new infirmary might not be able to open because of the shortage of funds available to the Health Service.

I understand from recent discussions that the time scale for the move of the centre for rheumatic diseases into the new Royal infirmary will be longer than had previously been thought. But it is not causing a great deal of concern, partly because of the tremendously good work that is being carried out in that clinic which serves an area much wider than the city of Glasgow.

My hon. Friend the Member for Fife, Central talked about the begging bowl having to be sent round. Recently I received a letter from a constituent, Mrs. Anna Docherty, who is promoting the collection of funds locally for a mobile artery and vein imaging system for Stob-hill hospital. That hospital is not in my constituency, but it covers a wide catchment area which includes some of my constituents. The secretary of the Greater Glasgow health board has told me that, if the people can raise the £40,000 or £45,000 required to purchase one of these machines, the board will meet the running costs. Incidentally, this system cuts out the need for the injection of dyes into veins and subsequent X-raying of patients who are being examined for the possibility of their suffering strokes. In other words, this system would save public money and be of enormouse benefit to patients and staff. Yet the health board does not have sufficient funds to make the necessary capital outlay, although it will meet the running costs if local people raise sufficient money, through raffles, concerts and many other activities in which they are now involved, to purchase such a machine.

We cannot afford a reorganisation of the Health Service by this Government as costly as the one left to us by the previous Conservative Government. The real problems in the Health Service are essentially increasing the financial and staffing resources to meet present-day demands.

Mr. George Foulkes (South Ayrshire)

Like my hon. Friend the Member for Hamilton (Mr. Roberston), I welcome this opportunity to debate the National Health Service in Scotland. However, I regret that Scottish Conservative Members, apart from the Minister, have been able to muster only the hon. Member for Perth and East Perthshire (Mr. Walker), and even he is committed to an untypical monastic vow of silence. However, even worse than that, despite all their protestations at Rothesay, Scottish National Party Members have not deigned to turn up. Of course, the Scottish Liberals, as usual, are also absent.

The difficulty about a debate on the National Health Service in Scotland is that the majority of the issues cross the border and span the whole of the United Kingdom. There is a danger, when we are discussing the National Health Service in Scotland, of getting down to the administrative detail of the structure—and that is what we have been forced to do in much of this debate. We are reduced to that or to the parochialism of Gerry Mackenzie on Radio Scotland, if one is an addict or aficionado, that the solution to every ill is to take one's tartan tablets. I am glad the debate has not been reduced to that level—at least until now.

I should like to concentrate on issues within the hospital service, the general practitioner service and the caring carried out by nurses, doctors and physiotherapists—the important elements in the National Health Service.

The title of the consultative document for England was "Patients First", a cruel irony. It was one of the most inappropriately named documents. Like my hon. Friend the Member for Fife, Central (Mr. Hamilton), I believe that the National Health Service is for patients and not for consultants. It is not for the facility and convenience of consultants. I see that the hon. Member for Dundee, East (Mr. Wilson) has entered the Chamber. The word must have got around. It may be that my predecessor, Mr. Sillars, instructed the hon. Gentleman to make an appearance.

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I was involved in the discussions on the siting of the new Royal infirmary in Edinburgh. We were told that it was vital that the infirmary should be near to the teaching hospital so that the consultants could slip in and out. No importance was attached to the convenience of the patients and its accessibility for patients.

In the present consultative document there is little talk of patients' interests and needs. It is said that if the Government reduced the number of local health councils that would not affect the effective discharge of their functions. If that were to happen, the areas covered by the remaining councils would be increased. Surely that would make the councils less effective.

There is a council covering an area that is described as South Ayrshire. It does not cover my constituency alone as it includes the constituency of the Secretary of State for Scotland. That is a takeover bid that I am not too keen to encourage. South Ayrshire health council covers a vast area. It covers hundreds of square miles of the county. To suggest that if its area were increased its effectiveness would not be reduced says something strange about the nature of the consultative document. Alternatively, it says something about the functions that the councils are discharging.

Some of my hon. Friends have said that the councils have not been given sharp enough teeth and sufficiently effective functions. When I hear some of my colleagues talk about giving local health councils more teeth, I am reminded of the need to get away from the administrative structures and to return to he service that we should be providing.

In our country we have the worst teeth of Europe. There are more people in Scotland with false teeth per head of the population than elsewhere in Europe. I should like to see much more effort put into health education and to fluoridation. I appreciate that the latter is a difficult issue that might divide me from some of my colleagues.

I am sure that what I am about to suggest will not cause any divisions. In an answer that I was given on 25 March, the Government indicated that to provide a free general dental service throughout the whole of Great Britain would cost £89 million. That small amount would vastly improve the dental health of our people, especially of our young people. That is something positive to discuss if there are to be changes and alterations in the Health Service.

