NATIONAL HEALTH SERVICE

HC Deb 27 October 1980 vol 991 cc65-166

Motion made, and Question proposed, That this House do now adjourn.—[Mr. Le Marchant.]

5.3 pm

The Secretary of State for Social Services (Mr. Patrick Jenkin)

During the passage through the House of the Health Services Bill 1980 an undertaking was given by the Government to the Opposition that the House would have an opportunity of a full day on the Floor of the Chamber to debate the reorganisation of the National Health Service on which we have now embarked. That is the purpose of this debate, which the Government very much welcome. I should perhaps make it clear to the House that, as indicated on the Order Paper, the debate is about the reorganisation in England. There was a full debate in the Scottish Grand Committee shortly before the Summer Recess. I am authorised to give an undertaking to the House that there will be an opportunity in the Welsh Grand Committee for a similar debate on reorganisation proposals in Wales. I shall concentrate, therefore, on the proposals for reorganisation in England which were the subject of the consultative paper "Patients First" and of the circular issued by my Department on 23 July last. In effect, I shall be giving the House a progress report.

I realise that some right hon. and hon. Members may wish to take the debate a little wider and discuss perhaps problems of finance or health strategy. As I understand it, subject to any ruling you may make, Mr. Speaker, this would be quite in order. I shall have a little to say on these matters towards the end of my speech, but if he should catch your eye, Mr. Speaker, my hon. Friend the Minister for Health will reply to other points when he winds up the debate tonight.

First, I shall put the debate into context. It is certainly important to get the structure and organisation of the National Health Service right. The Government have never pretended that that is the only thing, or even the most important thing, in our policy for health. On the contrary, structure and management are simply means to an end—the end being the good health of the people of this country in the widest possible sense. The promotion of good health, preventive medicine, health education, public health, a sound environment, proper nutrition and a carefully considered strategy on finance and priorities are essential for achieving an effective health policy. It is against that general background that we are discussing the particular matter of reorganisation.

No one relishes change for change's sake. There were persuasive arguments for leaving things as they were after the 1974 reorganisation. All change carries a cost and this cost falls inevitably both on the people working in the Service and on the patients—and others—whom they serve. Yet I have no doubt whatever that the Government were right to respond promptly to the very widespread feeling inside and outside the National Health Service that the arrangements as they have emerged since 1974 have not been satisfactory. That was the view which we came to as a result of a great deal of consultation when we were in Opposition. It was the view firmly expressed by the Royal Commission on the National Health Service and it was overwhelmingly the preponderance of opinion given in response to our consultation document "Patients First".

For me there is nothing to be ashamed of in being prepared to learn from experience. The 1974 changes which this party introduced had many virtues, but we now need to deal with the problems. There has been almost 100 per cent. support for four main propositions. First, there needs to be a substantial strengthening of the management of services right down at the local level. Those responsible for taking decisions in the hospital and in the community must have more authority, higher seniority, and more autonomy. Perhaps the loss of an effective decision-making capacity by hospital managements was one of the worst consequences of the 1974 changes.

Secondly, it has been widely agreed that the multi-tier structure below regional level is unduly cumbersome, involves confusion of authority, unnecessary bureaucracy and excessive management costs. There has been widespread support for a single-tier health authority below regional level, based in most cases on existing health districts.

Thirdly, it has been widely agreed that the planning system evolved after 1974 was altogether too complicated and needed to be simplified. Fourthly, the professional advisory machinery—not just for doctors but for nurses and other professional groups—was too elaborate and time-consuming for those involved.

There also is wide agreement within the Health Service that the policy of trying to fix the boundaries of health authorities to match the boundaries of local authorities at almost any cost has given rise to great difficulties. After all, local authority boundaries do not necessarily bear much relation to the hospitals to which people naturally look. It is fair to say, however, that local authority interests have all along attached much more importance to this principle of common boundaries. The Government certainly agree that, where they can be achieved in a way that makes sense both for health and local authorities, that has obvious advantages.

Finally, there has been a good deal of support, but again not universal, for the view that many clinical and non-clinical support services are better managed at the unit level without an elaborate management structure for each such service existing at district or other level.

It is on the foundation of these six principles—the four almost universally agreed and the two that have achieved a wide measure of support—that the Government have decided that a further reorganisation is necessary.

We have decided, therefore, that the authorities which provide health services should be based primarily at the district level. We envisage that there may be up to 200 such district health authorities covering England—a number of them of course being existing single-district areas which, with minimum changes, could be reconstituted as district health authorities.

Within the district we want to ensure proper delegation of responsibility to management of the individual units for the day-to-day running of the Service. To make that stick, health authorities will keep to an absolute minimum the number of management posts in the different disciplines between the level of the unit and the district management team. One of the errors made after 1974 was the insistence by the Department of Health and Social Security that there should be, as it were, a management pyramid for each support function. It was that, perhaps more than anything else, which had the effect of sucking decisions away from the ground, up the line, and which has been so heavily criticised. One of the contributory causes of the suction-pump effect has been the fact that consultants' contracts are held at regional level. As I have made clear to the British Medical Association, I am very anxious that we should reach agreement with the hospital and community doctors' representatives that the new district health authorities should be the employers. We are currently engaged in discussion with a view to seeing what safeguards they feel to be necessary if something along those lines were to be laid down.

So our plan is, first, to eliminate the area tier and to set up district health authorities covering populations of between 150,000 and 500,000. Secondly, we shall simplify substantially the management structure below the level of the district health authority in order to cut bureaucracy and strengthen local management.

What stage have we reached? I shall deal first with staff. Although we Say "patients first", and that is quite right, from the outset we have been concerned with the impact of the changes upon staff. It is they who bear the immediate impact of the reorganisation. Many senior staff have a crucial role to play in its successful planning and implementation. I wish to take this opportunity to pay a tribute to the senior staff in the National Health Service, who do an extremely good job.

It is easy to under-estimate the amount of disruption that the changes mean for people running the Service. I am under no illusion that the anxieties and upheavals that individual members of the NHS staff are facing, particularly at area level, are not considerable. I know that all of us, whether we are involved as Ministers, members of health authorities, management or staff side representatives on the various Whitley councils, are determined to do our utmost to minimise the problems.

From the outset, the Government always recognised that the personal needs of staff would have to be fully and fairly met. Accordingly, on 4 June my Department announced the proposed terms for premature retirement, redundancy compensation and the protection of pay and terms and conditions of service of staff changing jobs. I also made it clear that those matters, and the arrangements for filling posts in the reorganised Service, should be the subject of negotiation in the Whitley council. That has been taken on board by a special reorganisation committee of the general Whitley Council. I can tell the House that negotiations are progressing steadily. I think that it is helpful that staff in the Service are being kept fully informed by the wide circulation of joint statements of progress.

Perhaps this is not the time to go into details of the proposals under negotiation, except to say that I think that they are as generous as is consistent with the realities of our economic position, and that they are comparable with what is available elsewhere in the public sector. Taken as a whole, the terms offered—particularly those for premature retirement—will go a long way to ensure that the overall reduction of posts will be met largely by premature retirement and natural wastage with the absolute minimum of recourse to compulsory redundancies.

When I made my statement to the House on 23 July a number of hon. Members asked a perfectly fair question about how many posts would be lost. A good deal depends on how regions' plans for structural change emerge and also on what the new district authorities decide about their management. But, as the House knows, we have set ourselves a clear target for an overall reduction in management costs by the end of the year 1984–85—after the transitional period—of about £30 million. One does not need to be either a clairvoyant or a senior wrangler to draw some inference from that figure. A figure of £30 million means a reduction in management costs of about 10 per cent. As we are talking about a group of staff that numbers something below 50,000, it follows that we are aiming at a reduction in the number of posts of about 4,000 to 5,000.

I must make it clear that that does not mean 4,000 or 5,000 redundancies. On the contrary, natural wastage is al- ready having an effect as people retire or leave and posts are left unfilled. We visualise that a good many older staff will welcome early retirement. However, at the end of the day health authorities may find themselves with a few staff for whom no posts can be found in the new management. In such circumstances, I shall expect authorities to take the honest decision and declare a redundancy. It cannot be stressed too strongly that the National Health Service is neither a job creation project nor an employment agency. It is certainly of no benefit to patients, or even in the best interests of the individual staff member himself, if staff are retained indefinitely in a supernumerary position with no real job to do.

Mrs. Renée Short (Wolverhampton, North-East)

The Secretary of State may remember that when the Select Committee was considering the question of reorganisation and its effect on staff it was given a figure of £30 million saving. At that time there was no information available about the numbers of redundancies and, therefore, their cost. Does the £30 million include payments for any necessary redundancies?

Mr. Jenkin

If I did not make the matter clear when I gave evidence to the Committee, it was my failing. The £30 million is the reduction at today's prices in the running costs of management that we expect to be achieved after meeting the transitional costs that will have to be met in the immediate years ahead for early retirement, redundancy and protection. The £30 million is the figure at the end of the day. We cannot possibly achieve that immediately, because we have to meet intermediate costs. I hope that I have made the position clear.

We accept that redundant staff must be fairly compensated. Improvements to standing National Health Service redundancy compensation terms have been put to the staff side and are under urgent consideration. The next stage on staffing matters will be for the individual Whitley councils to negotiate much greater flexibility in the grading and salaries of individual posts, especially for senior management posts at unit level. That will not be easy, and staff sides will find it difficult to relinquish some of the very tight rules that have hitherto governed the appropriate grading for particular posts at particular levels.

I cannot stress too strongly that the health services and the patients that they serve will benefit enormously if the managers at local level are senior, experienced people able to wield authority effectively and to take management decisions on the spot By that I mean the people actually running the unit, for example, the community nursing service, the district psychiatric service or a district general hospital. To my mind, nothing will do more to improve the morale of staff at all levels than the restoration of that sort of local management authority. As my right hon. and hon. Friends said in July, if that means bringing back matron or, as has been put to me subsequently, the hospital secretary, I shall be delighted if the health authority finds it right to use those titles, because, in effect, that is what we are proposing. They are senior and authoritative people who are on the spot and who can lead the staff for whom they are responsible. To achieve that it is essential that we have the flexibility in grading and salaries for which the management side will be negotiating. I have no doubt that that will take a little time, but at the same time the prizes are great, and are worth waiting for.

Mr. Laurie Pavitt (Brent South)

Will the right hon. Gentleman give us a further indication? He was referring to senior administrative staff. I am thinking of two qualities that are necessary. For example, we have 90 area nursing officers and 90 area dental officers and we shall have, say, 160 to 180 district health authorities. Will each of those authorities have a unit officer? If that is so we shall have a greater number of senior administrative officers than under the present system.

Mr. Jenkin

Uncharacteristically, the hon. Gentleman has missed the point. If we are eliminating the area tier in a multi-district area, and instead have, say, three district health authorities, instead of having four teams as there are at present—an area team and three district teams—we shall have only three teams. Therefore, there will be a saving at that point.

But, of course, the saving again will come as between the district health authority management team and the unit—which was what I was referring to when I referred to bringing back matron—and it is our intention that the absolute minimum of management staff should exist at the intermediate level, that we should have a senior person at the unit level and a senior administrator, or senior nursing officer, or director of nursing services—call it what one will—reporting directly to the district management team.

In that way, I believe that we shall achieve the saving we are looking for, a saving which should thus be available to provide better patient services. Not only will there be savings but when the period of transition is over I am confident that staff will find themselves, as they have not been in the last five or six years, working in an environment which gives a great deal more job satisfaction because it will provide a better managed Service much more responsive to the needs of individual patients.

