HC Deb 09 June 1980 vol 986 cc223-53
Mr. Moyle

I beg to move amendment No. 36, in page 18, line 33, leave out clause 8.

Mr. Deputy Speaker (Mr. Bernard Weatherill)

With this it will be convenient to take the following amendments :

No. 8, in page 18, line 34, leave out and sections 59 to 63 of the Scottish Act of 1978". No. 4, in page 18, line 39, leave out "Scottish and".

No. 9, in page 19, line 21, leave out and sections 65 to 68 of the Scottish Act of 1978". No. 37, in clause 9, page 20, line 5, at end insert— (2) Section 65 of the Act of 1977 shall be amended by the insertion after the second 'and' in paragraph (a) of subsection (1) of that section the words 'in particular he shall direct a health authority to admit private resident patients to a health service only if he is satisfied that—

  1. (i) all potential private resident patients have been placed on the same waiting list as comparable National Health Service patients in the care of the same consultant and that the consultant concerned is ensuring that all patients selected by him for admission to such a hospital and all patients on the said waiting list are being so admitted for treatment and moved along the said 225 waiting list in accordance with common criteria ;
  2. (ii) in applying such common criteria the consultant concerned is applying social criteria where such criteria are relevant amongst others to admission to hospital and to progression along the waiting list but not to such an extent as may give either the class of private patients or the class of National Health Service patients an advantage in terms of the length of time on the waiting list over the other class of patient ;
  3. (iii) a potential private patients' place on the waiting list is being determined by the date upon which he was first referred to a hospital outpatients clinic or for a private consultation by the patient's general practitioner ;
  4. (iv) the District or Area Health Authority is ensuring that the provisions in sub-paragraphs (i), (ii) and (iii) of this section are being properly applied and that statistical monitoring has been instituted by the relevant health authority to ensure that paragraphs (i), (ii) and (iii) above are being so applied ;
  5. (v) sub-paragraphs (i), (ii), (iii) and (iv) above are being applied to diagnostic and other medical services ; and '.".
No. 10, in page 20, line 6, leave out subsection (2).

No. 11, in page 20, line 25, leave out from "above" to end of line 27.

No. 12, in clause 10, page 21, line 6, leave out subsection (2).

No. 13, in page 21, line 30, leave out from "above" to end of line 33.

Mr. Moyle

The object of this amendment is to retain the Health Services Board and to continue the policy of phasing private beds out of the National Health Service. For that reason, we can have no connection with clause 8.

The second point—continuing the policy of phasing private beds out of the National Health Service—we believe to be morally right. The basic principle of the National Health Service ought to be that treatment is without restriction by price. The Royal Commission supported that approach, and pay beds are a breach of it. They allow people to be admitted on the basis not of medical priority but of ability to pay. That principle offends many inside and outside the NHS.

First, talking about people within the Health Service, the consultants get the fees for treating private patients, but many others in the Service have to do a great deal of the work. There is no solution—

1.45 am
Mr. Grieve

At many of the London teaching hospitals the consultants receive no extra fees for treating private patients. The money goes to the hospitals and they benefit therefrom, do they not?

Mr. Moyle

That is true of those who are clinical teachers in universities, but they do not form the great bulk of the consultants who go in for private practice to make money out of it. They make money out of it while those who work for them and to them do not.

The Secretary of State's scheme when in Opposition for making extra payments to supporting staff in the Service who work to private patients has been sunk without trace. Health Service personnel will be forced by their contracts of work to work on private beds irrespective of whether they approve of them. Junior doctors are often forced to work long hours dealing with NHS patients to allow their consultant superiors to treat private patients, for which they get money.

When we return to office we shall want to continue to remove pay beds from the Service. The only point at issue is whether we shall do it by reinstating the Health Services Board and phasing out pay beds gradually, as we were doing before the 1979 election, or going for the short, sharp chop. We regard the Goodman compromise as dead. Doctors planning their future practice arrangements should bear that in mind.

The Health Services Board had the function of protecting the Service from the encroachments of private practice. Clause 8 says that the board should go and that the Secretary of State should resume the function of protecting the Service. We do not trust the Secretary of State to protect the Service. He is clearly a private practice and private bed fanatic. Every argument that he deployed in 1976 for saying that it was a mistake to phase pay beds out of the Service has been proved in practice to be totally unfounded. However, he still returns to the desire for more private beds in the Service. In consequence, we do not trust him to look after the Service. For that reason, we think that the board should be retained to protect the Service from the depredations of the private service which the Government are intending to operate.

In Committee we made it clear that, however much we might disapprove of the Secretary of State's six principles for the operation of common waiting lists, we considered them to be an improvement on current form. We co-operated fully with the Government in Committee by moving amendments to incorporate the six principles into the Bill. I regret to say that when it came to the crunch Ministers had insufficient confidence in their principles to support our amendments. They opposed our offer to help them.

In the circumstances, we have returned in our amendments to our first love, namely, to legislate to put into operation the principles adumbrated by the Health Services Board in Cmnd. 6728 of May 1977 on common waiting lists. The object of the amendment is to legislate those principles into the Bill. They are much more simple and direct principles than the Secretary of State's six principles. The fundamental assumption is that the consultant shall decide on admission and shall be in charge of the patients.

The factors that will be taken into account are set out in page 9, paragraph 9.2, of the report. We believe that justice should be not only done but manifestly seen to be done. The great advantage of the board's common waiting list principles over the Secretary of State's is that they suggest a good way statistically to monitor waiting lists to ensure that Service patients and private patients are dealt with on an equal basis. They suggest that hospital activity analysis statistics could be used and developed to ensure that the waiting lists are operated equally favourably for NHS patients and private patients.

I have stated our attitude to pay beds and our determination to resume phasing them out when we return to office. If at the end of this Parliament Ministers and the medical profession can convince the public that all patients, whether private or NHS, are being admitted to hospital on the basis of common principles, we may solve the pay bed problem that way. If, however, the Government start by rejecting these amendments, which are based on the report of the Health Services Board—and the Secretary of State and other Ministers have paid tribute to the excellence of the work of the board and the way in which it has carried out its remit—I think that they will have started badly from the public's point of view, and the public will ask the Government what they have to hide and whether they are in collusion with private practice consultants in the medical profession.