I disagree in part with my hon. Friend the Member for Fife, Central. He joined in what has become the popular knocking of the administration of the Health Service. I should be concerned if administrative costs were too large a proportion of the money that is spent on the delivery of the service. As the Minister said to me in his reply on 25 March, administrative costs represent only 4.3 per cent. of the total Health Service budget in Scotland. I challenge Sir Derek Rayner to tell us that Marks and Spencer has lower administrative costs.

Mr. Robert Hughes

It is 8.3 per cent.

Mr. Foulkes

I was prepared to hazard a guess that its administrative costs are much higher. I am told by my hon. Friend the Member for Aberdeen, North (Mr. Hughes), whose word I take explicitly, that Marks and Spencer's administrative costs are 83 per cent. of its budget. That proves my point. The administrators are often the whipping boys.

I said that I partly disagreed with my hon. Friend the Member for Fife, Central. I agree with him that the real problem is the lack of democracy and accountability in the Health Service. Its slim administration does not have a democratic body to which it is accountable. That makes it distinct from local authority councils. I regret that there is nothing in the consultative document and nothing in the Bill about democracy in the Health Service.

I give one small example of the lack of understanding, sympathy and accountability of an area health board. The Minister is aware of this example. I am glad to say that he is sympathetic. There was a district nurse in Auchinleck who was greatly revered by the local community. When she died, the local people raised a great deal of money to pay for a commemorative plaque and to contribute a piece of equipment to the local health centre. The proposition was put to the area health board and it turned it down. It said that to erect a plaque in memory of the district nurse who had rendered service to the community would create "an unfortunate precedent".

What administrative bureaucracy ! What rot! I am glad that the Minister agrees with me. The members of the area health board who were councillors and who happened to be directly elected in their other capacities voted that the plaque should be erected. However, all the doctors and the other non-elected members thought that it would create an unfortunate precedent.

That is a small example. It may appear to be unimportant. I accept that there are vastly more important examples throughout Scotland. However, it is a typical example and it illustrates the boards' lack of sensitivity.

I agree that what the Government are putting forward is nothing to do with the real problems in the Health Service. It is merely an example of trying desperately to save money so that Ministers may say to their great Prime Minister that they have managed to save some money.

I can suggest some ways in which they will be able to save money in Scotland.

Mr. James Hamilton (Bothwell)

They could resign.

Mr. Foulkes

That is the obvious and clear remedy.

I have asked about the bad debts of private patients in the NHS. It amounts to tens of thousands of pounds in Scotland. In England it approached £1 million over the year. In Scotland we have only 94 private beds. People are brought in by the consultants and given private treatment. They jump the queue and default on their payments. If we tried to get the money out of them or out of the consultants who admitted them in the first place, we should be getting some money to finance the NHS.

Private institutions providing health treatment outwith the Health Service—for example, clinics and private hospitals—are being provided with free blood by the blood transfusion service. They are being subsidised by the taxpayer.

I do not suggest that we should stop the provision of blood. I am not suggesting that the clinics and private hospitals should set up their own blood-gathering service, or their own private vampire service as in the United States where they pay over the odds for pints of blood. I am merely suggesting that they should pay the economic cost for the blood with which they are being supplied so that those who are in private clinics and hospitals—many of them are wealthy—pay for what is being provided.

I agree with my hon. Friend the Member for Glasgow, Maryhill (Mr. Craigen) that the central problem of the NHS in Scotland is one not of structure but of resources. The Minister has three reports on his desk. One relates to the changing pattern of care for the elderly, which was produced by a joint committee including members of the planning council. The Minister says that he wants people to note it. He is doing nothing about it.

The Minister has a report of a committee chaired by Peter McEwan on mentally handicapped people in Scotland and the provision that is necessary for them. He also has a report on confused elderly people which claims that we need hundreds more places for such people. There has been no action on any of these reports.

On one famous occasion, which will be remembered with great regret and concern in Scotland, the Minister said that he was the "no cuts" Minister. Nothing could be further from the truth. If one looks at the escalating costs in the NHS and at what the health boards are being asked to provide with the paltry increases being given to them, one sees that this Minister is as much a "cuts" Minister as any other. Also he is a "cuts" Minister in an area in which the only kind of cuts that we should have are those by the surgeons in our hospitals.

The consultative document produced by the English Minister, entitled "Patients First", had a cruelly ironic title. I hope that we can get away from discussions of bureaucratic niceties—the local health councils and the area board set-up—and discuss the things that really need to be provided in the National Health Service in England and Scotland, namely, improvements in services to patients.

Mr. Bill Walker

I had not intended to speak at length and I will not do so, but I take this opportunity to make a few comments about local health councils and health board districts. From the point of view of practical, first-hand experience, I expect I know more about what goes on in hospitals than most people, as I spent most of last year in hospital. I took that opportunity to study at first hand the workings of hospitals, and I must at this stage compliment the staff on their dedication to duty and the way in which they tackled their jobs. That is often overlooked.