Mr. Robin Maxwell-Hyslop (Tiverton)

Every time the organisation alters there is great personal disturbance. Therefore, would it not be sensible to reform the regional health authority structure at the same time as these alterations are being carried out rather than doing the reorganisation in two stages with two lots of dislocation?

Mr. Jenkin

That is a fair point. We examined it with some care but concluded, as we said in "Patients First", that it was probably better to do it in two stages, for two reasons. First, there needs to be an agent of change in each part of the country, and such an agent can really only be the regional health authority. My Department simply does not have the staff and resources to undertake the job. If the region were itself to be changed at the same time there would be a double difficulty.

Secondly, there seems to us to be an advantage—and perhaps this is more important—in our proposals in that not until the new district health authorities are in office, are working and have determined their own management structure can we say what further steps should be taken at regional level to enhance the authority and autonomy of the regional health authorities.

I think that in the circumstances it is right to argue that the upheaval if we did the reorganisation in one stage would be a great deal more than if we do it in two stages. We often talk about the process of voluntary change, but, of course, it may not seem quite as simple as that to the area nursing officer or administrator whose job as such is disappearing; so to spread it all over a period of three or four years is not unreasonable.

What else has been happening since I made my statement? Regional health authorities have been working on their plans for reorganising areas into health districts and by Friday next all 14 regions in England will have issued consultative documents setting out their plans for creating health districts.

These are substantial papers and, as I have asked, they have been distributed to a wide range of interests for consultation and comment. I hope that regions will have finished their consultations by about February next and will then submit their proposals to me. The impression I have formed—it may be belied by events, but I think that it is right—is that the majority of the proposals for creating district health authorities will meet with little objection, but there will be a few in each region where the answers are not immediately apparent and where difficult decisions will have to be made.

It would not surprise me if a number of hon. Members on both sides felt it necessary after February, when they know what the regions are finally proposing, to express their points of view directly to Ministers in person. I give an undertaking that my hon. Friends the Minister for Health and the Under-Secretary of State and I will do our best to respond to such requests, as I think we usually do.

I hope to make decisions by about the middle of next year and to appoint the chairmen of the new district health authorities shortly thereafter. The regions in turn will be expected to appoint district health authority members so that the new health authorities should exist in shadow form by the end of next summer. Most regions envisage the new health authorities taking over on 1 April 1982. As before, there will be a period when they may overlap.

One, however—the Wessex region—apparently expects fewer arguments than the rest—I am sure that one or two of my hon. Friends will not necessarily agree with that view—and is aiming for the handover to come on 1 October 1981. It remains to be seen whether the Whitley negotiations. which are vital to the change, are completed in time to enable that to happen.

The reason is that, until the new gradings and salaries are agreed, a district health authority cannot finally determine its management structure, because it will not know what flexibility it will have and therefore what posts it may create so as to live within the management cost limits on which we are going to insist.

Mr. Stanley Orme (Salford, West)

Would the right hon. Gentleman consider making the prescribed day for the changeover the vesting day, and fixing it for 1 April 1982? If authorities such as Wessex do not conform to that date along with all the rest, they will create problems for many of the staff in relation to compensation or perhaps to a wish on their part to move. I have had representations, as the right hon. Gentleman probably has, from staff representatives. They are concerned about this aspect. Since apparently only one authority at the moment is aiming at a different date, I think that it would be advantageous to aim at a single vesting day.

Mr. Jenkin

I am grateful to the right hon. Gentleman for making that point. It is obviously one of substance and we have given consideration to it. Indeed, I have had representations to just that effect from the staff side. If Wessex were the only one, we would want to consider very carefully what the right hon. Gentleman has suggested, but it will not necessarily be the only one. There may be a problem in the case of London, although we are hoping that it will meet the same timetable. But it would be rash to try to guarantee that by naming a national vesting day. The suggestion we have made is that most people should aim for 1 April 1982. We should have some degree of flexibility. I believe that that is the right answer, although I understand the problems that may be faced by staff.

Mr. David Penhaligon (Truro)

Can the right lion. Gentleman give an indication to staff in areas where no change, in effect, is taking place—such as Cornwall, for example? Does he expect that a senior administrator in that county will be paid more or less than he is currently being paid for administering the same area as now? That would give a good guide to whether the right hon. Gentleman will get the saving of money that he expects.

Mr. Jenkin

The hon. Gentleman can not tempt me into that. These matters are being negotiated in Whitley and it would be rash of me to comment. In the case of someone who will be fulfilling the same function under the new system as he is now, it would surely need persuasive argument to suggest that the nature of his task had been changed to such an extent that a change in conditions was required.

Dr. Alan Glyn (Windsor and Maidenhead)

The fundamental point about change in the Wessex area or in London is that the change must be based on Whitley council recommendations. Does not my right hon. Friend agree that when they are established it does not really matter on what day the authorities choose to carry the change out?

Mr. Jenkin

I shall turn to the question of London in a moment. I hope that my hon. Friend will recognise that there are considerable complications, not least arising from the university's position and from a number of other points, which will make it difficult. I hope that we shall have the same timetable, but it would be unwise to guarantee it at this stage.

I turn now to the management cost limits—an issue that I regard as extremely important. The Government attach great importance to those limits. In our view, a great mistake was made last time, when the Department sought to lay down centrally, and in great detail, the management structures for area health authorities and districts. As a result, many unnecessary posts were created, many of which have since been eliminated and many of which it is the intention of the present reorganisation to eliminate. However, it would be equally mistaken if we were to try to determine centrally the precise details of the new slimmed-down management structure. That must be a matter for the new health authorities.

How, then, do we prevent the proliferation of posts that seems to have accompanied so many other reorganisations—for instance, the local government and water authorities reorganisations? I believe that we have learnt the lesson. The key instrument must be an effective and enforceable management cost limit. We now have machinery for determining with some accuracy the management costs incurred in each health authority. We also have machinery to enable treasurers to hold the spending of health authorities within the limits determined first by the Government and then by regional health authorities. By combining those two financial disciplines and by fixing the management cost limits at the levels necessary to secure at the end of the transitional period the savings that we are determined to make we can achieve the objectives of this reorganisation and at the same time make the savings in management costs that we seek. We have the means. We are determined to use them to cut the costs of administration.

A great deal will depend upon the wisdom of the new district health authorities, and particularly their chairmen. When they are appointed, we shall impress on them, first, that it will be for them to decide what management posts to create; secondly, that they should create management posts only for which there is a proven need; and, thirdly, that their management structure, when finally settled, must be such as will meet the cost limits imposed on their health authority. They will have every incentive to do that because, as I have made clear on many occasions, both inside and outside the House, any savings in management costs will be money available to develop patient services. Neither I nor my right hon. and learned Friend the Chancellor of the Exechequer is seeking to claw back those savings. We are aiming to reduce the cost of administration and switch it directly into health care—whether for prevention or for the care of patients.

There are a number of other matters on which further consultation and further decisions will be necessary. I hope shortly to publish a consultative paper on the role and membership of community health councils in order to seek views on how their functions as watchdogs for the community can be made more effective.

Talks are also being held with family practitioner committee representatives about how to achieve better collaboration between these committees and health authorities on planning, particularly in primary care. Arising from those talks we shall prepare a further draft circular, on which we shall consult the Service. One of the issues for decision will be whether the present "principal/agent" relationship between health authorities and family practitioner committees should be retained or whether FPCs should employ their own staff. My hon. Friend the Member for Belper (Mrs. Faith) moved an amendment to the Bill to that effect in Committee.

Early next year I intend to issue a circular on the procedure for the appointment of district health authority members, which will spell out more clearly than has been done in the past the role of members. I hope also to discuss the simplified planning system with the regional chairmen during the autumn, with a view to publishing proposals on that in the new year.

The chief medical officer in my Department, Sir Henry Yellowlees, is making a good deal of progress on his review of medical advisory machinery in discussion with the profession. This is a complex matter, and it will take some time, but I certainly hope that the Government's conclusions will be published well before the first district health authorities are created. Similar progress is being made in respect of the advisory machinery for other professions—for instance, nurses.

Mr. Maxwell-Hyslop

Is the deputy medical officer in agreement?

Mr. Jenkin

I understand that all members of my staff are in agreement on these matters. There are four deputies, and I am not sure which my hon. Friend has in mind.

There is another minor but sensitive matter on which we would wish to consult the Service—the question whether district health authorities with teaching hospitals in their districts should be designated as teaching districts, as teaching areas now are. There are good arguments both for and against, and I shall not want to make up my mind on it until I have consulted the various interested groups, particularly the universities and groups within the Health Service.

My hon. Friend the Member for Windsor and Maidenhead (Dr. Glyn) raised the question of London constituencies. He and other hon. Members will want to know how these developments will affect London, where there are special problems. The Government are keen that this restructuring of London should keep in time with the rest of the country, but, because of the complications, and to help us in this task, I established the London advisory group as a high-level committee representative of all the relevant interests in London under an independent chairman, Sir John Habakkuk, to advise me. The group has already put forward specific guidelines for restructuring districts in London. which were attached to the Department's July circular.

In the meantime, London university has been considering the Flowers recommendations on the future of Medical schools in London, and it is ex-expected that it will be making its decisions very shortly. The London advisory group will then have to take account of these decisions by the university in making recommendations for the future of the major teaching and non-teaching hospitals in central London. It will also have to consider, in clue course, the Thames regions' proposals for new DHA boundaries in London. The group will also have to consider the development of an effective primary care service in some of the more difficult inner city areas. This is at present the subject of a study commissioned by the London health planning consortium.

The House will see that the advisory group has a heavy programme, but I am confident that Sir John and his colleagues are doing their utmost to make sure that we keep to our timetable. I should like to pay tribute to the staff of my Department, who are bearing a considerable burden during this period of transition, and to thank them for what they are doing.

Dr. Brian Mawhimiey (Peterborough)

Before my right hon. Friend leaves these matters, will he say what progress has been made by the group that is considering the ambulance service, when we are likely to receive a report from the group, and what opportunity there will be for the House to consider the report before decisions are taken about the ambulance service in the new district health authorities?

Mr. Jenkin

In order not to take up more time of the House at the moment, my hon. Friend the Minister of Health will deal with that point when he replies to the debate. The subject is important, and an important recommendation was made by the Royal Commission, which we shall examine carefully.

That is a progress report on reorganisation. but the House would not want me to complete it without some reference to other matters that are being pursued by my Department at this time. Reorganisation is only part of our programme.

The Government will be laying before the House a number of documents within the next two or three months in which we shall be setting out our policies on wider issues. For instance, the Social Services Select Committee, under the chairmanship of the hon. Member for Wolverhampton, North-East (Mrs. Short), made some interesting comments in its third report on the Department's expenditure. As I made clear in my statement at the time, the Government do not accept all the criticism of the hon. Lady's Committee, but we shall be replying to this report in a few weeks' time and I shall not today anticipate what we shall be saying.

Again, the Select Committee's report on perinatal mortality put forward a large number of important recommendations, which I and my colleagues have been studying with great care. Here, too, we shall be putting forward our response fairly soon.

On the question of strategy in health and social services and of the priorities that we shall expect health authorities and local authority social service committees to take account of in their planning, we shall be publishing a document, I hope early in the new year. It will be aimed primarily at the chairmen and members of health authorities and their social service committees. We want to give them guidance on the policies and priorities for which they will be looking to us when they make their plans for running the new district health authorities and for estab- lishing proper colloboration with local authorities.