Mr. Race

I referred to this clause in Committee as the queue-jumper's charter, and that is precisely what it is. It is nothing more and nothing less than that. It is an attempt by the Government to try to undermine the whole principle of the NHS. I say that advisedly because in Committee the Minister refused to provide an important piece of information, namely, the upper limit of pay beds that he would authorise in the NHS. He refused to tell us how many pay beds would be phased into the NHS. At the moment there are just over 2,000 pay beds in NHS hospitals, and the proposal in the clause to abolish the Health Services Board will increase the ability of the Secretary of State to increase the number of pay beds in NHS hospitals. That means that a number of important priorities will be distorted in the NHS.

The first important point about pay beds and the people who use them is that everybody who uses a pay bed is, in one way or another, jumping the queue for services. Those concerned are jumping the queue because they are paying for a service, and that means that the medical priorities on which the Service is based, namely, free and equal access at the point of use, are being distorted, because people are saying to their consultants "We want a higher priority than we would otherwise get for our operations and we are prepared to pay you and the NHS to achieve that priority". That seems to us to be wrong in principle, and that is why we are opposed to pay beds.

It is not just Labour Members who are opposed in principle to pay beds. Numbered among those who are opposed to pay beds are the vast majority of the staff employed in the NHS, and one of the consequences of the withdrawal of the Health Services Board will, inevitably, be an increase in the use of industrial action in the Service, aimed at private patients. One of the things that the Government will have to live with over the next two or three years is that whenever there is a dispute in the Service over pay or conditions, or grading, or even health and safety, there will be a tendency for those concerned to say "How can we attack privilege in the Service? How can we undermine the Government's policy? "and they will come up with the answer" We will attack the services for private patients because we want to concentrate our attention, our support, on NHS patients."If anybody is to suffer inside the National Health Service as a consequence of industrial action, it will be argued that private patients, who jump the queue and distort medical priorities, should be those to have their treatment changed by such industrial action. The Government should be aware that they are running the risk in the clause of increasing the kinds and scope of industrial action which is taken against private patients.

Another aspect of the clause is the problem of the charges themselves. One aspect of the charges which have been made for private practice in the past has been that the charges, before the amendment to the 1977 Act was made, did not reflect the full economic cost of treatment or, indeed, the capital cost of the provision of beds and services. That was rectified, but one of the important problems which remains is that of bad debts which are incurred by private patients and of the failure of consultants to charge private patients for the use of National Health Service facilities.

One of the big grouses and gripes which have always been levelled against private patient facilities inside the Service—the charge has been made by the staff and others—has been that private patients use and abuse NHS facilities. They do this consistently day after day, week after week, year after year. The laboratory services which are used by consultants for their private patients is a case in point. It is clear to me from my experience in the NHS that it is rare for a consultant to go to a laboratory and say "This slice of liver comes from a private patient." I do not know of one case in which laboratory charges have been properly made.

There is great suspicion amongst staff in the NHS that there is fantastic abuse of the facilities of the Service for the profit of consultants and of private patients. Medical and social priorities are distorted in another way by private patients. That is why we want to see them out of the system altogether. Those facilities are distorted because the staff have demands placed upon them by private patients which are out of all proportion to the medical importance of the cases of the private patients themselves.

In other words, a private patient may say to an ancillary worker or to a nurse on the ward "Change the water in my rose bowl" or "Do this for me" or "Do that for me." The implication is that the member of the NHS staff must do that because that private patient expects a higher standard of service from the workers in the Service, or because he is paying for it, than if he were an ordinary patient. That is deeply resented by the staff. Nurses and ancillary workers and doctors want to concentrate their attention and their scarce resources of skill on the patients who most need their assistance, and not on those who have paid for the privilege of being in a pay bed. That is the real importance of the debate and the clause. That is why we shall oppose it and why we have tabled the amendment to delete it.

In Committee we found the assurances given by the Minister absolutely laughable. One of the six criteria which were laid down by the Minister for dealing with the question of distortions of service by pay beds and private practice was that people inside the NHS—in other words, NHS patients—should be treated on an equal basis with private patients. In other words, private patients should not be able to obtain an advantage by paying for treatment. Of course that is absolute nonsense. The whole basis of obtaining private facilities and becoming a private patient is to gain an advantage over someone who cannot afford to pay and needs to maintain himself or herself as a NHS patient.

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Therefore, the whole basis of the Government's approach in the six principles is absolute nonsense, and they know it. They cannot possibly deliver the position that they set out in those six principles, namely, that there should be equality of access and equality of treatment between private patients and NHS patients. That is another very important reason for our voting against this clause tonight.

I do not think that the Ministers on this Bill really understand the deep feelings of resentment and nausea about the Government's policy on this question. I believe that the policy that is put forward in this clause is the first part of a broader attack on the principle of the NHS, that services should be available free at the time of use to those people who need them most and whose medical priority is the highest.

The Government's policy is to try to replace that kind of Health Service with one which is based on entirely different principles. This clause has the most important principles in the Bill. It tries to reopen the whole issue of private practice inside the NHS. The Government will find that over the next few months and years this principle is not worth the candle or the trouble that it will cause. This clause is part of a wider attempt to create separate facilities for private patients, inside and outside the NHS, because not only do the Government want to increase the number of beds available for private patients ; they also want the private sector as a whole to grow.

We must see the importance of this clause in relation to other policies. The increase in the number of pay beds must be seen in the context of an increasing number of private hospitals and private hospital units where people who will be able to get their treatment outside the Health Service. That combination of factors will impinge on the services which are available for NHS patients. In an area such as central London, the impact of the Wellington hospital and all the other private hospitals which are at present being looked at by the Health Services Board will be very important. The numbers of trained staff—nurses, doctors, para-medical workers, and those who work in laboratories—who are available for work within the Health Service will drop because of the increase in private facilities.

Clearly, the Government want people in this country to pay an increasing amount of their private income and resources for their own health care. Indeed, this clause is part of a wider principle, namely, that people should pay for the cover that they receive on an insurance basis and should not receive the Health Service treatment, free at point of use, and paid for out of general taxation. That principle is also at stake as a result of this clause. The increase in the number of pay beds which will take place because of the authorisations must be seen in the context of the increase in private sector facilities which will automatically take place.