We talk a lot about efficiency, but what we are really worried about is resources. Funds must be obtained from somewhere. Either they are borrowed or they come from taxes. There is no magic pot of gold, and we must all recognise that fact, It may be sad, but it is true and it is a fact of life. We must link that fact with what appears to be the undemocratic structure of the health boards. On this point I am at one with the hon. Members for Fife, Central (Mr. Hamilton) and for South Ayrshire (Mr. Foulkes) I should like to see more democracy within the Health Service so that the patients could have an obvious avenue in order to make their points. This is absolutely essential. I do not look to any major reconstruction of the NHS ; because no one wants another reconstruction of the kind that we had before. But we must all seriously look for revenues which give the consumer some sort of access. Sadly, very few members of the public know who the members of the health councils are. Some people know who their locally-elected councillors are, and there is probably an avenue of access there.

We should not give the impression in Scotland that we think that our Health Service is falling apart. It is not. If a person is seriously ill in Scotland, they know how to look after him. There are resources there to look after people. The problem lies elsewhere. I stress that the Health Service in Scotland, and particularly on Tayside, is very good if one is very ill.

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Mr. Robert Hughes

It is worth while recalling the origins of the local health councils. Before the last reorganisation we had the regional hospital boards and the boards of managements of particular groups of hospitals—for example, the children's hospitals, the mental hospitals and so on. There was nothing else. With the reorganisation two things happened. First, the boards of management disappeared. It is worth commenting that at that time every regional hospital board gave evidence to the Government to the effect that it did not want the boards of management to disappear. Some of us thought that the boards of management, being appointed bodies, were, to some extent, bodies of patronage. But as time has passed we have realised just how important these bodies were, not just becauses they reflect a different tier of administration, but because they were able to visit the hospitals regularly to see what was happening in the ambit of their influence.

The second major thing that happened was that the services provided by the local authorities, which now go under the grand title of community health services, disappeared into the ambit of the area health boards, with the exception of the environmental health services. As a result, there was no democratic participation whatsoever in the running of the Health Service. Not only was the democratic element removed ; the amount of lay participation in the Service was also removed.

I have a great deal of sympathy with the area health board members. They are appointed by the Secretary of State to do a difficult job. I have the highest respect for them, but whenever there is a clash of opinion or problems in an area, it is the health board members who suffer because they get the blame. The local health councils are in the invidious position that they have no authority to demand from the area health boards any information as to how the Service should be developed. Unless they get that information, there cannot be informed discussions.

I do not want to open up again the whole argument that has been taking place in Aberdeen recently about open-heart surgery, except to say that there was a very good meeting organised by the local health council to which members of the public were invited. About 300 turned up. People might say that that was not a particularly large attendance but, given that it was the first attempt to discuss Health Service priorities, it was a reasonable attendance. By and large, it was a good meeting and everyone had a good hearing. One of the consultants, who was arguing the case for greater resources in his specialty, said that he found it very difficult to discuss such issues at a public meeting because he was not used to arguing the case in public. I ask myself why not, because, irrespective of the main argument of the resources of the Health Service—and I believe they are too few and that they are decreasing in relation to inflation—even in times when money is easier than it is now, there will always be an argument about how the money should be shared out. We all agree that the Health Service, since its inception, has developed in an unbalanced way. The hospital service is the ivory tower of the NHS. All the major resources go to it because very emotive issues are involved, especially in acute specialties and certain surgical and medical specialties. Very little attention in the public mind has been given to the elderly or the mentally handicapped. That part of the Health Service has flagged over the years. The only way we can get this argument before the public eye is to have a public discussion, with the doctors going to the public and arguing their case openly.

This is a job that the local health councils can do. They can provide a platform on which people of differing points of view can argue the case. There are far too many facile opinions expressed about the Health Service. People imagine that it is easy to run, but that is far from true. The local health councils could play an important role there. Clearly, they have been in operation only a short time, but there is still a certain amount of distrust there which existed when the councils were set up. They were set up to provide some sort of lay body which could look at the Health Service and discuss its development. But many health boards were a bit chary about these bodies. They felt that, having no power or authority, they would not understand the priorities in the Health Service, which would be bad for the Health Service.

I do not believe that those fears are borne out. Local health councils have done a first class job, and could do a much better one if there was closer cooperation between area health boards and local health councils.

I have two other points. First, there is not a proper avenue for patient complaints. Even the Health Service ombudsman has no right to look at clinical matters. Such complaints can be dealt with only through disciplinary procedures handled by the General Medical Council and local medical committees, which examine such complaints in the first place. The press, God bless its heart—none of us can do without it—is interested only in complaints about the adulterous or drug-taking doctor or the illegal abortionist, who may still exist even today. Complaints about general practitioners not attending to patients or not going out when called by parents of sick children get little attention from the press. Apart from disciplinary procedures, there is no way of dealing with clinical complaints, which should be discussed properly. Treatment by or behaviour of people in the Health Service should be channelled partially through local health councils. Otherwise, we shall drift on with people losing faith in the Health Service.

The hon. Member for Perth and East Perthshire (Mr. Walker) said that no one wants a radical reorganisation of the Health Service. I disagree. I do not blame individual administrators, who cost less than those with Marks and Spencer or ICI. However, they are not the right people to look after the interests of patients. Even if there are such people, they still do not see what is happening.