While hon. Members may wish to take the occasion of this debate to state their views on all these subjects and, perhaps, others, I am sure that the House will understand if Ministers reserve most of their comments until the documents that we have in preparation are published and are available.

Mr. Paul Dean (Somerset, North)

Will my right hon. Friend say a word about the future of donors of kidneys and other human organs, in view of some disturbing reports that appeared in a BBC "Panorama" programme the other day, which suggested that in a number of cases organs are removed before patients are clinically dead? These are disturbing allegations and they will have a very bad effect on possible future donors unless they are disproved. Can my right hon. Friend tell us anything that will help to reassure the House and the country on this important matter?

Mr. Jenkin

I am most grateful to my hon. Friend for giving me a chance to say something about this matter. The broadcast was very disturbing, and nothing that has happened since then has gone any way to modify the grave anxieties that have been aroused in the mind of the public because of what the public fears about being an organ donor. As my hon. Friend the Minister for Health said at a conference over the weekend, torn-up kidney cards are now being sent back to the Department by people who have been frightened by what they saw. Much more important is the grave anxiety of the medical profession, because it feels that that programme got it entirely wrong.

The programme was based on the proposition that three American donors who would have been pronounced dead under the British rules subsequently survived. Hon. Members will have seen the article by Tony Smith in The Times and the letter by Professor Jennett in the current issue of The Lancet. Under the British rules established by the organ transplant committee of the profession none of those three patients would even have had the British tests applied to him. The most disturbing factor about the way in which the programme was constructed—Profes- sor Jennett made this point in his letter—was that he did not see that evidence—and he took part in the programme—about the American cases until the same time as the members of the public saw it. The failure of the BBC to give the leaders of the medical profession, who had vigorously protested before the programme went out, any opportunity to comment after having seen that is really shameful.

I hope that members of the public will now pay as much attention to the statement that I believe will be drawn up by the group from the Royal medical colleges, which is concerned with this, as they did to the original programme. I hope that the BBC will be persuaded to give the British medical profession an opportunity to answer the programme.

Mr. Orme

I take note of the Secretary of State's comments, but he knows that the programme created a great deal of public concern. It needs answering, and possibly his Department ought to answer, point by point, the issues that have been raised. In that way an alternative answer will be given and, if necessary, the BBC can be asked to give as much publicity to that as to the points originally raised. The House should recognise, as I am sure the Secretary of State does, given the reactions he must have had to that programme—reactions that I, too, have had—that there is public concern. That concern must be answered fully at the earliest opportunity.

Mr. Jenkin

I take the right hon. Gentleman's point, but I ask him to hear this factor in mind. The original recommendations and the code produced by the transplant advisory committee are produced by the medical profession. It is the medical profession that can draw up these provisions and that has the authority to make the rules effective within the profession. I believe that it is therefore right for us to look to the profession for the effective refutation of the charges that were made in the programme.

I think that the representatives of the Royal colleges are meeting today—I ask not to be held to that—and we must wait to see what they produce. I entirely take the right hon. Gentleman's point that there is now a need which there ought never to have been to reassure the public so that we can continue with pro- grammes of organ transplants as they have been conducted in the past. The terror that one has is that patients—particularly those requiring renal transplants—may go without the operation they need and may die because people have become frightened unnecessarily and irresponsibly by a television programme.

I turn now to the so-called Black report on inequalities in health, which was published after I made my statement on reorganisation in July. It has had an interesting reception. The right hon. Member for Lewisham, East (Mr. Moyle), almost within days of the appearance of this substantial report, suggested that it would be the basis of future Labour policy. We put the cost of implementing the report at not less than £2,000 million a year. The right hon. Gentleman and his right hon. Friend the Member for Salford, West (Mr. Orme) were Ministers in the Department when, so far from adding £2,000 million to expenditure on the Health Service, they cut capital spending on hospital and community health services from E.552 million, which it was when we left office in 1974, to £358 million in 1978–79—a reduction of one-third.

One simply cannot take seriously anybody who in office presided over health cuts on that scale and who in opposition cheerfully and blindly appears to welcome as the basis for his party's policy a report with a price tag of £2,000 million.

Mr. David Ennals (Norwich, North)

rose—

Mr. Jenkin

I will not give way to the right hon. Gentleman. No doubt the Opposition will seek an opportunity to debate the report, which, let it be said at once, and as I said in the foreword, contains much interesting information even if it does not shed much light on the fundamental causes of health inequalities. We certainly look forward to hearing the Opposition explain why, for instance when we have had a National Health Service for over 30 years, which has been overwhelmingly financed from taxation, which is virtually free at the point of delivery and which covers the huge majority of the British people, inequalities in health care have in some respect increased. That is the evidence in the report. The Government are right to treat the report with considerable caution.

A number of proposals in it warrant careful consideration, and that we are giving them. But anyone in the House—especially anyone who was a Minister in the last Labour Government—who argues that it is in any way conceivable that any Government in the foreseeable future could contemplate earmarking the finance that would be needed to fulfil Professor Townsend's dreams is living in cloud-cuckoo-land.

This is a serious point, because it brings into question the whole credibility of political debate. We read in the press that the Labour Party has just completed a series of meetings across the country on health affairs, including a substantial conference addressed by the right hon. Member for Salford, West the weekend before last. It is difficult not to feel some sympathy with one of the reporters who covered that event, because he wrote: It's certainly good to know what the goals— of the Labour Party— are. But a little greater emphasis on how they are going to be achieved might have helped avoid that sagging cynical feeling at the end of the day. The sympathy is increased when one realises that was the man reporting for Labour Weekly.

I have tried to show what we can do and are doing to improve care for National Health Service patients at a time of great economic difficulty. Our plans are realistic, and the House may think that the progress we are making is encouraging. They have the overwhelming support of those most closely concerned.

This may not be the stuff for political rhetoric and conference tub thumping, but for the patients, whose care must be our first concern, these plans will mean better housekeeping, better management and. above all, better care.

5.51 pm

Mr. Stanley Orme (Salford, West)

The Secretary of State finished on Sir Douglas Black's report, and I shall have something, to say about that later.

"Patients First" is the basis of the Government's current policy. We all want to see improvements in administration and the cutting of costs, but it is worth noting that the British Health Service is one of the lowest administrative cost health services in the world. That is primarily because it is based on a policy of funding through direct taxation. It does not have any insurance input and it does not carry with it, as in other countries—for example, the United States and certain European countries—high administrative costs because of the costing of bills, insurance collecting, and all that goes with it.

The Labour Party fully supported the removal of the tier in the reorganisation of the National Health Service proposed by the right hon. Member for Leeds, North-East (Sir K. Joseph) in 1974. We think that will lead to some administrative improvements. Nevertheless, that is only part, not the whole, of the story.

Today, the Secretary of State has given us some figures of savings in staff ranging between 4,000 and 5,000.

Mr. Patrick Jenkin

Places.

Mr. Orme

Yes, places. I accept that these are not redundancies. The vast majority will be achieved through natural wastage and early retirement. The Secretary of State referred to savings amounting to £30 million. But those savings will not be made in the first year or two years, because it will be very costly to arrange early retirements and to enable people to accept redundancy. As we know from local government reorganisation, this is not by any means a cost-free exercise. Therefore, we should be interested to hear when the Secretary of State believes we shall be in the £30 million savings era.

I raised the question of a vesting day with the Secretary of State because of the anxiety of staff and the problem of overlap which could occur. The London situation immediately springs to mind. My right hon. Friend the Member for Lewisham, East (Mr. Moyle) will deal with that matter and the staff position in more detail if he catches your eye, Mr. Deputy Speaker.

The title of this document, "Patients First", is misleading. It is not about all patients or a whole health policy. Essentially, it is about patients in hospitals. It fails to reaffirm the importance to the community of the Cinderella services and the effect of the expense on acute medicine. It fails to indicate priorities, such as prevention—Sir Douglas Black comes into that—and to place the structural aspects of the NHS in a social or general medical context. A simpler structure is necessary, but this reorganisation does not guarantee better quality management, though we hope that that will be achieved in future.

We have to judge the proposed changes against the background of the Government's current economic policy. The National Health Service faces five years of unprecedented financial stress, and its ability to make sensible decisions will be even further impaired. Reorganisation, however good, is no substitute for the resources that are urgently needed by the NHS.

It is argued that there will be increased conflicts over money and unwanted variations in local health services by devolution to the districts. That, combined with RAWP and cash limits, suggests a frightening outlook, and there is a loss of morale in the NHS due to the Governments' economic policy and the severe cuts.

"Patients First" has little to say about capital investment, replacement of outdated hospitals, attempts to improve staff-patient ratios, community care, health education and investment in the Cinderella services. Sir Douglas Black's report is crucial to this debate, for he deals with patients and priorities.

The Secretary of State said that to implement Sir Douglas Black's proposals in toto would cost £2,000 million. No one suggests that this should be done overnight at a stroke. It would be impossible. However, certain proposals in the Black report, that would cost very little were not dealt with by the Secretary of State. The short-term investment in the problems raised by Sir Douglas Black would mean longer-term savings.

The Black committee was set up by my right hon. Friend the Member for Norwich, North (Mr. Ennals) when he was Secretary of State, and that committee reported to the present Secretary of State. That committee was set up because we were becoming aware that the NHS, freely available on a universal basis, was not necessarily getting to and dealing with some of the problems within our society. We readily admit that. Therefore, it was essential that a fresh look be taken at the lower income groups and the effects on family and child health, ante-natal problems, and so forth. Sir Douglas Black and his colleagues have produced a wide-ranging analysis, of which any Government should take note.

I did not like the way in which the Secretary of State dismissed the Black report, or the fact that copies were not readily available. Indeed, the Secretary of State in his letter to me admitted that initially copies were not available. A report of this nature should not be duplicated within the Department. It should be a parliamentary paper. I asked the Secretary of State to print it as a parliamentary paper and to make it available on that basis. I accept, as he rightly states in his letter, that hon. Members can now obtain copies. However, some hon. Members were told initially that they would have to pay £8 for a copy.

Mr. Patrick Jenkin

That was a complete misunderstanding on the part of someone in my Department. I think that the right hon. Gentleman will recognise that no Minister could conceivably have given an instruction of the sort that he has described. I agree that we underestimated the demand at the first printing. However, after a few days, when copies were not available, further printing took place and every demand is now being met. It is probably cheaper for my Department to publish the paper. It costs £8—about the same amount that had to he paid for the document that the Royal Commission published. The Department can commission printing to meet demand. The suggestion that we tried to hush it up must be set against the fact that we sent 100 copies to the national, provincial and specialist press. That is an odd way of hushing it up.

Mr. Orme

I accept what the right hon. Gentleman says about hon. Members. I accept that Ministers would not issue such an instruction. Nevertheless, the report should be a parliamentary paper. The right hon. Gentleman appears to have made up his mind, but I press him to keep the matter under consideration. I have no doubt that some of my hon. Friends will do likewise.

Sir Douglas makes some statements that we cannot ignore. For example, the report states that the difference between social class 1 and social class 5—I do not like that terminology; I prefer to talk of those who are better off and those on lower incomes, which is much more civilised—means that children in the first category are twice as likely to die at birth or in the first month of life, and four times as likely to die in the next 11 months, than children within the latter category. The study indicates that in some respects there has been no improvement in relative conditions over about 30 years and that by some standards the health of those in the lowest income groups has deteriorated.

That is something that I am not prepared to countenance. Mistakes may have been made in the past, and the result of those mistakes must be dealt with in the future.

The Secretary of State has talked about our hospital service. The NHS is far too hospital-orientated. It is a service that is based on hospitals. I should like to see a wider development, which would enable us to take some of the pressure off hospitals.