Those are substantial reasons for opposing the clause. The reintroduction of private practice on the scale that the Government envisage will cause a great deal of trouble inside and outside the Health Service. They will not be able to say at a later date that we have not warned them of the consequences of their actions.

Dr. Roger Thomas

Private medicine is a non-starter without support from almost all sections of the National Health Service. Through the private sector, a privileged few, using their own financial resources, gain speed and convenience over those on lengthy National Health Service waiting lists. The waiting time for corrective surgery or for increasingly complex investigations is considerably shortened for those who can pay. It is a system whereby a specially select, relatively small number of patients is facilitated to jump the queue, yet whether he or she at the end of the day gets better medical attention is open to doubt.

Health care is an essential commodity which is not exactly in abundant supply. Private medicine can acquire it for a small minority. Unfortunately, to a greater or lesser degree, private medicine consequently deprives a patient or patients totally dependent on the NHS.

The biggest private patients' organisation in Britain is much in favour of a mixed Health Service. When we realise how dependent the private sector is on NHS facilities, including trained staff, that is hardly surprising. Such organisations want the private option to be allowed to expand alongside the State-provided service. Further advance of private care can take place only if the national provision bears the heavy costs of chronic illness and long-term dependency, leaving the far more financially profitable acute sector to blossom in private hands.

All the advantages of private care and the getting of value for money in that sector depend on the NHS remaining alongside it, as a form of safety net. Genuine independent medical care would never survive alone. It would be far too costly to organise, its value for money would drop and ultimately its provision would be so restricted as to ensure its dwindling unpopularity.

Private medicine offers unparalleled opportunity for profiteering, which is not quite such an offence if those being taken advantage of share a similar philosophy or can easily bear the financial strain of what is, after all, very little extra medical provision. However, it amounts to a far from limited dimension as far as extra or paramedical trimmings are concerned. Private medicine does not pretend that its organised providers can cover chronic conditions. The inclusion of, say, maternity services may well undermine the private facility altogether.

Increasing the private sector will, without doubt, make our health provision even more divisive, and will make our caring service one that will be easily recognisable as dual standard service, a two-tiered system, which is clearly a Tory goal and an upper crust ambition. We must never forget the degree of social equality in the community that universal access to health care has brought over the past 30 years. That is one of the great advances that Tory Governments of the post-war era have accepted and have even made a fine contribution towards, yet this Administration are all out to prove that they are the exception.

The NHS being free at the point of need and access seems to displease the present Administration, though it does not displease all their supporters. It also displeases the ultra-conservative, probably dominant, elements within the medical profession. The system of payment for a comprehensive Health Service through the resources and distribution of general taxation, raised by a democratically elected Government, still remains the fairest and easily the most desirable solution and provision for all.

Mr. William Hamilton

We are debating nine amendments, seven of which are in the names of Scottish Members. They all seek the same objective—to get Scotland excluded from the provision of any private sector of medicine within the confines of the NHS.

It is not a big problem in Scotland. We went over the ground in Committee. The private sector is small in Scotland compared with England—as is the public school syndrome—but it is a nasty little problem. The principles on which it is based are just as objectionable as they are in England. We seek to delete the provision in clause 9 that is designed to encourage the provision of Health Service facilities for private patients.

The amendments are in the name of my hon. Friend the Member for Glasgow, Queen's Park (Mr. McElhone), but I drafted them with his advice and guidance. My hon. Friend was for a time the Minister responsible for the NHS in Scotland and he was extremely indignant about the abuses of private practice by the consultatifs engaged in it, particularly in the NHS in West Scotland.

If my hon. Friend had been here, he could have given us specific examples. I gave examples in Committee, in relation to England, by quoting the Expenditure Committee that dealt with these matters a few years ago under the chairmanship of my hon. Friend the Member for Wolverhampton, North-East (Mrs. Short). That Committee heard oral evidence of the theft of NHS equipment, some of it quite expensive, by professional people, including consultants, for their private use. I think that "extended loan" was the euphemism which was used.

There is no doubt that facilities and equipment are used and abused by the private sector for personal gain. When the Minister for Health was replying to some of those charges on Second Reading, he said that our attitude showed the worst facets of Socialism. He says that our view is based on envy of the fact that someone can buy something superior to what those whom we represent can buy and that we are motivated by malice and envy. That is not the case.

I do not object to a private sector. It is impossible to prevent people from using their money to buy privilege, whether in health or education. As long as there are private chemist shops and the facility to buy drugs, and as long as consultants or GPs are authorised by law to engage in private practice, there is nothing to stop individuals from buying privilege and what they regard as a superior service.

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Our objection is to using a public service to that end. If people want a private service—the same applies, in my view, to private education—they should pay for it wholly and completely separately from the public provision. When the overlap occurs and the National Health Service, provided from the taxpayers' purse, is used for private patients, that is not only an abuse ; it also creates friction between private and public patients, between private and public staff, and between the poor and the rich. It is divisive.

My hon. Friend the Member for Wood Green (Mr. Race) has spoken of the increasing friction that will be created by the provision of private health facilities within the Health Service. At a time when inflation is rampant, we should be doing everything possible to lessen friction and persuade people to get together to solve the problems within the Health Service.

I am not inviting the Under-Secretary of State for Scotland to speak at this hour. I am a masochist, but not a masochist to that extent. I know what he would say in his reply. The hon. Gentleman should, however, understand that when the Labour Party is returned to office—the time will surely not be long delayed—we will destroy the wretched private enterprise system within the Health Service. There is no place for market forces in the provision of health services. It is an offence against the basic principles on which the original Health Service was launched.

I suspect that a determination to undermine those principles lies behind the Bill. It bears repeating that the Government are determined to lessen the area in which the State operates, whether in health education, housing or anything else. They dislike public services. They like the profit motive. If people cannot afford the health services that they need for medical reasons, they have to go without. That is the basis on which the Government argue their case. It is the American system, now to be copied in this country, that if one cannot pay, one dies. It is not necessary for the Under-Secretary of State to say that he rejects the amendment. We know he rejects it. The hon. Gentleman had therefore better keep his mouth shut.