Some years ago, as a member of what was then the north-east of Scotland regional hospital board, I visited a mental hospital. We were taken on a tour by the physicians who ran the hospital. Two of us were buttonholed by a nurse who said "Just come with me a minute, please." She took us to a ward that was not on our route. She merely wrote on the wall with her finger "This wall is filthy." The administration had not been spending its maintenance money properly, because of graver pressures on its budget.

We have seen a number of reports recently about maladministration by nurses in mental homes. Without outside interest there cannot be proper supervision of that section of the community who cannot itself adequately complain. If such patients complain, it is said that they are elderly, mentally ill or confused. We should return to a system akin to boards of management.

The pressures on the Health Service are growing year by year because of shortage of funds. People are at then-wits end running the Health Service. Let us have more labour participation and a greater sense of democracy. We can then see that patients are properly cared for.

Mr. Allen Adams (Paisley)

My hon. Friend the Member for South Ayrshire (Mr. Foulkes) rightly chided the Government for their lack of interest in the debate. That also applies to the Liberal Party and half the Scottish National Party.

People do not want to know about the Health Service and nursing until they are ill. They put such matters to the back of their minds. It is our duty to try to raise the level of public consciousness about preventive medicine, and not jibber inarticulately and incoherently about structures, as the Government have been doing. My hon. Friend the Member for Fife, Central (Mr. Hamilton) put his finger on the matter when he said that patient care and the needs of the sick were phrases that the Government rarely use.

The Government's proposals are an attempt to obscure the realities of the Health Service in Scotland, which is grossly under-financed. They merely say that the problems can be solved by administrative reform. They cannot. The Government maintain, and some health boards even back them up, that there is growth in the Health Service in Scotland. Such arithmetic would insult even primary 1. The rate of inflation is 21 per cent. In the Health Service in Scotland we need to increase expenditure by at least 25 per cent. even to stand still, and that is assuming that we are starting from a sound basis. The Health Service in many respects, particularly in the care of the elderly and mentally handicapped, is in a bad state. Even an increase in expenditure of 25 per cent. would not raise such care there to an acceptable standard.

I do not argue that structure of the Health Service is perfect. I have doubts about many areas, which may need reform from time to time. However, the Government are attempting to cover up the need for a basic injection of capital for the Health Service in Scotland and probably the rest of the United Kingdom.

People's health should be the first priority, but the Government do not seem aware of that. Let us take a wee look at specific examples ; for example, nursing in Argyll and Clyde, which is perhaps the worst health board with regard to nursing care in Scotland. By its own admission, the number of nurses in post is 25 per cent. below the Scottish average. Instead of talking about structures, the Government should tell us how they intend to tackle that problem within the next year. It is a serious problem and people are dying as a result of it.

In the Argyll and Clyde area we have a 20 per cent. shortfall of midwives. The Government should not be talking about structures, but should be telling us how they intend to rectify that shortfall. Five hospitals have closed in the Argyll and Clyde area in the past year. What do the Government say about that? How is that improving the health of the people of Scotland? There have also been hospital closures in Glasgow. How will the proposed structural change help that situation?

There is also the notorious situation at the new Inverclyde general hospital, where one ward has not yet opened. Inverclyde is an area with one of the most serious health problems in Western Europe. It is one of the highest unemployment areas and has one of the highest infant mortality rates in Europe. It also has a high incidence of lung cancer and heart disease, yet one ward in the hospital has still not opened. What do the Government say about that? How will their administrative change improve the health of the people of Greenock? What will it do tomorrow? What will it do next week?

8.30 pm

Some of my hon. Friends have pointed out that there is an undeniable need for a massive increase in expenditure on geriatric care. Estimates vary, but it is agreed that in the next decade the number of those aged over 65 will increase by 10 to 15 per cent. It is an acute problem which will be solved not by administrative tampering, but by more money for psychogeriatric units and home helps.

The national scandal of the decade, on which perhaps all parties stand indicted, is the lack of input for the mentally and physically handicapped. It is not difficult to predict what percentage of children born in the next year will be mentally or physically handicapped. We can easily calculate what provision we shall have to make in about 15 years' time when those children are at an age when they can be trained or can go to work.

At present, many parents have children of 16 who are mentally or physically handicapped and who have to sit in the house with nowhere to go, no training facilities and no prospects. That is an area where much more money needs to be spent.

Circumstances in Glasgow and the West of Scotland clearly indicate that the NHS has been disgracefully neglected. For example, is there not a good case for massive sums to be spent on research on the drug Interferon? It has been known about since 1956, but little has been spent on that sort of research.

The Southern general hospital in Glasgow has one of the most advanced neurosurgical units in Europe, but half of it cannot open because the money has not been spent to train the staff to man the unit. That is another example of where hard cash rather than administrative tampering will solve the problem.