The Black report refers to school health statistics, the results of hearing and vision tests and the measuring of height and weight. As a first step it recommends that health authorities, in consultation with education authorities, should select a representative sample of schools and initiate routine assessment. If that were implemented it would not cost a fortune and it would take some of the pressure off the NHS.

The report recommends a study of the relationship between income and ill health in our society, including types of job. That points to a much wider occupational health service and preventive medicine. There would be savings if people were dealt with before they went to the doctor or hospital. Professor Black argues that further resources within the NHS and personal social services should be shifted more sharply towards community care and especially towards antenatal, postnatal and child health services and home help and nursing services for the disabled.

The report deals clearly with school meals and school milk. It states that free milk should be available in schools, especially for those in the income groups of which we are talking. It is recom- mended that that provision should begin for couples with their first infant child and for infant children in large families. Sir Douglas asks that there should be accessibility to the facilities of antenatal and child health clinics and that steps should be taken to increase utilisation by mothers, especially in the early months of pregnancy.

Sir Douglas deals with an issue with which the Secretary of State is not dealing—one that the right hon. Gentleman and his Department are ducking and that would not cost money, namely, smoking and advertising and the Government's attitude. We have now waited nearly 12 months for the Government to make a statement. The Minister for Health is always on the verge of telling us that the discussions with the industry are about to be concluded. However, we receive no firm information from the Department. If the industry is deliberately using tactics to delay and frustrate the Minister, it is time that the Government considered legislation. We have promised them support.

We should be dealing with some of the disquieting aspects of the smoking industry, which widen into sport and the arts and the way in which the restrictions on television advertising are being circumvented. Sir Douglas goes so far as to talk of the ultimate phasing out of cigarette smoking advertising and an agreement being reached within the industry to redeploy and to introduce fresh products. He says that studies should now be taking place between employers and the trade unions.

I accept that we can make a start only if we carry the public with us. I am convinced that the public are ready to be carried along on this issue. It is about time that we had some Government action. If they need legislation, let them tell us and we shall consider how we can assist.

Mr. Ennals

Will my right hon. Friend repeat the Opposition's commitment to support the Government if they introduce legislation that will impose further limitations on advertising? That would be a helpful assurance for the Secretary of State and the industry.

Mr. Orme

I am happy to repeat the commitment. When we are discussing this issue we are not seeking cheap political popularity. There is much criticism, as well as agreement. It is time for action to be taken. I reaffirm the Opposition's commitment.

Sir Douglas deals with health care at school on a wide front by including school medicals, school milk and school meals. He deals also with child benefit. Many Conservative Members are concerned about that issue, and they should take note of those points. There is speculation about the Government's intentions in relation to child benefit and uprating. This is seen as a key factor, particularly in relation to helping working-class mothers and one-parent families. The Secretary of State was once a strong advocate of child benefit. I wonder where he now stands.

Sir Douglas Black also deals with other points, including the maternity grant. Many of the proposals cost money. Nevertheless, they point in the right direction. Sir Douglas deals with the need for a comprehensive disablement allowance for people of all ages and suggests that it should be introduced in stages at the earliest possible date, beginning with those on a 100 per cent. disablement allowance. Sir Douglas Black's report is one of the most important reports to be published. Together with the Royal Commission report, it is as important as the Beveridge report was 30 years ago.

I make no apologies for raising the subject of the Black report. No doubt we shall consider it again in more detail. We may ask the Government to give not only the blanket cost but also the cost of individual items. Let us see which items cost very little. We could then consider the matter on that basis.

Recently, there have been some disquieting events. We heard the statement that the Secretary of State made at the Conservative Party conference about volunteers. The Labour Party is opposed not to volunteers but to using those volunteers for jobs within the National Health Service that should be done by National Health Service employees. We have heard of a terrible lottery that was held in a Liverpool hospital. Today, the British Medical Association has attacked the Health Service cuts which forced a surgeon to select patients by lottery. Mr. Lowe, head of the BMA's hospitals division said: It must be very distressing for all the people involved. He said that nine women at Mill Road maternity hospital, in Liverpool, drew lots for five empty beds in a gynaecological ward. The losers were sent home. He also said that it was very important that a doctor should be the only person to judge whether somebody should be admitted to a hospital.

Mr. Patrick Jenkin

Hon Members from all parties will condemn the heartless publicity-seeking action taken by the surgeon in that case. The BMA is right to say that only the doctor in charge can decide which patient should be admitted. However, that doctor knew that there were not enough beds for the patients that he summoned in. The whole episode gave the impression of having been set up for the benefit of the press. That is a matter for the doctors' professional bodies to consider. It is for them to decide how far that accords with the high standard of ethics that the medical profession rightly has.

Mr. Orme

I welcome the Secretary of State's condemnation. I was not seeking publicity. The facts are contained in the BMA's statement. I do not wish to see such developments within the National Health Service. If decisions about priorities are based on whether there is sufficient money, such things may occur. That is wrong, However, I welcome the Secretary of State's remarks. Perhaps we should wait until we have heard what the medical profession has to say. I should welcome a clear statement from it.

There is a great concern about the ambulance service and the possibility of disruption within that service. There is extensive disquiet, which needs to be cleared up. Rightly or wrongly, some of those who administer and work in the ambulance service feel that the reorganisation will be used to cut back the service and to restrict its facilities and job numbers. I hope that the Minister will respond to that point when he winds up the debate.

I listened to the Secretary of State's remarks about London and about the committee that he set up. We still feel that this subject is being dealt with on a piecemeal basis. We recognise the size of the problem in terms of teaching hospitals. We recommended a wider study which would take account of the Flowers report and of the consortium. We are concerned, and I hope the Minister will give us some clear guidelines.

We are also worried about rapidly rising unemployment and the link with health problems. There is evidence of a relationship between unemployment and some health problems. An American study has been made, and a British study was carried out by a lecturer at Warwick university. The Government should consider this issue and perhaps sponsor an inquiry. Many people, particularly one-parent families or parents of families in which unemployment exists, come to my surgery. To an increasing extent the women that I meet in my surgery are on drugs of one form or another—drugs that have been prescribed by their general practitioners. The taking of drugs is becoming prevalent in our society. It is a danger to our society. The stress and strain that some find as a result of living with the rigours of our society must be taken into account, particularly in terms of the Government's current policy.

We are not satisfied with the uncertainty that still surrounds community health councils. We are aware of what the Secretary of State said about community health councils and that Scotland is excluded from this debate. However, there are problems about Scotland. The Secretary of State has made a holding statement about community health councils, but a more positive approach is needed.

We are also concerned about democracy. The hon. Gentleman did not touch on that subject. I have received—as he has probably received—a decision from the Associated Metropolitan Authorities about local representation on area health authorities. That representation may be reduced from eight to four representatives in most areas. I do not say that that is the figure, but representation will be dramatically reduced. Such representation is a form of indirect democracy within the National Health Service. It would be wrong. to remove those people.

We have to keep a balance between those who work in the National Health Service—the ancillaries, as well as the medical staff—and those whom it serves.

We must bear in mind that although the National Health Service employs I million people it serves 55 million people. who have a right to some say about its running.

I have received a letter that says: The AMA's Policy Committee resolved today (23 October) that further efforts should be made to persuade the Secretary of State to reconsider the question of representation following the results of inquiries by us into the views of the constituent authorities. How do we get the right input? It is a direct democratic input and it is an input that the Secretary of State does not appoint. These people are elected by local authorities. I have lately been receiving many representations about the wholesale sackings of Labour Members on area and regional health authorities. I do not know what sort of attitude the Secretary of State will take with the creation of the new authorities, but I believe that there must be some safeguard—democratic representation that is not solely at the behest of the Minister. I do not care whether that Minister is Tory or Labour. There must be some protection in this situation.

Finally, I wish to make an important point. In his Department the Secretary of State has responsibility for both health and social security. We are told by the press—it was in The Observer on Sunday and has not been denied—that there are discussions going on in the Government about Treasury proposals for cuts in public expenditure. We are in some difficulty here. I have called the Secretary of State a Treasury mole, and I still believe that he is, but he has a responsibility within his Department to defend that Department against some of the wild propositions that are being made at present. God knows we have suffered enough already.

We have had enough cuts already under this Government. But the items that have been listed talk about a big increase in the revenue raised by prescription charges by removing the blanket exemption for old-age pensioners. That, in itself, could have health repercussions. Surely even this Government are not mad enough to do that, but, having seen some of the things that have already happened, we fear that this could be so. I warn the the Secretary of State that we shall watch very carefully the proposals that have been made—for example, the cancellation of the commitment to increase child benefit in line with inflation next November. It is not keeping in line with inflation at present. Sir Douglas Black's report says that the commitment is crucial to low income groups. We are also told that there could be possible cutbacks in housing and in the health budget as such.

Obviously, we totally disagree with the Government's economic policy. We have made that very clear in many debates. But what we are talking about here is the Health Service which affects millions of our people who depend on that Service. To have cutbacks at this time will be disastrous.

We are discussing reorganisation, but reorganisation is for people and for patients. It is for the people who work within the industry whether they are hospital porters or consultants. On that sort of basis we impress upon the Secretary of State that we want greater efficiency. We shall not obstruct the reorganisation and the removal of the tier but we insist that the points that I have raised this afternoon—Sir Douglas Black's points—are considered carefully. Threats are hanging over parts of the Service, and the Treasury is running rampant again. We believe that the British people will not stand for the Government going as far as some of their proposals.

6.25 pm

Mr. Anthony Grant (Harrow, Central)

As a number of hon. Members wish to speak in this important debate, I hope that the right hon. Member for Salford, West (Mr. Orme) will forgive me if I do not follow his speech directly. He will be pleased to hear that I have given up smoking, and I have no doubt that my hon. Friend the Under-Secretary will be even more pleased. There has not been any particularly noticeable improvement in either my health or my temper. My hon. Friend will be less pleased to hear that I strongly oppose any legislation in this area, which I believe is essentially one for individual decision.

I wish to touch on an important and essential point—the effect of reorganisation on the ancillary services of the National Health Service. Here I declare an interest in the Pritchard Services Group which used to be in my constituency and which has a subsidiary company with a commercial interest directly in this field.

The National Health Service is in a mess. It has been so for many years and will continue to be in a mess unless firm decisions are taken. it has failed to live up to the dreams that were held for it at one time. The service that it provides compares unfavourably with that provided, often in the private sector, in many countries which hitherto had envied our Service. Therefore, clearly something had to be done.

In the present economic climate the solution is not to be found in merely pumping more money freely into it, even if that money were available. Therefore, quite rightly, the present Government identified that the better use of existing resources and a cutback in bureaucracy were the priority policies to be followed. I am glad to give them my support for what they have done so far.

I have raised before in the House the question of how a more efficient use of resources could be achieved through the greater use of private enterprise in the ancillary services, such as the provision of cleaning services and laundries. When I raised this matter I drew attention to the millions of pounds a year which could probably be saved out of the enormous bill—it is close to £½ billion a year—that is incurred for cleaning within the National Health Service. If more private contractors were used in this area with financial disciplines and competition, a substantial saving could be achieved. This saving could be used for essential and much-needed medical equipment.