Mr. Haynes

I am not surprised that we have to propose this amendment to challenge the Government over their proposals in the Bill. Nor am I surprised that talks took place during the years of the previous Labour Government between the British Medical Association and prominent Tories about a pay-off after the election if the Tories were returned. That is exactly what has happened. I am sorry that my hon. Friend the Member for Carmarthen (Dr. Thomas) has left the Chamber because I promised him that I would have a dig at the doctors. I have seen what goes on. The issue is raging through the nation because of what happened to the nurses and what happened to the doctors and consultants not long ago.

The trade union movement is talking about a 30 per cent. increase for doctors. Some trade unions, including mine, are saying that that is the norm. The Government can look in that direction in respect of other workers. I tabled a question to the Secretary of State not many days ago to try to get more information. He ducked the question and passed it to the area health authority.

The consultants and doctors received a massive increase not long ago. In addition, they have a private rake-off. The Government are giving them even more. The consultants and doctors receive payment for National Health Service work, for private work and for providing domiciliary services. That is a continual rake-off. Because of what is going on, and because more and more private beds will be provided in the National Health Service, it is no wonder that the Minister will not come clean and say what the limit is. There is no limit. Government policy is "The more, the merrier."

I intervened when my hon. Friend the Member for Wood Green (Mr. Race) was speaking some days ago to mention my area. We have a famous football club-not Notts County—with a famous centre forward. He received an injury. Immediately he was put on a stretcher and taken to an orthopaedic hospital and was given a National Health Service bed. The following Saturday an 85-year old constituent told me that she had been waiting for a hip operation at the same unit for two years. If a person can pay, he can jump the queue. If a person can afford to pay, he can get in at the expense of the poor National Health Service patient who will have to wait.

The Minister tried in Committee to tell us that waiting lists were shrinking. That is not true. Waiting lists for National Health Service patients are becoming longer. The Government are encouraging people to pay twice to get off the waiting list, jump the queue and acquire a hospital bed.

Mr. Race

Would my hon. Friend care to reflect on the fact that as this Government undermine British industry, and as they remove the prospects of creating profitability in certain sections of manufacturing industry, it becomes necessary for them to create profitability in areas which have traditionally been part of the State sector? Is that not exactly what is happening in this situation in what have traditionally been areas where State provision has been the norm and where profits have not been made?

Mr. Deputy Speaker

I hope that the hon. Member for Ashfield (Mr. Haynes) will not pursue that line, which has nothing to do with the National Health Service.

Mr. Haynes

I always respect the Chair, Mr. Deputy Speaker.

I turn now to the issue of insurance, which is related to the pay bed system. It was said tonight by a Minister—Frank Chapple and his mob have been mentioned—that people are looking at the possibilities of private health care. If that interest grows, we shall be back to square one. We shall have long lists of people waiting to obtain service and pay beds are not the answer.

I have been trying for ages to get an answer from the Prime Minister to the following question relating to the National Health Service : How can the Government afford to provide weapons to destroy life and not find additional money to provide the necessary equipment and hospital beds to preserve life?

Mr. Pavitt

I always enjoy the robust comments of my hon. Friend the Member for Ashfield (Mr. Haynes) because he brings a tremendous amount of grass roots experience to these debates. I part company with him on one point only, which is that one must be careful when discussing the few doctors who exploit opportunities. It would be quite wrong to label the whole medical profession as the result of the conduct of a few.

I find clause 8 and the policy of the Government in this context incomprehensible in the light of the report of the Royal Commission. Anybody who knows anything about the National Health Service knows that whoever the administrator is or whoever the Minister is there are enough unavoidable problems to be faced in the NHS.

The Royal Commission said that we should get the issue of pay beds into proportion. There are half a million NHS hospital beds and, as my hon. Friend the Member for Wood Green (Mr. Race) said, we are now down to about 2,000 pay beds. The Royal Commission pointed out that the controversy and the heat generated by this question were far greater than the impact of the number of pay beds. The controversy was generated by the principle of pay beds and all that flowed from it.

In the light of that evidence and the reasoned approach of the Royal Commission, I find it incredible that the Government should embark upon a reversal of the work of the Health Services Board, once again encouraging problems in the Health Service. They could have avoided creating difficulties in this area.

My hon. Friends have pointed out that pay beds merely buy time. They do not buy extra clinical care. The pay bed system does not buy anything extra other than time and convenience. But unless there is an unlimited supply—and there is not—the services that flow from the pay bed system into the various departments of a hospital mean that once we establish a cash basis for the selection of services we cannot have selection without rejection.

Inevitably, therefore, the fact that the bed is occupied and has been selected by the power of the purse means that somebody who has equal clinical need—and perhaps more social reason for needing a bed—is excluded. This is a piece of social injustice that Labour Members condemn, and I very much welcome the forthright statement on it by my right hon. Friend the Member for Lewisham, East (Mr. Moyle). I hope that when we win the next general election, as inevitably we shall, we shall forget about the Goodman compromise on this question. We are talking of only 2,000 beds. In the very early days of our next five years in office, let us get rid of them immediately and get on with tackling the real problems rather than continuing this everlasting debate.

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My hon. Friend the Member for Wood Green put his finger on the spot when he spoke about the distortion that pay beds give to the whole of the National Health Service. There is a distortion between the doctor and his patient. Most of our doctors are able quite clearly to understand their patients. They know them and their homes and family circumstances. They can make a clinical judgment on need. But the moment the pay bed comes into it and payment for services arises there is a distortion of the relationship between the doctor and his patient. There is also a distortion between doctor and doctor.

A friend of mine was a radiologist in one of the teaching hospitals. He was a registrar and he was intensely angry at the fact that his consultant was piling work on him relating to private patients. He received nothing for it. The consultant, of course, was being paid at the other end of the scale.