I could refer also to the problems with kidney machines and many other difficulties. It is clear that the Government are trying to draw red herrings across our path. The simple solution for the NHS in Scotland and in Britain is more cash, and not administrative tampering.

Mr. Ernie Ross (Dundee, West)

New clause 18 draws attention to the fact that the Government's consultative document causes grave concern to the trade union movement in the NHS. One has only to think back to the problems during the winter of discontent to realise that if any future changes in the Health Service are to succeed they must take account of the trade union members in the NHS.

I agree with my hon. Friends who have said that the Government's plans to remodel the Health Service will make the provision of health care inefficient and remote. If the Government remove the district tier, inevitably they will cause industrial relations problems as well as administrative muddles.

The Dundee district is a major teaching hospital district, which includes the Nine wells hospital, the Dundee Royal infirmary, the Royal Dundee Liff hospital, Strathmartine hospital, Dundee dental hospital, Ashludie hospital, King's Cross hospital, Royal Victoria hospital, Sidlaw hospital and the Dundee limbfitting centre, with a total of nearly 3,000 beds. There are 20 clinics, including community clinics, and four health centres. The annual budget is about £39 million. The number of staff employed is nearly 7,500, including full-time and part-time employees.

The responsibility for managing the district lies with the district executive group that consists of the district administrator, the district medical officer, the district nursing officer and the district finance officer. There are sector and unit executive groups for individual hospitals or groups of hospitals and for community services.

Although the consultative document suggests that management responsibilities at sector and unit level should be strengthened, it is obvious that if the district executive group is eliminated, there will be no management team with similar powers to the district executive group between the area executive group at board headquarters and the sector executive groups in Dundee. It is recognised in the Dundee district that the district level is the important level for industrial relations with the trade unions for many reasons. It is apparent that the district level is the real management level for the district and that the sectors and units continually look to the district for guidance on industrial relations problems.

If the district executive group did not exist, there would be great difficulty in dealing with industrial relations problems and the problems that arise because of management failures at unit management level. It is difficult to see how board headquarters could deal expeditiously with such matters as personnel and pay given the fact that it has not had to deal with such matters and assuming that it is busy with present board functions.

I would contend that failure to deal promptly with problems affecting trade union members in the Health Service would be certain to give rise to difficulties, no matter how much union members may wish to avoid such difficulties. These problems should be resolved promptly if patients are not to suffer.

The consultative document for Scotland is out of accord with the declared objectives of the Government. The consultative document for England sets out the main criteria for the establishment or continuation of the district in England. It says that an ideal district is a locality that is natural in terms of social geography and health care, large enough to justiy the range of specialities normally found in a district general hospital but not so large as to make members of the authority remote from the services for which they are responsible and from the staff who provide them. It says that a district should have a population of 200,000 or more, although a few might have fewer than 150,000. There should be a geographical identity for links with local government, and there should be appropriate links with any medical school within the district.

On the basis of these criteria, Dundee ought clearly to be a district, and there can be no reason for eliminating district management. The population served by the health services in Dundee is about 210,000. I have already referred to the hospitals in the district. Apart from Dundee's natural suitability for local administration, the size and importance of the health services in Dundee are more than enough to justify the continuation of a district with district management.

These views are held not only by the local unions but also by the local health council which has made similar points. The abolition of the Dundee district board would be a step backwards in the running of the Health Service in the Dundee district. It would be as disastrous for Dundee as the complete abolition of Dundee district council and its absorption into the Tayside region that would govern Dundee by remote control. It would distance the people who make the decisions in the Health Service from the people who work in it and use it.

If we are not to have a re-run of the problems experienced during the winter of discontent, the views of those who serve the Health Service and work in it are crucial. Union members in the Dundee district would oppose any effort by the Government to do away with the district health boards.

The Under-Secretary of Slate for Scotland (Mr. Russell Fairgrieve)

We have had a fairly lengthy but interesting debate. It is the first time during the course of the Bill that Scottish Members have had a chance to talk widely about the Health Service in Scotland. The hon. Member for Hamilton (Mr. Robertson) rightly said that the debate gives Members the chance to talk about the consultative document. One of the main threads of speeches has been the question of districts and councils to which I shall refer briefly later.

There was also quite a lot of contradiction among hon. Members. One minute, the consultative document was short and rudimentary. Then it was not full enough. Then it was too full, and it was said that we did not need one. We have to make up our minds whether we want major change or no change in the Health Service in Scotland, or something in between. There was the feeling throughout the debate that some hon. Members did not know whether they wanted no change, a lot of change, or just a little change.

We are fortunate in Scotland. We have not got the problems that face the Health Service south of the border. The same applies to the Health Service in Wales, which is on similar lines to that in Scotland. We do not have the extra tiers. We are not taking legislation in Scotland to remove a tier of administration.

I might tell the hon. Members for Hamilton and for Fife, Central (Mr. Hamilton) that I am in the course of meeting every health board in Scotland. I have worked my way through about three-quarters of them The consultative document is one of the items that come up for discussion. I am not continually being told about low morale in the Health Service in Scotland.