At that time the amount of private contract work done in the provision of ancillary services was about 2.3 per cent. of this total. I regret that that has now fallen to 1.6 per cent. for reasons which I shall explain later. However, the Government took on board the wisdom of this policy and issued a circular in June this year in which the Secretary of State drew attention to the fact that the contractual arrangement for ancillary services had established itself as a recognised way of providing such services. He said that facilities used in this way had proved to be a valuable supplement to facilities available in the NHS and that he was anxious that authorities, in deciding on the best and most economic provision of services, should give early consideration to the use of non-NHS facilities. The Secretary of State went on to say how the system could give an authority greater flexibility. That admirable intention is being defeated as a direct consequence of the Government's reorganisation plans.

Reorganisation is necessary. It is a second leg of the Government's policy. Attention was drawn to the problem by the Royal Commission when it stated that there were too many tiers, too many administrators in all disciplines, a failure to take decisions quickly and money was wasted.

As my right hon. Friend said, the consequence of reorganisation is a reduction in the number of administrators, officials and bureaucrats. There is, therefore, the inevitable and traditional running for cover. Bureaucrats will try to create work in order to justify their existence, as outlined by Professor Parkinson many years ago. With regard to the provision of ancillary services, the figure has gone down from a miserable 2.3 per cent. to an even more miserable 1.6 per cent.

Administrators are turning down private contracts because they retain a degree of importance if they have to administer direct labour schemes. It is done in a grossly unfair manner. Tenders from private contractors are turned down because the administrators say that they can do the work better directly. They do not have to make that dirty thing, profit. That is an over-simplistic approach. I hope that the Government will look at contracting in the Health Service. Are full costings prepared by hospital managements for directly controlled services? Are they prepared prior to receipt of commercial tenders in good faith or after, with the advantage of having looked at commercial tenders? Are costings prepared on a like-for-like basis? Are hospital administrators given the opportunity to express opinions, or are decisions taken at district or area level without such consultation?

It is essential to look at the matter urgently, establish a properly controlled and audited system of tendering and cost comparisons and make it work. I should like the Government to consider temporarily freezing all decisions until there has been a proper investigation into this question.

I believe that I have drawn this case to the Minister's attention. The firm concerned offered one free year to the authority, but the contract was still declined without justifiable reason. The authorities simply want to return to direct labour. It could become a scandal if the practice gains momentum.

I should like the Secretary of State to issue a fresh circular reminding authorities of his earlier expressed intention to encourage the greater use of private enterprise. He should insist on a proper comparison between direct and contract labour and proper financial monitoring of the system. He should in no uncertain terms tell bureaucrats who are minded to thwart his intentions that, unless they co-operate, far from saving their jobs, they will speed their demise. Unless my right hon. Friend comes to grips with the problem, I fear that his admirable intention of achieving greater efficiency and better use of resources will be thwarted, much to the disadvantage of the Health Service and the health of the nation.

6.34 pm

Mr. David Ennals (Norwich, North)

I congratulate the hon. Member for Harrow, Central (Mr. Grant) on giving up smoking, but I go no further in supporting what he said.

The hon. Member suggested that the Secretary of State should send out more circulars instructing administrators what to do. That would be the worst way to start the reorganisation. He suggests that the private sector should take over large sections of the Health Service, such as laundry, catering and cleaning. The private sector has to make a profit, unlike the public sector. Private companies may not be prepared to take the really dirty laundry and could not cope with laundry at the required speed. The hon. Gentleman may make his examinations to see whether we can save money, but I believe that it is a wild goose chase and could cause trouble.

The reorganisation is a difficult and important operation. I am glad that the Secretary of State paid tribute to the staff and administrators of the National Health Service. He is right not to be dogmatic about an appointed day and to say that, if there are changes in the regions, they will be at another time. The concept of an appointed day and everything happening at once was a misfortune of the previous reorganisation. The changes will nevertheless lead to uncertainty and turmoil. When I became Secretary of State, the staff were only beginning to come to terms with the 1974 reorganisation. It would have been grossly unfair for me or my predecessor to push forward further reorganisation at a time when they were settling down. We had to wait for the report of the Royal Commission. I wish the Secretary of State and the Health Service well in the reorganisation and in reducing one tier. The administrators will have a difficult task.

The three issues that I wish to deal with concern the Public Expenditure Select Committee and the Black report. It was strange to publish only 263 mimeographed copies of that report, and the Secretary of State now admits that 100 went to the press. There were not enough left for even a quarter of the Members of Parliament, let alone the health authorities. The right hon. Gentleman grossly underestimated the response. My third point concerns Westminster hospital and the medical school.

I hope that the Secretary will take seriously what my right hon. Friend the Member for Salford, West (Mr. Orme) said about money. The Times on Saturday suggested that the Secretary of State had asked the British Medical Association whether prescription charge exemptions could be further limited, including the exclusion of old-age pensioners.

Mr. Patrick Jenkin

The right hon. Gentleman will be aware of the extent to which the press speculates on such matter. He had to put up with it when he held office. It is pure speculation.

Mr. Ennals

I accept that absolutely. An advantage of the debate is that the Secretary of State can state firmly that such suggestions are untrue.

Mr. Pavitt

Not yet true.

Mr. Ennals

Does the Secretary of State support the widely publicised view of the Minister for Social Security that the cuts were too little and too late and if it means more cuts, so be it? Is that his attitude to the already hard-pressed NHS and the scandalous cuts in benefit entitlement, or will he stand up in Cabinet, as the Minister for Social Security would not conceivably do, to those who are trying to push him into making even more damaging cuts?

I turn to the third report of the Public Expenditure Select Committee, which included an interesting exchange based on interviews with the Secretary of State, the Minister for Social Security and the Minister for Health. I was struck by how little the Minister said and how little they seemed to know about the costing and administration of the Health Service—matters that are the meat of the DHSS at the Elephant and Castle.

The Minister for Health was asked about priorities in health and personal social services. He said that the only major and fundamental change in priorities from those that he had inherited was the planned cut in spending on the social services. That was an important statement and I suppose that it was correct. He said that otherwise he agreed basically with the priorities of the previous Government.

The Secretary of State said that it was not a fundamental change and the Minister for Social Security bobbed up in the House and told us that there had been no cuts and that we could rest assured that in real terms the growth in social service spending would continue to rise. I do not know how that links with his reference to "too little, too late" or what his Cabinet colleagues felt about the suggestion that social service cuts were not to be made.

It was clear that no serious thought had been given to the consequences of social services cuts for the service provided by the NHS. Cuts in residential and domiciliary care for elderly or handicapped people would clearly have a push effect on the demand for social services. The Secretary of State was asked about that and replied: I do not think it is possible to quantify, let aloc. estimate, what the impact of the cuts on the health service might be. It is extraordinary that the Secretary of State had not made those calculations. The 16 per cent. increase in joint funding, which we all welcome and to which DHSS Ministers repeatedly drew our attention, is inadequate to compensate for the planned cuts in social services. As the Select Committee report succinctly put it: The increase in the former"— that is, the joint funding— represents less than 10 per cent. of the planned reduction of the latter"— namely, social service programmes. Yet the Secretary of State blandly reasserts that the increased expenditure on joint funding will go quite a long way—if not the whole way—to prevent there being … overspill from the personal services cuts into the NHS. The Select Committee's wry comment was: since it appears he cannot 'quantify' or 'estimate' such overspills, nor monitor the effects of expenditure cuts in either service, this assertion seems to be based more on wishful thinking than realistic analysis. I desperately hope that there will be no more cuts in the NHS, but if there are to be such cuts I hope that the Secretary of State and his Ministers will consider carefully all the implications of every action that they take, particularly during the reorganisation.

Mr. Patrick Jenkin

Was the right hon. Gentleman quoting from a document?

Mr. Ennals

I was quoting the report of the Select Committee and the evidence given by the Secretary of State.

Mr. Jenkin

Will the right hon. Gentleman confirm or deny that he was quoting from his own article on the back page of Social Work Today?

Mr. Ennals

I was drawing from writings that I have produced. Any of us is entitled to quote from our writings on the subject. If the Secretary of State thinks that he has scored a point, he should think again.

Let us see whether the right hon. Gentleman can score any points on the Black report. He has already admitted that he underestimated the demand for the report. He also underestimated the importance of the report and the task that was set the Committee.

Sir Douglas Black was asked to set up a study because the previous Labour Government were concerned with a serious situation, namely, inequalities in health. He set up a distinguished team, which did a thorough job. We were faced with some sharp distinctions and crude differences. For example, mortality rates between the various social classes were worrying. To take an extreme example, in 1971 the death rate for adult men in social class 5—unskilled workers—was nearly twice that of adult men in social class 1—professional workers—even when account had been taken of the different age structures of the two classes. The gap is even wider in death rates for specific diseases. For tuberculosis, the death rate in social class 5 is 10 times that of social class 1; for bronchitis it is five times that of class 1; and the rate for lung cancer and stomach cancer is three times as high. There are many other examples.

The conclusion reached by the Black committee was: The problem of inequalities in health … lies at the heart of the problem of better integrating British society…. Present social inequalities in health in a country with substantial resources like Britain are unacceptable and deserve so to be declared by every section of public opinion. I had hoped that the Secretary of State would agree with that conclusion and that in looking forward to changes that are required during the reorganisation of the NHS he would recognise that one of the principal tasks that we have to tackle is the problem that although we have a basically free Service available to those who need it, large sections of the public are not using it, and we must find ways, through our organisation, to ensure that they have the opportunity of using it and are encouraged to do so. That is what the report was all about. It concluded its introduction by saying: We have no doubt that greater equality of health must remain one of our foremost national objectives and that in the last decades of the twentieth century a new attack upon the forces of inequality has regrettably become necessary and now needs to be concerted. It looks as though another Government will have to do that, judging by the peremptory way that the Secretary of State introduced the document. Even if he had printed it on gold-leaf paper, his introductory words indicate that he had virtually no intention of considering it. That is a disgrace, not only to the report and its subject but to the distinction of those who produced it.

I hope that the right hon. Gentleman will have second thoughts not just about the publication but about taking seriously the problems that lie behind the report. It is no good saying that we cannot carry out the recommendations because they would cost £2 billion, or whatever. Many parts of the 37 recommendations would not be costly. Some would cost nothing.

It is my sad conviction that the Secretary of State wrote only three miserable paragraphs in introduction because the objectives set out in the report were not accepted by him, his party or his Government. They do not accept that the task before us is to try to bring about greater equality in health for all our people.

Mr. Patrick Jenkin

The right hon. Gentleman may be right. I have never regarded it as a fundamental part of my political philosophy to achieve a greater equality. I have devoted my political life to raising the quality of service for everyone. It matters to me far less that there is inequality, provided that I can point to a steady improvement in the condition of the people. That is a Tory tradition that goes back to Disraeli and beyond.

Mr. Ennals

I find that very disturbing. If our task is simply to provide a service and not give a damn whether or not people use it, or to what extent they use it, or the effect that it has on their health, it shows a very crude and inhumane approach to the concept of our National Health Service. I am certain that all those involved in the establishment of the National Health Service and all those involved in it today are not simply concerned with providing a service. They are concerned with the effect on the human beings involved. What did the Secretary of State mean by his document "Patients First" if it was not the welfare of the people dependent on the National Health Service? If he is concerned about the welfare of the people dependent on the Health Service, he must be concerned about the health of the patients. Yet he has made it clear that this is not his concept. We must take his word for that.

My final point, although there are many other remarks that I would have liked to make, relates to an urgent matter—the future of the Westminster hospital and the Westminster medical school. I recognise that hon. Members on both sides of the House have referred to this problem on previous occasions. It seems that a decision will be taken by the Senate of the University of London on Wednesday this week which could herald the end of the Westminster medical school and eventually of Westminster hospital itself.