A great deal has been made by Labour Members of the fact that the Government seem determined to abolish the basic principle of the Health Service relating to need and clinical decision. But the result of the pay bed system is that, instead of the service being free at the time of need, those who take advantage of the system pay for jumping the queue. The average weekly payment of the average taxpayer for the services he gets under the NHS is £5.70. He pays that week in and week out. People who need a hernia operation or need to have varicose veins treated, and people with gynaecological problems, may have been paying week after week for a lifetime, and yet suddenly they find they are at the end of the queue because someone is able to pay extra to jump the queue.

This is particularly bad in the case of people with hernias and those with gynaecological problems or varicose veins. People do not usually die of these things, so apparently they can wait in acute discomfort and acute pain. The person with money is able to jump the queue if he is prepared selfishly to use his money in that way. This must be to the detriment of others in the queue.

The Government ought at least to agree to the common waiting list, as proposed in amendment No. 37. The discussions with the BMA went on far too long. The quite detailed proposals in that amendment would do much to ensure that clinical judgment and social needs were the only criteria. Queue jumping would then be very much less.

I want to put one last point to my right hon. Friend in relation to future policy. He will recall that under the previous Labour Government the Chancellor of the Exchequer, in his wisdom, put a small tax upon BUPA and other similar bodies. When we are drafting the next manifesto, I hope he will discuss with our colleagues the question of a direct tax on the fringe benefit of the person who receives it. A large number of the group schemes, which at the moment are given as part of a fringe benefit to the professional people and the top echelons in industry and commerce, should attract a direct tax. There would then be far less willingness to join in the bonanza that BUPA provides. It would save the Health Service, the workers in the Health Service, doctors and patients a lot of problems if even at this eleventh hour—or this 2.34 am hour—the Government accepted the deletion of clause 8 from the Bill and returned to what the NHS was originally all about.

Mr. Dubs

Earlier this evening we debated an amendment dealing with the structure of the Health Service in London. It was important, and it dealt with major issues of concern to the Health Service. But it was not nearly so important as this amendment, which goes to the heart of what the Health Service is all about. The Health Service can be threatened in a major way by a great expansion of private practice. I believe that the Government are against the Health Service and that they do not like the Health Service being as successful as it is. In fact, the Government have made two major attacks on the NHS since they were elected—first, by starving it of funds and, secondly, by encouraging the development of double standards through the expansion of the private sector.

Last October, I had the opportunity of paying a brief visit to the United States. Time and again, when discussing the NHS with ordinary Americans, and when discussing the quality and cost of their health care, I found that they were amazed at how well the Health Service, for all its faults and weaknesses, was working. They had been so bamboozled and hoodwinked by the publicity put out by the American Medical Association that they did not realise what the NHS was about, what sort of service it provided, what freedom of choice within the NHS was available both for doctors and patients and what high standards of medical care we were able to provide for all our people regardless of their ability to pay.

Many of the Americans to whom I spoke were very impressed by that and said that they wished they had something comparable in the United States, because, despite the high living standard in North America, it is still true to say that for many Americans to fall seriously ill is equivalent to going bankrupt. That is what they said, and they have no alternative. Only those who are very rich indeed can survive a major illness, or those who are very poor indeed and have second-class health care at public expense.

But for the broad band of people between those two extremes illness is a disaster not just because of the illness itself but also because of the financial consequences for themselves and their families. If we publicised in America and elsewhere the way in which the NHS is working, we might win more converts to the type of Health Service practice which exists in this country.

I should like to make four specific points about private practice and the damage that it does to the basis of the Health Service. The first relates to queue jumping, which has already been referred to by several hon. Members. I fully understand that people want privacy when they are ill, and that some people do not like to be ill in front of others in a ward. They may not be aware that they get a great deal of privacy in NHS wards, particularly those which are curtained off and divided into small sections.

Nevertheless, there is a way of providing privacy within the NHS. It is a way which is seldom publicised. I refer to the amenity bed. It is true that it is not al- ways available, but at least it is there for people who want to pay a little more as NHS patients for privacy without queue jumping or in any way seeking to gain an advantage over others who are waiting for medical care.

Secondly, I believe that private beds produce a number of important conflicts within the staff and operation of NHS hospitals. Many staff—nurses, hospital workers and others—who joined the Health Service to work for ordinary people do not like being put in the position of having to work for the privileged few private patients in a National Health Service hospital. There is another conflict for doctors and, particularly, consultants. If they are working partly for the Health Service and partly privately, there must be an intolerable conflict between the needs of the Health Service patients and their ability to earn more money if they devote more of their time to private patients. That conflict is undesirable and it must produce much strain for the average consultant. I do not know how they can come to terms with it.

For consultants, or for doctors aspiring to become consultants, there is a conflict between going into the fashionable specialties which will then lead to lucrative private practices and going into the Cinderella services such as caring for geriatric patients or psychiatry where there are few opportunities of earning money from private patients. There is also the conflict of running the hospital in such a way that a fair attribution of the costs is borne by private patients, given that many hospital services can be operated efficiently only on the basis of common provision for all patients. X-rays and pathology are examples of services for which I doubt whether it is possible for private patients to be charged the fair cost, and where the process of having to impose an accounting system on a National Health Service hospital increases the cumbersome nature of the bureaucracy and increases the overall costs of running the hospital.

There is also the problem of the different relationships between the private patient and the hospital and the National Health Service patient and the hospital. As my hon. Friend the Member for Wood Green (Mr. Race) said, pressures will be brought to bear by an individual who feels that he or she is paying, and is therefore entitled to something extra over and above that received by National Health Service patients.

How much private practice do the Government want? What proportion of total health care should be private? It is our contention that even the present proportion of private health care is damaging to the National Health Service. If there is a significant increase, it could be disastrous to the future of the National Health Service and to the many millions of people who do not wish to be or cannot afford to be private patients.

Mr. Race

Will my hon. Friend reflect on the market philosophy of the Government with regard to health care? The failure to set an upper limit for the number of pay beds in National Health Service hospitals leads me to believe that the Government are simply trying to encourage market forces to generate demand for private patient facilities, both inside and outside the National Health Service. Thus, they will be able to say in three or four years that the demand for private health care is increasing dramatically, and that they were right in not placing a limit on the operation of market forces.