The hon. Member for Hamilton suggested that the Scottish approach was inflexible. Possibly he overlooks paragraph 5 of the consultative document, which invites contrary views. Where such views have been submitted, they are being considered.

The hon. Member for Fife, Central began by talking about the consultative document. He suggested that the Government had made up their minds. I do not think that a Government of any party describe a publication as a consultative document if they have made up their minds. We shall be very interested in the views which come up from the many bodies and individuals, and I have no doubt that the hon. Member for Fife, Central, as an individual, has submitted his own recommendations to the Secretary of State.

The hon. Gentleman asked what was the state of play and which authorities had said what. I know that the hon. Gentleman is a far more experienced parliamentarian than I am, but he also knows that even I, having been here only six years, will not fall for that one. All the views had to be in by 30 April. Some have come in a little later, but we shall not rule them out. The hon. Gentleman will be surprised when he gets some of the views. I can assure him, without giving any names, that there are certain boards which have looked quite seriously at whether, for example, they should have a district structure. This will come out when we get all the submissions together.

The hon. Gentleman said that the structure needed changing. The same comment was made by other hon. Members. The general view of Opposition Members seemed to be that the 1974 reorganisation was a disaster. This is being said continually. It is not for me to comment on it, but again I remand Scottish Members, without saying that it was a disaster south of the border, that in Scotland, in my opinion, it has not been anything of a disaster.

I might in passing say to the hon. Member for Fife Central that no one on the Government Benches could ever accuse him of using a bullying approach. We absolve him of that.

I doubt whether the changes will be substantial. There will of course be the maximum consultation with the staff. In a previous debate, the hon. Member for Fife, Central tried to get me on my feet. It is not my normal practice to speak for long or to intervene more than is necessary in debates in this House. As I said, the closing date for comments in Scotland was 30 April and I repeat that some of them were late coming in. The large volume of evidence sent to the Secretary of State is being considered, and he intends to make an announcement as soon as he can.

8.45 pm

Hon. Members must wait until my right hon. Friend can do that. There is nothing inconsistent in this with Scottish participation in the Whitley council machinery in dealing with jobs and redundancies. Hon. Members know that in Committee I gave a guarantee that a start would be made on this subject in Scotland. I should have thought that if as a result of our deliberations in Scotland there were cases of possible redundancy they could be achieved by natural wastage. At the very worst people who wished to do so could take early retirement. I do not see a great number of redundancies occurring in Scotland.

If individuals have complaints against GPs they are dealt with by the statutory service committee procedure and boards advise patients on how to make complaints. If the complaint is against a hospital, it is dealt with, first by the health board, but the complaint may also be put to the Health Service Ombudsman, though he is debarred from dealing with clinical matters.

I turn to the remarks of the hon. Member for Glasgow, Maryhill (Mr. Craigen), who mentioned another reorganisation. I have said, and I shall keep on repeating it, that this is a consultative document. Labour Members may not always agree with what is done by a Conservative Government, but when we send out a consultative document we do take into account the views we expect to get back. The hon. Gentleman also spoke of a resource problem. Of course it is a resource problem. As I have said to health boards, it would have been pleasant to have been a health minister for Western Germany or France which can spend more per head on health and social work and on behalf of the disadvantaged in society than we can.

It is interesting to recall that 15 years ago that was the position we were in. We were about the wealthiest nation in Western Europe with almost the highest standard of living. Today we are at the other end of the scale. We are about the poorest nation in Western Europe with almost the lowest standard of living.

Mr. Andrew F. Bennett

Is the hon. Gentleman aware that during the whole of that time we have had to spend more on defence than the countries to which he has referred? Would it not be a good idea for us to spend the same amount on defence as they do in relation to our gross national product?

Mr. Fairgrieve

All I say about that is that the last 15 years were mainly under a Labour Government, and the 15 years previous to that period were mainly under a Conservative Government. Hon. Members can, therefore, draw their own conclusions.

Mr. Craigen

Perhaps the Minister will answer the point that I have raised. How much money is being spent on the consultative process?

Mr. Fairgrieve

I cannot give the hon. Gentleman the figure off the top of my head, but I will find out how much money is being spent on the consultative process and let him know. However, I do not think that it is all that large.

I accept that Glasgow has problems. In the consultative document we did not say that districts should be abolished. The hon. Gentleman is correct in saying that there are many districts in Glasgow that are bigger than some health board areas. We have said that if possible the norm should be a one-district authority but that if a health board says that a situation is ridiculous in Glasgow it will be allowed to do as it thinks fit. In many cases a district structure will, of course, be allowed to remain.

Population predictions are always difficult in relation to working out the number of beds that eventually will be required to deal with the great geriatric problem that faces us. The hon. Gentleman spoke, shall I say, of the spectre of raising money. We say, after all, that friends of hospitals have raised money in the past and that we see nothing wrong in making statutory provisions in that respect.