The Secretary of State will know that a plan has been put forward on the basis of eight months' consultation following the Flowers report and that the proposals that will come before the Senate envisage four combined medical schools. In three of the statement says: "The Westminster Medical schools would combine, but the integral parts would remain based on their own hospital. That is a quotation from a letter that I wrote to The Times. I hope that the Secretary of State will not feel that it is necessary to intervene. I occasionally quote myself. That is perfectly reasonable. I wrote: This applies to University College and the Middlesex, Bart's and the London, and Guy's, St. Thomas's and King's. Only in the case of the fourth merger—Westminster and Charing Cross—is it suggested that one of the new partnerships is to be totally uprooted. As the statement says: 'The Westminster Medical School would have actually to move to the Charing Cross Hospital Medical School site'. All my inquiries show that there is not enough room in Charing Cross to take in the Westminster medical school. It is suggested that there will be some overspill to St. George's, in Tooting. That would mean the dismemberment of a great medical school—a centre of excellence in every sense, and the heart of vital research of which our country has reason to be proud. It would also tear the guts out of the very hospital itself. Not only would many of the most distinguished doctors depart; the whole entity of the pathology department would also disappear. As a hospital, it would never again be able to perform the sort of service that it has provided until now. I mean not the service provided to Members of this House but the service to the community of Westminster.

I believe that this decision will be taken on Wednesday, unless the Secretary of State intervenes. The right hon. Gentleman knows the feelings that exist on both sides in both Houses. It would be a great tragedy, which the House would for ever deplore, if the Westminster hospital and its medical school were now to start on the process of dissemination and disintegration. That is the direction that is likely to be taken following the decision to be made on Wednesday. It can be stopped only if the Secretary of State decides to intervene.

6.54 pm

Mr. David Crouch (Canterbury)

The House will be pleased to notice that the right hon. Member for Norwich, North (Mr. Ennals) is in such good voice and will also appreciate that he has been active on paper in the few weeks that we have been away from this place. We regard seriously his contributions to health matters, particularly those concerned with health administration and the running of the Health Service. As Secretary of State he made it his task to do what he could to sustain the Health Service and not to run it down, and that is in line with the theories and philosophy of his party.

On my way here this morning I passed Alexander Fleming House, where the right hon. Member for Norwich, North used to be found and from where my right hon. Friend now operates. I have no doubt that when I passed by my right hon. Friend was sitting at his desk, accompanied by his other Ministers. It is quite the most unstructured building in London; the worst office building that I have ever seen.

I could not help wondering what was going on in the minds of my right hon. Friend's officials—senior and less senior—at the prospect of the House of Commons coming back to discuss the structure and administration of the Health Service. I wondered whether they had come to work any earlier to get ready for this taut and difficult day. It occurred to me that the permanent secretary, besieged by people worried at the prospect of so much discussion and decision on the matter, might say to them "Do not give them a second thought. They will debate for six hours and then we can get on with the job".

In all my years in the House I have never run down the importance of this place in the determination of real things that matter, but when listening to the right hon. Member for Salford, West (Mr. Orme) I had to remind myself several times that on the first day after the recess we were debating the structure and management of the National Health Service. The right hon. Gentleman touched on that subject only about twice in his speech. My right hon. Friend, on the other hand, made a speech proper to the occasion. I suspect that there will not be many speeches that are proper to the occasion about the structure and management of the National Health Service.

We have debated a Bill and made it an Act of Parliament. We have decided that the National Health Service should be reorganised, but we should give some thought to stopping people in Alexander Fleming House and officials in the National Health Service in the regions—I serve as a member of one of those regions—from thinking that they can have matters all their own way. The only word used by the right hon. Member for Salford, West with which I agreed was "democracy". Thank God that he mentioned it, because that is what we are about. The officials are concerned with the structure, administration and management. We have to make sure that the structure and management are what we want and, in the words of this oft-quoted pamphlet, what patients want. I maintain that the new structure should be what patients want.

During the recess I spent some time working on this matter as a member of the South-East Thames regional health authority. I should like to take a few minutes of the time of the House to relate to hon. Members some of the complexities in which officials and lay members will be involved, including myself, as they consider implementing what Parliament has enacted, namely, the Health Services Act. I remind the House that what we are really seeking is better and more efficient management. We are seeking to ensure that local decisions are taken by local people. My right hon. Friend emphasised this requirement impressively and properly when he referred to strengthened management at local level, and that should not be forgotten. Another important factor was touched upon by my right hon. Friend. One of our objectives is to find a significant reduction in costs.

I hope that the House will not think that I am running down the Department in these apparently denigratory remarks. I am talking about the difference between officials and Members of Parliament. There is a significant difference in responsibility.

The Department has sent out criteria which should be very helpful in seeing that we achieve what we are seeking to achieve in the three matters that I have suggested. My right hon. Friend referred to the circular containing those criteria—circular HC(80)8. I wish to single out some major headings that should determine the proper structure of the new Health Service.

The first requirement is that the new district health authority should be the smallest geographical area, with a population of between 150,000 and 500,000. Secondly, that area should be associated with a district general hospital and—in the best of all worlds—with some other hospitals as well—hospitals for the elderly, the mentally handicapped and the mentally ill. The circular goes on to say that of course one cannot expect the new district health authority necessarily to be self-sufficient in regard to the last of those.

Another requirement that I think to be very important is that the new district should comprise a natural community, that it should be coterminous with the social services authority and with an education authority if possible—give or take a little.

The circular also mentions that London presents special problems and is sometimes a special problem in itself.

Having looked at those criteria, I hope that as we debate we shall not neglect them, because the officials must not neglect them. If the officials think that we neglect those criteria, which my right hon. Friend has sent out and which they know about, there could be a change of emphasis when it comes to interpretation at regional level. That is what I have tended to see in the region in which I serve. It is quite a difficult combination of criteria to achieve. There will have to be some give and take and some flexibility.

When one provides flexibility, one must aim all the time to produce a structure to serve the patient and not to serve the consultant or the convenience even of the senior nurses, the ambulance men or the administrators. The Department, the officials and the regions have a tendency to go for what they perceive as the best management solution. That sounds right in industry. It sounds just what we are looking for—the best management solution—but it could be interpreted as a signpost to bigness rather than smallness.

I have already seen that happening in the South-East Thames region, where the management, the administrators and their medical advisers have found a larger district much more attractive for management purposes, because they can see centralised control—either from the region or in the district itself. A small district identifying with a natural local community with strong local management may not be strong enough to have an identity back at region. It may suit the region to deal with higher forms of equals by having larger districts with slightly more powerful people to deal with. That happens in industrial management and elsewhere. I can imagine a region disliking the idea of having a proliferation of small, important district management teams to deal with, and perhaps preferring to deal with a smaller number.

We have debated this subject many times. We spent nearly two months in Committee during the passage of the Bill this Session. I want to say something about time. My right hon. Friend is asking for a further three months' examination of provisional proposals. The provisional proposals from the South-East Thames region were, I think, published on 16 October. They cover well over 100 pages. The regional health authority is required by my right hon. Friend to let him have a report by the end of February. That means barely three months in which to examine a detailed structure across the whole region, and that applies to all the other regions.

I welcome the period of three months, but it is a very tight schedule, bearing in mind the number of people to which such a document is sent. In the South-East it goes to over 200 bodies—councils, committees, societies, trade unions and so on, all the local authorities and all the local parties, and every Member of Parliament. I imagine that the great majority of those groups and people will be interested on behalf of their constituents. Not only Members of Parliament, but trade unions, local authorities and so on will seek to make a submission. They must do so in writing to the region.

Who will read all those documents? Will they be read by the officials? We assume that some officials will read them all, because they are required by the circular to make a summary for the Secretary of State, a summary to be sent to the Department at the end of February of all the submissions and protests, praise or whatever, that may come from those consulted.

That is democracy at work, and I welcome it, but it is a tight schedule. The work must be done. I do not want to make the period three years, or even six months, because I take on board what others have said in the debate—that there is unsettlement when the structure is altered. People are concerned about their future, where they may live, their future job and whether they will have a job at all. We need to get the show on the road, I hope by the date suggested, which is 1 April 1982.

We must show that what we are doing is working democracy. We must make a special effort. In the South-East Thames region I have suggested that there should be public meetings as well as paper submissions. We must show that we want to hear what people think, that a person can get up at a public meeting and say "I have listened to your presentation, but it is not right for me", or "I do not think that it is right for our council", or "I do not like it". I want people to have that opportunity. I do not want them to think that their written piece of paper goes along with several hundred other pieces of paper in one region, multiplied 14 times, ending up in a summary on the Secretary of State's desk, with him asking his permanent secretary "What on earth do I do with all this paper?"

We know that my right hon. Friend is as concerned as anyone about administration in the Health Service and making a success of it. We wish hurt well in his task, which is formidable. But when we practise democracy we must show that it works, and we must make a special effort.

We cannot afford to be wrong again in this reorganisation of the Health Service. We are on our mettle. It is we in the House who are on our mettle. It was Parliament that decided to restructure the Health Service. Therefore, we have a duty to repeat the word "democracy" and show how it can be worked outside Parliament. We must tell people "We are redoing it again. Come and look at it. We believe that the proposals are pretty good." Those that I have seen are pretty good, but in my region I have spoken strongly against some and have voted with one arm up. That is the only way that anyone can vote, but I assure the House that it is a very strong arm. We changed some of the proposals put forward by the officials. That again is democracy at work, at a regional level.

We must allow a few strong arms to be raised in the country as well as we present the proposals for the new National Health Service. That is all that I am asking my right hon. Friend and the Government to accept today.

7.10 pm

Mr. Laurie Pavitt (Brent, South)

One of the pleasures of debates on health is that I seem always to follow the hon. Member for Canterbury (Mr. Crouch) or that he follows me. There is a great divide across the Chamber, but often I nod my head in response to a number of his arguments. We both made similar points in the months that we spent in Standing Committee and in the Second and Third Reading debates. I must slightly disappoint him because, like all my hon. Friends, I cannot obey the hon. Gentleman's discipline. He addressed himself fully only to reorganisation and structure.

Fortunately, the word "management" features in the debate. From the start. the Secretary of State made it clear that, although he was talking about saving resources in administration, fundamental and basic to the problem for the last 10 to 15 years has been the question of resources as a whole.

My hon. Friends and I wish to take up not only the points made by the gentlemen in Alexander Fleming House this morning. In the press we can hear the sharpening of knives by the Treasury. The Treasury has ordered all Departments to lop pieces from their spending.

The debate provides an opportunity to look at the Health Service in toto and to seek to discover what might happen. Like my right hon. Friend the Member for Norwich, North (Mr. Ennals), I am scared stiff at the rumours about prescription charges being imposed upon the elderly. That worries the soul case out of me. In spite of the Prime Minister's protestations during the election campaign that she had no plans to impose or increase Health Service charges, since 1979 the sick have had to pay for the healthy because of the increase in prescription charges. It would be unforgivable and insupportable if the elderly, who take twice as many prescriptions as the middle-aged, had to pay for middle-aged mothers looking after their families. I welcome the denial by the Secretary of State that such a decision has yet been made. I share the hopes expressed by the hon. Member for Canterbury that what we say in the House sometimes has an effect. I hope that our comments will have an effect in the DHSS.

Reference has been made to structural changes providing resources. We are speaking of the £10 billion resources available. Sometimes I believe that the Ministry, or the Minister, is petty about small items. The Government have just rejected a proposal that disposable syringes be supplied to blind diabetics. They would cost an infinitesimal amount. A person who is suffering from two such handicaps should, for hygiene reasons, be able to obtain disposable syringes on prescription. Such pettiness annoys me, particularly when 1981 is to be the year of the disabled. The Secretary of State should be able to take such small items in his stride without any bother or fear of financial difficulties.