2.45 am
Mr. Dubs

I agree with my hon. Friend. There are clear dangers that the encouragement that the Government are giving to market forces and to the development of the private sector will generate an increase in that sector. Unless the Government have a clear sense of when they want to stop the process, the danger is that the private sector will go on increasing to the detriment of the National Health Service. That is why we on the Labour Benches are opposed to the expansion of the private sector. We would like to see private practice taken out of the Health Service.

Sir George Young

It would have been amazing if, at this hour of the morning, in a 90-minute debate any new light had been shed on the age-old debate about the role of private medicine. It is no reflection on the sincerity of Labour Members' speeches that nothing new or original has been said on the subject.

The right hon. Member for Lewisham, East (Mr. Moyle) began by quoting the Royal Commission to support his views. That is a game that both of us can play. The Royal Commission did not declare itself in favour of the Health Services Board and the phasing out of pay beds. It said : That the establishment of the Health Services Board led to a welcome respite from discussion of this emotional subject. But it went on : we have no wish to enter into the 'pay beds' dispute.... Private practice could at most have a marginal and local effect on the NHS … We have reached no conclusions about the overall balance of advantage or disadvantage to the NHS of the existence of a private sector, therefore, but it is clear that whichever way it lies it is small as matters now stand. Finally, it said : We do not consider the presence or absence of pay beds in NHS hospitals to be significant at present from the point of view of the efficient functioning of the NHS. The right hon. Gentleman also implied that in some way the Health Services Board was an independent body preferable to the Secretary of State. The board was not neutral on the issue of pay beds. It was set up with the specific function of phasing them out.

The hon. Member for Wood Green (Mr. Race) raised a number of issues, including the question of laboratory services, in Committee. I ask him what evidence he has for the allegations that he made. Was he talking about inpatients or out-patients? If the former, the charge that they pay is all-inclusive, and an element for pathology tests is included in the daily charge, as I explained to him in Committee. If he is talking about out-patients, there are separate charges for pathology, and there is no evidence that this charge is not being levied. So I must ask him, if he has specific examples to produce, to let my Department have them. I repeat that this was an invitation that I extended to him in Committee to which he has not so far responded.

Mr. Race

I should be happy to give the Minister instances of where these charges are not levied. One of the problems in this area is that if a certain degree of concealment is indulged in by a consultant it is very difficult for anyone to break through that circle of concealment. People who work in pathology laboratories have often made the point to me that, although they know that private patients are treated on a regular basis in their hospitals, they never see specimens identified as having come from private patients. The system needs that. The specimen should be so identified if a charge is to be levied. That does not operate in many laboratories of which I am aware at present.

Sir G. Young

The hon. Member has a duty to make available to my Department precise details of the allegations he has made so that we may follow them up. I hope that he will respond to the invitation this time because he did not do so the last time I asked him to make specific accusations.

I must put this question to him. If my right hon. Friend the Secretary of State is not to be trusted, as the hon. Member implied, to look after the NHS, why has my right hon. Friend taken on board the Royal Commission's recommendations about the aggregate of small developments and tabled an amendment to the powers in the 1976 Act to designate areas where all developments are subject to the need for authorisation, thus providing an additional degree of protection to the NHS that the previous Administration did not extend to it?

The hon. Member asked what the upper limit on pay beds will be. As we made clear in Committee, we do not know, but we would be surprised if all the pay beds phased out by the previous Administration were phased back in again. We do not know what the demand will be, nor do we know how the applications for pay beds will be dealt with by the NHS.

The consultation letter on 31 January made it clear that pay beds will not be allowed back automatically on demand and that the local authority will have to satisfy the Secretary of State that there will be no significant prejudice to the NHS patients. This is a statutory requirement in clause 62.

The hon. Gentleman then raised the old chestnut about private patients' debts. I do not normally read the Derby Evening Telegraph, but I saw an article in it headed : Etwall campaigners probing tip-off of £¼million pay bed debts. It said : Campaigners fighting for the reopening of Etwall Hospital are to urge Derbyshire MPs to investigate shock allegations that £¼ million is owed to the Area Health Authority in bad debts by private pay bed patients. I pursued this matter with the Derbyshire area health authority. I have here a letter from the treasurer which makes it clear that the amount of bad debts incurred by private patients for the year in question was £217.70—not £¼ million, but 1 per cent. of that figure. Many false allegations have been made about bad debts by private patients, but, when looked into, we find that the percentage of bad debts by private patients is exceptionally low.

Mr. Rooker

Then why not publish them?

Sir G. Young

I have given the figures for one specific hospital. The information collected by the previous Labour Administration, as by this Government, does not enable us to identify automatically the amount of debt owed by private patients.

Mr. Race

Then how does the hon. Gentleman know that that statement is right?

Sir G. Young

In this instance a specific exercise was carried out by the Derbyshire health authority in response to certain allegations. I am glad that it did, because it showed how false the accusations were.

Mr. Race

Will the hon. Gentleman give way?

Sir G. Young

No, I am not giving way.

Mr. Race

On that particular point.

Sir G. Young


Mr. Race rose

Mr. Deputy Speaker

Order. The Minister is not giving way.

Sir G. Young

I turn now to the speech made by the hon. Member for Fife, Central (Mr. Hamilton). I deplore any abuse of facilities in the National Health Service whether by consultants or, indeed, by shop stewards. The hon. Gentleman is on very weak ground if he uses that as an argument against private practice. I would not use the argument that occasionally shop stewards abuse NHS facilities as an argument against trade unions being in the Health Service, and the hon. Gentleman should not apply a similar argument to private practice.

The six principles provide for common waiting lists for urgent cases and the seriously ill and for specialised treatment. Otherwise, they are concerned that both paying and non-paying patients, once admitted, are treated equally.

The second principle deals with outpatient waiting lists which Labour Members did not try to tackle when they were in government.

The six principles are deliberately non-statutory. They have been freely negotiated with the medical profession and we expect them to be implemented. To set them in the Bill would not help. The Opposition have not realised that the sanctions of the law are not the most effective way of influencing doctors in their handling of patients. It would be impossible for administrators or politicians to say whether the same criteria for admission were being applied to patients. Only doctors can resolve that conflict.