The hon. Member for South Ayrshire (Mr. Foulkes) spoke about the absence of Scottish Conservative Members. Let me remind him that in the last Parliament—though he was not a Member of it—the situation was the same. There was a continual absence of Scottish Labour Members when, for six years, the previous Government were putting Bills through the House.

The hon. Member said that there was little talk of the needs of patients in the document. Everything in the document is directed towards achieving better patient care. I shall come later to whether the health councils should have more teeth I agree with the hon. Member about the great problems of Scotland's health and the need for a better education programme in Scotland.

Mr. Foulkes

I am grateful for the Minister's agreement, but how will the Government achieve that better health education?

Mr. Fairgrieve

If the hon. Member will contain himself, I think that my right hon. Friend the Secretary of State will have something to say later in the year about health education.

Preventive medicine is easier and more pleasant and might even cost less than curative medicine. We have kept administrative costs in the Health Service in Scotland down to 5 per cent. I must check about the Auchinleck nurse to which the hon. Member referred. He will not expect me to be diverted to speak about the vampire service because that involves the question of blood donors and whether they should specify to whom their blood should go.

I accept that there is a resource problem. We have made that clear in documents on the elderly and the mentally handicapped. The hon. Member for South Ayrshire knows that we have not made any cuts in the Health Service in Scotland and that we have restored the squeeze. This year there is a 2.5 per cent. real increase in spending on the Health Service in Scotland.

I was pleased about the tribute paid by my hon. Friend the Member for Perth and East Perthshire (Mr. Walker) to hos- pital staffs in Scotland. I am sure that we all agree with him. He mentioned money resources and said that money does not grow on trees. For the last 20 years the country has believed that money has no particular value and that it is either borrowed or printed. Perhaps that is why we are in our present difficulties. He mentioned the undemocratic structure of health boards. Health councils and boards are not elected. Both bodies are appointed.

The hon. Member for Aberdeen, North (Mr. Hughes), in his interesting contribution, mentioned reorganisations with which he was closely connected. I am sorry that he is not in his place, but he has attended the entire debate. The NHS in Scotland remained substantially unchanged for 25 years. It had five regional hospital boards for planning hospital services, 65 boards to deal with day-to-day management and 25 executive councils for pharmaceutical, general medical, dental and ophthalmic services. In addition—and this is interesting—it had 56 local health authoriies which provided services for mothers, young children and the elderly.

The hon. Member expressed sympathy with health board members. Apart from an honorarium to the chairman, the work is done voluntarily, and all of us in this House must thank those people in Scotland who are members of health boards for the amount of time they put into this work.

The hon. Member for Paisley (Mr. Adams) mentioned preventive medicine. He spoke about the Health Service being grossly under-financed. I suppose we can say that everything in this world in grossly under-financed if we can get the chance to double the expenditure. He also mentioned that in Argyll and Clyde patients were dying because of the shortage of nurses. I should be most grateful if he would write to me giving me chapter and verse so that I can look into the matter.

The hon. Member also talked of the closure of five hospitals in Inverclyde. He knows that that is not unconnected with the opening of Inverclyde district general hospital. One ward was not closed ; it was never opened. [Interruption.] Nevertheless, Argyll and Clyde still have a higher bed ratio than the rest of Scotland, and I think that the hon. Member knows that full well.

The hon. Member for Dundee, West (Mr. Ross), with his knowledge of and interest in the trade union movement, was able to give us his views on the trade union set-up in Dundee, particularly at the district level. He felt that this is where industrial relations should best be sorted out. He emphasised the necessity, in his opinion, for the district level.

We have listened with great interest to all the points made by hon. Members. These will be carefully noted in our full consideration of the response to the consultative document "Structure and Management of the National Health Service in Scotland". I cannot at this stage say precisely when the Secretary of State will be in a position to make his decision known about the various issues in the consultative document. We are aware of the need, for the well-being of the Health Service, to reach our decision with all reasonable speed. At the same time, we need to give proper consideration to all relevant matters, including those concerning staff terms and conditions, which I spoke about earlier in the day. Work is proceeding on the terms and conditions of staff.

Our consultative document gave assurance on these issues, and I repeat that we shall be as fair as possible to all staff involved in such changes as we propose. We shall be discussing with staff interests in due course the arrangements for filling posts and protecting the interests of those who may be adversely affected by our proposals. I expect, however, that by means of natural wastage in the Service, as I said earlier in the debate, it should be possible to keep to a minimum the extent to whch NHS officers will be seriously affected by the changes that we implement.

Some hon. Members seem to have been suggesting that the Health Service in Scotland should remain unchanged, and stay in its present form. I am well aware that six years, since the reorganisation of 1974, is not a long time for a large organisation such as the Health Service to adjust fully, but it is also important that the Health Service should not stand still. While we do not consider that the Health Service in Scotland requires the same radical change as is envisaged in England, it is right and proper for us to take this close look at the present structure and management of our Health Service. It is important that such a large employer and spender of public money should be as efficient as possible, and that decision making should be simplified and kept on as local a level as possible.