If more resources are to be released, we must bring down the drugs bill. A working party has been established to investigate the cost of drugs. It is a piece of supine camouflage. The answers have been known for ages. The pressure of the drug manufacturers is such that it is easier to establish a working party than to act upon the 1958 Hinchcliffe report, which has been available for 22 years.

The Secretary of State said that he was worried that the cost of our drugs bill has risen by 57 per cent. since 1970 whereas the total cost of the NHS has risen by only 39 per cent. He must grapple with the problem. He can do that in two ways. First, he can follow the Hinchcliffe report. His new structural administration could be given the ability to do that through a genuine British pharmacopoeia, not written by bureaucrats but so that doctors could understand it and use it to bring down their drugs costs. Secondly, the Secretary of State can accept the pressure of the dispensing chemists for triple FP 10s, which would save a considerable amount in prescribing costs and in the number of drugs prescribed.

I turn to the question of the district health authorities and the consultations. I welcome the fact that the Secretary of State made it clear that hon. Members will be able to make direct representations about the way in which boundaries will be affected. Hon. Members come under pressure from local social services departments and from patients and health workers. The hon. Member for Canterbury talked about his regional authority. I welcome the documents which I have received from the North-West Thames region which come out strongly on the question of coterminousity for social service departments and district health authorities.

Accountability has been discussed. When one receives a consultative document, one first examines how it will affect one's own constituency. I am satisfied with the boundaries to be drawn for my constituency. They will leave the constituency with a district general hospital—the Central Middlesex hospital. We shall lose one district hospital which is more in Harrow than in my constituency. The borough boundaries will be the same as the hospital and general practitioner services, the community health service and the ambulance service. This is coterminousity in practice.

I have been fighting for one hospital for 15 years. My right hon. Friend the Member for Lewisham, East (Mr. Moyle) will remember all the parliamentary questions that he has answered on that topic, as will the hon. Member for Reading, South (Dr. Vaughan). I speak of the Willesden general hospital which we have been fighting to have turned into a community hospital rather than be designated a geriatric hospital. I have received many assurances from Ministers and from the regional health authority and yet the consultative document designates it a geriatric hospital.

This is an example of how the bureaucrats can defeat us. Only after action is taken by them do we have any say. Fortunately, it has been decided to have a young chronic sick unit. We might also achieve a health centre, and there will still be some type of out-patient service in that hospital. I resent the fact that even after my local authority, the local trades council and others have made their opinions known, the regional health authority completely ignores them and designates Willesden a geriatric hospital and we have either to take its decision or leave it.

I listened with care to the Secretary of State when he spoke of the circular on DHA appointments. I should like to make a suggestion. It will be a sad day if the number of local authority representatives is cut. Even more important is that the director of social services should be a fully fledged member of the district health authority so that he is there when resources are being planned and when the budgets and the balance between the pressures are worked out.

One of the big faults of the present system is that it perpetuates the joint committees and funding arrangements which lead to people dashing from one committee to another before making decisions. If only we could find the right mechanisms within the restructured NHS, we could cut out many of the liaison committees that meet simply to pass papers to each other.

I am afraid that the Secretary of State is once again dodging confrontation on the question of the place of the family practitioner committee within the new structure. He dodges the issue because the general practitioners have so much muscle that no Secretary of State, with all respect to my right hon. Friend the Member for Norwich, North, likes to take on the family doctors. The result is that the family doctors are left alone. The whole purpose of the Act introduced by the present Secretary of State for Industry was aborted because the family doctors refused to become an integral part of a medical team consisting of consultants, hospital doctors, registrars, community physicians, the general practitioner service and doctors involved in various specialist areas such as mental health, which should now be incorporated under the district health authority into a medical organisation which includes the family practitioners.

The Secretary of State announced today that he wants better liaison with the district health authorities. He said that the options are being considered for the family practitioner committee, but only in relation to planning. Who is considering the options? Is it the Secretary of State, his Department, the British Medical Association, or the General Medical Services Committee? What is happening about family practitioner committees? Until such time as we are able to get rid of the barrier between hospitals and the community medicine and domiciliary services we shall never make any sense out of a unified National Health Service. The pressure for that must come from the doctors themselves.

The Government's policy seems to be firmly committed to a first-class service for those who are able to pay, and a second-class service for those who are unable to pay. I refer to a recent circular about the Government's policy on private practice. At present we know that doctors do not give favoured treatment in medical and clinical services. Neither doctors nor nurses have different standards of treatment for private and National Health Service patients. However, certain privileges such as time and convenience can be bought. Those commodities are for sale. However, when I consider the cutback in public expenditure and the way that that affects hospitals in my area I am frightened that capital and minor capital expenditure may be cut back to such a degree that the ordinary hospital service becomes so uncomfortable that there is a tremendous incentive for people to go to BUPA.

I wish to quote the example of my local hospital, the Central Middlesex. It was originally a workhouse. The plan for refurbishing the wards is now approaching stage three. In some wards 25 patients are using one lavatory—but not in the wards that were refurbished under stages one and two which have been completed, and that will not happen on wards included in stage three when that is completed next year. It would be a disaster if the present economy cuts meant that stage four was arrested. The work will have to be undertaken at some time, and the cost to public expenditure will be much greater. Other problems at the hospital include the refurbishing of the maternity ward and the modernisation of the telephone exchange Every hon. Member could find similar problems in his district hospital where the cuts are eating into the quality of services.

I direct the attention of the House to the present calamity in the nursing profession. There has been no clear statement from the Secretary of State about the impact of lodging charges on nurses. The Whitley council machinery has broken clown on that point. I can understand that. With due respect to my right hon. Friends who have served as Ministers and Secretaries of State, I have to say that nurses have a vague feeling—which goes back 25 years—that the moment that they receive a rise in their pay packets there is immediately an increased debit for board and lodging charges, and that what is given with one hand is taken away with the other. The present lodging charge system is wrong because the charge is the same irrespective of the lodging. A student nurse sharing one bathroom with 10 nurses—and I could name a number of hospitals where that happens—pays the same amount for her lodging as a nurse at St. Thomas's hospital who lives in the style of the Hotel Ritz. Inevitably, that practice is not fair to the nurses.

I look forward to hearing the Minister's remarks on that matter when he replies. There should be a break between the amount of the lodging charges. They should not only be attached to salary but should take into account the lodging facilities themselves. There should be a greater degree of equality. Currently, senior nurses receive the best accommodation and the poor little student nurses receive the worst accommodation. We should raise the standards, but I know that we shall not get the sort of public expenditure needed to get rid of that injustice and inequality.

The Secretary of State referred to the £2,000 million needed if the Black report were to be implemented. No Government will achieve the Health Service that we want unless we move up to an expenditure of about 7½ per cent. of gross national product. That is a massive increase. It means that health must be given priority and that the matter must be debated with other Departments. I have been through all this before in the past 20 years. We usually do not win, but that is the aim that I wish to see achieved. There must be a greater allocation of resources towards prevention. More action should be taken on the Black report. I shall not repeat the arguments that were advanced so effectively by my right hon. Friend the Member for Norwich, North. No doubt they will arise again.

When the Secretary of State gave the figure of £2,000 million for implementation, and then quoted what happened under the previous Labour Government, he failed to point out that that Government had a deliberate policy between 1974 and 1978 that the money available had to go to people and not either to bricks and mortar or to equipment. The figures that the right hon. Gentleman gave in relation to minor and major capital works ignored the switch of resources that took place in a number of ways. In my view that priority was right.

I wish to discuss a subject that has been mentioned by a number of hon. Members, namely, prevention. Sir George Godber, the previous Chief medical officer, once said that the single greatest step towards preventing illness would be to do something about smoking. When the Queen delivers Her Gracious Speech we shall listen carefully to hear what will happen in the area of health.

In spite of a year's negotiation, the last agreement between the Department and the tobacco industry is now 12 months out of date. It may be that because of various pressures, and because Cabinet colleagues wish to introduce legislation first, the Secretary of State will say that there will not be an opportunity to introduce a Bill to deal with tobacco advertising.

I wish to make an offer to the Secretary of State. I have already introduced 14 Bills under various procedures. The House may recall that one Bill resulted in that innocuous notice on the side of cigarette packets which has not done much good at all, but which was at least a step in the right direction. Irrespective of the Government's intentions, I shall present a Bill at the first opportunity to deal with tobacco advertising. The Government need not do their homework on the subject: I will do it. All the Government need to do is to tell the Chief Whip that when I introduce the Bill he should not block it.

When the Secretary of State enters into fresh negotiations with the tobacco industry he can say that he is under pressure from his colleagues in the House and that, if the industry does not introduce suitable measures, Parliament will. I make this offer across the Floor to the Secretary of State. It is a genuine offer.

When considering expenditure it should be remembered that we never "spend" on health, any more than we spend on education: we invest in it. In 1979, which was quite a bad year for strikes, industrial action cost 310 million days of productivity whereas sickness and invalidity cost 386.2 million days. As a result, we should no longer talk about cuts in expenditure, but rather ensure that the new, restructured organisation does something to create a healthy community which in turn can lead to a healthy economic community.

7.30 pm

Mr. Den Dover (Chorley)

I should first like to say how fair, constructive and well balanced the Secretary of State's announcement was today. He was extremely constructive in many ways. However, in answer to a question from one of my hon. Friends he intimated that this was part of a two-stage reorganisation. I hope that that is not the case. My right hon. Friend intimated that regions will be reorganised at a later date, and I hope that the Minister for Health will deal with that.

Over the years, both before reorganisation in 1974 and since, the regions have played a major role in carrying cut the provisions of the Health Service, by the balancing of regional requirements, the allocation of capital funds among their various areas and hospital schemes, and the overall supervision and management of the Health Service throughout the country. I welcome what the Secretary of State said about the fixing of financial limits, although I am not sure whether that applied to the district health authorities or the regions.

In the North-West of England, where my constituency of Chorley is located. there is an unbalanced view of financial allocations around the country. We receive between 8 per cent. and 12 per cent. less share of funds—both capital and revenue—than the rest of the country. Something must be done about that. If that problem is to be overcome in the reallocation of resources, I very much welcome it. Here I draw the attention of hon. Members to the excellent speech made by the hon. Member for Rochdale (Mr. Smith) in the recent debate on the Health Service.

The views of the local authorities on the reorganisation of health services are extremely important. On that score, I agree entirely with their requests for a better representation on the new district health authorities. South Ribble, in Chorley, has had no representative at all on the Lancashire area health authority over the past six years. Only recently has there been one member. I regard that as poor representation for 180,000 out of a total population of 11 million. I agree entirely with the local authorities that they should have better local representation and an additional number rather than a reduced number on the health authorities.

When the Secretary of State has collected all the views from people throughout the country, perhaps he will bear in mind that the districts as they exist at present need not necessarily be the framework for the new district health authorities. In some cases swaps and exchanges between one existing region and another might be better. I also hope that my right hon. Friend will consider the possibility of allowing regions to work on an agency basis in respect of surrounding regions, as I believe that would improve the efficiency of the Health Service.

Like my hon. Friend the Member for Canterbury (Mr. Crouch), I wonder whether sufficient time has been given for local views to be obtained on the reorganisation proposals. The North-Western regional health authority has produced an excellent document, but it has asked for views within three months. By the time people have absorbed the contents of that document, discussed it locally, and reached a view upon it, I doubt whether sufficient time will be left for a considered view to be put from the region to the Minister.