The proceedings on the Bill would not have been complete without an intervention by the hon. Member for Ashfield (Mr. Haynes), with his homespun philosophy. I think that he is a fully paid-up subscriber to the conspiracy theory of government. It is no use telling him that waiting lists are down from 750,00 to 700,000 because he made it clear that he would not believe them.

Mr. Haynes

That is not true.

Sir G. Young

These are the best estimates that the Government are able to make of the numbers on waiting lists. They are available in parliamentary answers. They show that in March last year there were about 750,000 people on the waiting lists and that in October the number was down to 700,000. The figures may be inconvenient for the Opposition, but they are the best that the Government have been able to find. They are derived on the same basis for waiting lists as was used by the previous Labour Government, and there is no reason to cast doubt on their accuracy.

The hon. Member for Brent, South (Mr. Pavitt) accused us of attacking the principle of the NHS. Private practice has been a feature of the NHS since it was set up in 1948. Only the Labour Government's Act of 1976 and the campaign which preceded it caused conflict. Basically, we are freeing private practice and returning to the pre-1976 position, but there are additional safeguards for the Health Service which we believe give added protection to it.

Clause 8, which the Opposition seek to delete, is an introduction to clauses 9 and 10, which deal with private practice in the Health Service. It is the foundation for that which follows.

A number of amendments deal specifically with Scotland, but no case was made out, especially by the hon. Member for Fife, Central, that Scotland should be dealt with differently from England. If the hon. Gentleman agrees, I do not propose to deal specifically with the Scottish amendments.

The right hon. Member for Lewisham, East dealt at some length with common waiting lists. The effect of the amendment would be to apply common waiting lists to all NHS and private patients. Opposition Members always claim that their objection to pay beds is that they are unfair. Having listened to their arguments this evening, it seems that their main objection is to private medicine as such.

Mr. Orme

Hear, hear.

Sir G. Young

It is a variation on the theme that if the State cannot provide it no one should provide it. It is an example of Socialism at its worst. The Opposition amplified that argument many times in Committee. It is aimed at a prohibition of private medicine. It is clear that the cry "Unfair" is merely a cover for their fundamental objection to private medicine.

Mr. Moyle

Will the hon. Gentleman comment on my observation that if the Government can convince the public by the end of the Parliament that common waiting lists are operating equally for private patients and National Health Service patients we may be on the way to solving the problem of private patients in the Service?

Sir G. Young

We have already gone as far as we can in implementing common waiting lists for urgent cases. The principles that have been referred to go much further than Labour Members were able to go when in government. There are statutory safeguards in the Bill. Pay beds will be authorised only when that does not prejudice NHS services. No new pay beds will be authorised unless the Secretary of State is satisfied that making those beds available will not prejudice services to other NHS patients. That is a statutory requirement that is set out in the Bill.

There is a non-statutory safeguard which lies in the agreement which the Secretary of State has reached with the medical profession on the six principles for arrangements for private practice in the NHS, which have been referred to on many occasions. The agreement is an integral part of our policy.

We are concerned that provision for private patients shall not be at the expense of the Service. We made that clear in the first letter that my right hon. Friend set out on 22 June after coming into office. That made it clear that arrangements for private practice in the Service should operate fairly and should be seen to do so. We have kept that promise through the retention of the legislative safeguard and through the new agreement with the medical profession.

The principles make it clear that it is unacceptable that the treatment of an NHS patient who is seriously ill and in need of urgent medical care should be prejudiced because priority has been given to a private patient in less need.

Mr. Pavitt rose

Sir G. Young

No, I must make progress.

It is equally unacceptable that a patient who has had a private consultation should be given a greater degree of priority for treatment under the NHS than would have been available to any other patient whose medical needs are the same. The principles to which I have referred outlaw that. The agreement on the principles is a notable achievement and goes far beyond what the previous Labour Administration achieved. It demonstrates what can be done through co-operation and negotiation.

I think that many of my right hon. and hon. Friends were hoping to hear a definite exposition of the Opposition's current policy on private practice. They have a duty to tell us of their policy. Is it the policy that was administered by their two Front Bench spokesmen when they were Ministers, namely, phasing pay beds out of the NHS but allowing the independent section to exist outside the Service subject to satisfactory safeguards?

3 am

Is that perhaps their policy? Or is it the policy put forward in Committee by the right hon. Member for Lewisham, East, which in practice would have frozen private sector provision at the current level? Or is it the position outlined by the right hon. Member for Salford, West (Mr. Orme) in a speech to the treasurers a few weeks ago, when he said : I do not believe that there should be the right to private medicine within our society because the choice is based on a monetary consideration rather than a health consideration"? Is that their policy?

If that is the case, how do Labour Members reconcile that with what a former Labour Secretary of State for Social Services, Barbara Castle, said : I believe that it would be intolerable in a democratic society to prevent people buying private medical care if they felt it was an essential part of their personal interest"? What exactly is the policy of Labour Members on private practice?

We have a wide range of choice before us, and in his speech the right hon. Member for Lewisham, East carefully avoided saying anything about the role of private medicine in our society.

Mr. Moyle rose

Sir G. Young

Before the right hon. Gentleman intervenes, let me give him another option. Perhaps he prefers to follow the policy adopted by many trade unions, which is to negotiate access to private medicine for their members in response to their demands. Is that perhaps to be their policy?

Mr. Moyle

The hon. Gentleman has asked a number of questions. He obviously did not listen to my speech. The situation is clear. Either we shall phase pay beds out of the Health Service under a Health Services Board arrangement, or we shall go for a short, sharp chop as soon as we return to power. AH that the hon. Gentleman is doing is helping to confuse doctors who have decisions to take about practice in the Health Service and how they will organise it by the smoke-screen that he is putting up. We are putting doctors in hospitals on notice about what will happen to private pay beds in the Health Service when we get back to power.

Sir G. Young

The right hon. Gentleman has ducked the issue again. The questions that I was putting to him were directed not at pay beds within the NHS but at the role of private medicine outside the Service. I asked him to say whether the Labour Party's policy is that which they adopted when in government, or the policy put forward by the right hon. Member for Salford, West a few weeks ago, when he said : I do not believe that there should be the right to private medicine within our society".