Although I have not yet had the opportunity to consider in detail all the comments submitted, I know that, with different emphasis on the practical problems, the broad aims which underlie our consultative document are shared by the vast majority of those who have commented.

I turn now to the new clauses. New clause 17 seeks to make variations in schemes for local health councils subject to parliamentary scrutiny. In our consultative document we asked for views on the value of work done by these councils, and whether their number could reasonably be reduced. These questions needed to be asked, since local health councils in Scotland cost about £½ million each year, and this is money which could be spent on direct health care. We have received a large body of comment on this issue from local health councils, from voluntary and community groups, and from the health professions and health boards.

It is clear that the local health councils have found friends among the voluntary and community groups. But the impression that I have gained so far is that there is a more mixed response from other health interests. We are giving this question very careful consideration. We are not so rich that we can afford to sustain bodies which do not contribute to better health care nor, in view of our wish for a local voice in the Health Service, would we sweep away these councils if we are convinced of a real local need and desire for bodies of that sort.

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At this point, one must also realise that for 27 years prior to 1974, somehow and in someway we managed to exist in Scotland without health councils. That is a point which must be considered.

New clause 18 deals with control of the numbers of boundaries of districts within health board areas. Again I ought to mention that in Scotland we are fortunate that our health board areas are contiguous with local government regions, which is not the case everywhere south of the border. We start off with that advantage, and we go along the regional boundaries, except for Strathclyde which was broken up into four board areas.

The question of what district arrangements there should be in Scotland below the level of area health board is one to which we are giving particular attention in the context of the consultations. However, we are not yet in a position to make a statement about it. What must be said however, is that, given the clear support for their to be greater decision-making at the local level, it is most important that we get the balance right at the levels of administration and area. Therefore, the question of districts in Scotland is one which cannot be debated in splended isolation but must be considered in the context of the overall planning and the operational task which a health board must perform.

As I have already said, we have consulted widely in Scotland about what should be done. We are now considering carefully the views that we have received. I welcome the debate as an opportunity for hon. Members to make their views known—and that they have done—before decisions are taken. Having taken views, the matter is one to be settled between the Secretary of State and the health boards, as has always been the position under various Governments. The new clauses would add an unnecessary complication to that position, and I ask the House to reject them.

Mr. George Robertson

At the beginning of this debate I asked for a simple assurance from the Government that if major changes were to be made in the structure of the NHS in Scotland or in the number, size or scope of the local health councils, Parliament should have an opportunity to debate the matter. That is all that the new clauses say, and that was the only assurance that we sought this evening.

It took the Minister almost 20 minutes of a waffling smokescreen, which included the breath-taking sight of him reading verbatim from a Scottish Office fact sheet, finally to arrive at the point at which he said that ultimately it would be a matter for the Secretary of State for Scotland and the health boards—not Parliament—to decide on the way in which the NHS would be run north of the border. That is not good enough, nor is it in line with practically everything that has been said in this fortuitous debate on this important issue.

It is remarkable that the debate has been characterised by the fact that only one Conservative Member of Parliament from Scotland has bothered to take the time to come along and participate in it. If Conservative Members were to show any interest in the subject and in the future of the Health Service in Scotland we might, perhaps erroneously, have some confidence in the Secretary of State's ability to look at the outcome of the consultations and to arrive at a proper conclusion. But we are not so satisfied, and we shall seek to divide the House on this matter.

It is inappropriate that decisions on the future of the structure of the Health Service in Scotland, and on the future of consultations with consumers in the community as well as patients in the Health Service, should take place behind closed doors rather than in front of the people in Scotland in their elected Parliament.

The Minister, in the usual bland style that we expect from the Under-Secretary of State for Health and Social Security, carefully went over a number of the points that were raised. He proclaimed that he was a Minister of no cuts, yet he is supervising a regime of cash limits that is cutting into the real resources that the Health Service has to spend on the Scottish population. The hon. Gentleman defended every dot and comma of the existing health board structure—a system of quangos, to use the pejorative expression that his leader uses continually. It is remarkable that the spectre of the Prime Minister is not hanging over him tonight while he is defending this almost totally unaccountable level of administration in the Health Service.

When hon. Members suggested genuine and reasonable ways in which that system could and should be made more accountable, he said that there was no evidence to suggest a need for that. He used evidence from the health boards for that assertion. The real question in the Health Service is not of structure, but of resources—the priorities that would be given to the Health Service by any Government who cared about the problems afflicting the Scottish population today.

The consultative document deals with the structures. Its conclusions are put forward irrespective of the recommendations made by the Royal Commission on the National Health Service. When hon. Members asked moderately and reasonably for assurances that they would be consulted before the final decisions were

taken, they were told arrogantly by the Government that the final decision would be made more appropriately by the Secretary of State for Scotland and the health boards. That is totally unacceptable to the House. We shall divide the House on this important issue.

Question put, That the clause be read a Second time :—

The House divided : Ayes 112, Noes 167.

Question accordingly negatived.

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