Which of these two options represents the policy of the Oppositon? I note that the right hon. Member for Lewisham, East, is not now springing to his feet to say what is the answer.

Our party is united behind our policy, which is a policy based on partnership, not on apartheid. It is a policy based on freedom of choice, not State monopoly. It is a policy supported by the vast majority of people in this country.

Question put, That the amendment be made :—

The House divided : Ayes 69, Noes 124.

Division No. 347] AYES [3.5 am
Alton, David Flannery, Martin Richardson, Jo
Atkinson, Norman (H'gey, Tott'ham) Foster, Derek Roberts, Ernest (Hackney North)
Beith, A. J George, Bruce Robertson, George
Benn, Rt Hon Anthony Wedgwood Graham, Ted Rooker, J. W.
Bennett, Andrew (Stockport N) Hamilton, James (Bothwell) Ross, Ernest (Dundee West)
Booth, Rt Hon Albert Hamilton, W. W. (Central File) Rowlands, Ted
Bray, Or Jeremy Harrison, Rt Hon Walter Sever, John
Callaghan, Jim (Middleton & P) Haynes, Frank Silkin, Rt Hon S. C. (Dulwich)
Campbell-Savours, Dale Hooley, Frank Skinner, Dennis
Clark, Dr. David (South Shields) Howells, Geraint Soley, Clive
Cocke, Rt Hon Michael (Bristol S) Hughes, Robert (Aberdeen North) Spearing, Nigel
Cohen, Stanley Lamond, James Spriggs, Leslie
Coleman, Donald McCartney, Hugh Thomas, Dr Roger (Carmarthen)
Cowans, Harry McKay, Allen (Penistone) Tinn, James
Cox, Tom (Wandsworth, Tooting) McKelvey, William Walker, Rt Hon Harold (Doncaster)
Crowther, J. S. Maynard, Miss Joan Welsh, Michael
Cryer, Bob Millan, Rt Hon Bruce Winnick, David
Dalyell, Tam Moyle, Rt Hon Roland Woodall, Alec
Dixon, Donald Orme, Rt Hon Stanley Wrigglesworth, Ian
Dobson, Frank Palmer, Arthur Young, David (Bolton East)
Dormand, Jack Pavitt, Laurie
Douglas, Dick Powell, Reymond (Ogmore) TELLERS FOR THE AYES:
Dubs, Alfred Prescott, John Mr George Morton and
Eastham, Ken Race, Reg Mr. Terry Davis.
Evans, John (Newton)
Alexander, Richard Fairgrieve, Russell Lloyd, Peter (Fareham)
Ancram, Michael Faith, Mrs Sheila Lyell, Nicholas
Aspinwall, Jack Fenner, Mrs Peggy McNair-Wilson, Michael (Newbury)
Benyon, Thomas (Abingdon) Fisher, Sir Nigel McQuarrie, Albert
Berry, Hon Anthony Fletcher-Cooke, Charles Major, John
Biggs-Davison, John Fookes, Miss Janet Marlow, Tony
Blackburn, John Garel-Jones, Tristan Mather, Carol
Body, Richard Grieve, Percy Maude, Rt Hon Angus
Boscawen, Hon Robert Griffiths, Eldon (Bury St Edmunds) Maxwell-Hyslop, Robin
Braine, Sir Bernard Gummer, John Selwyn Meyer, Sir Anthony
Bright, Graham Hannam, John Mills, lain (Meriden)
Brinton, Tim Haselhurst, Alan Mitchell, David (Basingstoke)
Brooke, Hon Peter Hawkins, Paul Montgomery, Fergus
Brown, Michael (Brigg & Sc'thorpe) Hawksley, Warren Morrison, Hon Charles (Devizes)
Bulmer, Esmond Heddle, John Morrison, Hon Peter (City of Chester)
Cadbury, Jocelyn Henderson, Barry Myles, David
Carlisle, John (Luton West) Hogg, Hon Douglas (Grantham) Neale, Gerrard
Carlisle, Kenneth (Lincoln) Hooson, Tom Needham, Richard
Chapman, Sydney Howell, Ralph (North Norfolk) Nelson, Anthony
Churchill, W. S. Hunt, David (Wirral) Neubert, Michael
Clark, Hon Alan (Plymouth, Sutton) Hunt, John (Ravensbourne) Newton, Tony
Clarke, Kenneth (Rushcliffe) Jenkin, Rt Hon Patrick Normanton, Tom
Colvin, Michael Jopling, Rt Hon Michael Onslow, Cranley
Cope, John Kellett-Bowman, Mrs Elaine Page, John (Harrow, West)
Costain, A. P. Kershaw, Anthony Page, Rt Hon Sir R. Graham
Cranborne, Viscount Kitson, Sir Timothy Page, Richard (SW Hertfordshire)
Dean, Paul (North Somerset) Knight, Mrs Jill Parris, Matthew
Dorrell, Stephen Lang, Ian Patten, Christopher (Bath)
Dover, Denshore Lawrence, Ivan Patten, John (Oxford)
Dunn, Robert (Dartford) Le Marchant, Spencer Pollock, Alexander
Price, David (Eastleigh) Squire, Robin Wakeham, John
Proctor, K. Harvey Stanbrook, Ivor Walker, Bill (Perth "E Perthshire)
Rathbone, Tim Stanley, John Waller, Gary
Rees-Davies, W. R. Stevena, Martin Ward, John
Renton, Tim Stewart, John (East Renfrewshire) Walls, Bowen (Hert'rd A Stev'nage)
Rhodes James, Robert Stradling Thomas, J. Wheeler, John
Rhys Williams, Sir Brandon Taylor, Teddy (Southend East) Wickenden, Keith
Roberts, Michael (Cardiff NW) Temple-Morris, Peter Young, Sir George (Acton)
Sainsbury, Hon Timothy Thompson, Donald
Silvester, Fred Townond, John (Bridlington) TELLERS FOR THE NOES:
Sims, Roger Vaughan, Dr Gerard Mr. David Waddington and
Speller, Tony Viggers, Peter Mr. John MacGregor.
Spicer, Michael (S Worcestershire)

Question accordingly negatived.

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