Special circumstances arise in Chorley. The Minister for Health was extremely good to us, in that he heard our pleas a week or two ago. We find ourselves sandwiched between the existing district health authority, of which we are part—which represents a population of more than 300,000—and a smaller existing district health authority—the West Lancashire authority. If there are to be nearly 200 district health authorities, a population of 250,000 or 300,000 will be quite large. We in Chorley feel that so far we have received poor treatment. We are part of a large district health authority—probably larger than the national average—but we are not receiving the fair treatment that we deserve.

In the proposals of both the National Association of Local Government Officers and the regional health authority we see ourselves being squeezed out. On the one hand, a district with a population of only 105,000 is asking that it should be retained, whereas, on the other, our own district, with a population of more than 300,000 and growing quickly, is to be retained as a large authority.

That means that we shall not achieve the aim that the Secretary of State has laid down—in other words, a response to local demands and better local control by people who are responsive to local wishes and needs. That is a trend that Chorley is clearly showing to the rest of the country, and I hope that the Minister for Health will back that up by receiving our views and taking note that we need a better full-time casualty service and upgrading to district general hospital status as soon as possible, certainly by the 1984 start date if existing funds permit.

Chorley is an expanding new town, and there are not many expanding new towns at present. I draw the Minister's attention to the fact that where growing or large new populations have formed over the last six years since reorganisation, adequate funds should be made available, for otherwise health services in such areas will suffer. That is not good for expanding industry in those areas, or for future populations. I hope that the Minister will reply to some of those points, particularly my comments on the regional health reorganisation that I hope does not come about.

7.38 pm

Mrs. Renée Short (Wolverhampton, North-East)

The hon. Member for Canterbury (Mr. Crouth) gave an interesting and graphic account of his work on his regional hospital authority. He said that it would be difficult to unscramble this particular omelette. It is, of course, regrettable that we must have a go at it at all. Had we got it right last time, we would not now be in a position of having to do this again so soon afterwards.

I hope that the Minister will take on board the hon. Gentleman's suggestion that the authorities should be encouraged to hold public meetings so that constituents in their areas can listen to and discuss the proposals that are put forward, because once the proposals reach the Minister it will be extremely difficult to remedy any mistakes.

We could say "We told you so", because it was the present Secretary of State for Industry who, in his previous incarnation as Secretary of State for Social Services, brought forward this rotten proposal in 1974. We said at the time that it would not work. It was based on a scheme put forward by an American public relations firm which knew nothing at all about our NHS set up, did not understand the situation and was not really in sympathy with it. We said at the time that the scheme would be too costly, burdensome and difficult to operate. But we are having to carry out this exercise, and I hope to goodness that we have got it right this time.

We must look at the effect of reorganisation on the services provided by the National Health Service. One of the major problems facing the Service today, and which is leading to many of the problems which are said to be health problems but which are really socio-economic, is the distribution of resources among the regions. The Royal Commission report dealt at length with the problem. The way in which resources are distributed at present constitutes an assault on the regions with the most difficulties. The Royal Commission report shows that the West Midlands and Merseyside receive considerably less for the hospital service and for the community health and practitioner services than do the London regions. The allocation for the West Midlands is £92 per head, compared with an allocation of £122 per head for North-West Thames and £139 per head for Northern Ireland. The same pattern appears in the distribution of doctors, dentists and nurses.

Many of the problems that stem from socio-economic conditions as well as National Health Service problems—such as bad housing conditions—remain large in the West Midlands and the North-West. It may even be said that some of the perinatal mortality problems stem from that, and therefore it is not surprising that the rates remain high in areas such as the West Midlands and North-West.

The effects of the Government's cash limits on the National Health Service—with roaring inflation, high unemployment and the high cost of borrowing—are bound to reduce still further the service to patients and to increase still further regional deprivation. The assumed level of wage and salary agreements at 14 per cent. is likely to be unrealistic. The price paid for goods purchased by the National Health Service is rising at a rate of 20 per cent., so the Secretary of State will have to fight hard to maintain the Service as it is at present, with all its inadequacies and poor distribution.

The Secretary of State must be aware of the acute problems faced by the Service in the regions. He touched on one of the problems when he referred to the committee, chaired by Sir Henry Yellow-lees, which is examining the work of senior medical staff. Part of the problem today is the enormous burden that has been placed on them in attending administrative committees. Those committees take medical staff away from their work with patients, and there is certainly frustration among senior consultants at having to attend so many committees.

All hon. Members can tell similar stories about longer waiting lists and frustrated doctors and patients. In my constituency there is a waiting list of over 4 years for hip replacement operations, which represents pain and continuing immobility for elderly patients.

When I was in Liverpool last week I visited one of the ancient Poor Law hospitals that is now being used for geriatric patients. It made my heart sink. I have seen many such hospitals in different parts of the country. The working conditions, as well as the conditions for patients, are deplorable. The staff of the hospital in Liverpool were engaged in a sit-in, and I have every sympathy with them. In view of the amount of money that is spent on the Health Service it is deplorable that working conditions are so bad in this day and age. The staff cannot be expected to do their best work in such conditions. I heard about the gynaecologist who held a lottery to decide which six of nine patients should have their operations. The whole place was buzzing with the scandal. It was a drastic way of drawing attention to the acute problem facing the hospital and patients.

Mr. Patrick Jenkin

One of the points that I might have added when I intervened in the speech of the right hon. Member for Salford, West (Mr. Orme) was that I understand that Mr. Attlee was a member of one of the committees that approved changes in gynaecological services against which he protested.

Mrs. Short

One meets illogical behaviour everywhere, even among consultants and Ministers.

There is also the problem that emergencies can put the operating list out of joint. A consultant may have had one or two serious emergencies and may have had to put some of his other patients further down the list. Clearly, there is a moral here.

I wonder whether the Minister is monitoring the difficulties and frustration that the Government are imposing on the hospital services and whether he is aware of the effect on patients who have to wait for urgent attention. Does he know the Government's expenditure plans and their policy objectives? If his expenditure plans are not adequate, and if there are cuts in Government expenditure, the policy objectives will go out of the window.

We were told that the reorganisation and restructuring would save administrative costs. The Minister suggested to the Select Committee that there would be a saving of £30 million per annum. At that time he was not able to say how he arrived at that figure; nor was he able to say what the likely cost of redundancy payments would be. Further, he could not say what the effects of boundary changes would be on local authorities. That might have some effect on the estimated savings that he hopes to make.

The planned cost cuts in personal social services expenditure in 1980–81 are bound to have an effect on National Health Service expenditure—that is inevitable—but the Minister of State could not give the Select Committee any information on the likely cost of the transfer of demand from community services to the more expensive hospital services. Elderly people are fitter and more active if they are allowed to remain in their own homes, supported by the meals-on-wheels service and by home helps, who are paid for by the local authority. When those services are withdrawn by the local authorities, the geriatric ward is the only alternative, deterioration is often rapid, and the costs escalate.

It was made clear to the Select Committee that the Secretary of State was, and still is, putting all his hopes on a corresponding upsurge of activity in the voluntary sector in order to meet the deficit in the personal social services expenditure. But if more and more men are losing their jobs at every level in industry and commerce, fewer women will be able to do voluntary work and less money will be available to support the voluntary organisations. The high cost of postage, petrol and public transport all serve to diminish voluntary effort rather than encourage it, and the Secretary of State has not taken that problem on board.

In 1977 the Select Committee proposed ways in which resources spent on attempting to cure certain serious diseases could ultimately be better used in preventing them. That is something that no Secretary of State—not this one, not his predecessor and certainly not the one before that, because he was beyond the pale as Secretary of State—has really taken on board. They have done nothing about switching resources from curing disease to preventing it. Prevention must, of course, include health education, and the amounts allocated by the Department for that under any Government are appalling.

Preventive medicine has had a very low priority for a long time—certainly since the last reorganisation, and before that as well. The Health Education Council received the derisory amount of £3 million in 1977–78 to carry out all its health education obligations across the board. Cigarette smoking places a huge burden on the Health Service. Lung cancer, coronary heart disease and bron- chitin take their toll, and the cost of treating these smoking-related disease was estimated in 1977, in evidence given to the Select Committee that looked into preventive medicine, at £85 million a year. Smoking causes between 50,000 and 80,000 deaths a year. Road accidents cost the Health Service about £50 million a year. Dentistry cost the Health Service £200 million in 1977.

However, in spite of all those facts, successive Governments, including the present, have refused, first, to ban cigarette advertising. The Select Committee that looked at preventive medicine recommended very strongly that we should follow the Norwegian example and ban it except at the point of sale—in tobacconists' shops. That would stop all press and magazine advertising, and there would be no advertising at football grounds where there is so much free television coverage of advertisements. No one would weep to see all that go.

In spite of the facts that I have explained, the Government refuse, secondly, to make compulsory the wearing of seat belts in motor cars. They refuse, thirdly, to fluoridate water supplies. The evidence on fluoridation shows that it is highly cost-effective. In Birmingham it costs about 2.3p per head of the population—about 10p per child under 15—to provide the support and help of fluoridation in reducing dental caries.

The British Association for the Study of Community Dentistry has said that in Birmingham, with the expenditure of £30,000 on preventing disease that would cost £1 million a year to treat, fluoridation is well worth while and is saving a large amount of Health Service money. In Watford, another area where fluoridation has been carried out for some years, about £1.62 a year is saved on this basis on each pre-school child. The cost of protecting by fluoridation the health of those aged between 3 and 14 is £3,000 a year, yielding a saving of £53,000 a year in dental costs.

Why, therefore, do the Government not switch resources from attempting to cure diseases that are often incurable but which may be preventable over a period? Why cannot the resources allocated to the Health Education Council be increased considerably so that it can do very much more? Why do not the Government accept the suggestion of the reintroduction of the Radio Doctor for five minutes before the 8 o'clock news every day and the carrying out of a planned programme of health education?

The high perinatal mortality rate was one of the socio-economic problems to which I referred. Especially in groups 4 and 5, the poorest women tend to live in the worst housing conditions in the country. They have the poorest diet. and they are often those who tend to smoke. All that is a major scandal. Will the Secretary of State try to duck the responsibilities which the Select Committee has placed upon him to reduce the level of perinatal mortality? That cannot be done overnight, but it must be started somehow.

We cannot remove all the sub-standard housing, especially that in the inner city areas, but we must make a start. The Government are playing with fire if they are proposing to bring in another programme of cuts across the board, as has been suggested in the press in the past few days. The Cabinet is now deciding where to inflict greater cuts, particularly in the social services, the Health Service and the education service. If that happens, will the Secretary of State refuse to carry out further cuts in the Department for which he is responsible and resign? If he does not, it will be a scandal.

I hope that when the proposals and the considered views come back from the health authorities the Minister will take on board the need to ensure that the resources that are allocated to the new authorities are adequate. No one in the House—certainly not the Secretary of State—has so far mentioned his appalling inheritance of the old and ailing hospitals. Hospital engineers and public works officers have suggested that about £4,000 million is needed to make good the deficit in hospital building alone. Again, that is not something that will happen quickly, but it has to start, and the old Poor Law hospitals, the geriatric hospitals, and some of the old hutted maternity hospitals that are still in use even in some of the new towns—Hemel Hempstead, for example—must be replaced.

The Service cannot flourish as it should and the health of the people cannot be improved as long as those appalling working conditions are imposed on doctors, nurses, ancillary workers and, above all, the patients. I hope, therefore, that the Department will make sure that the Secretary of State is aware of the concern of the Opposition and, I hope, of Government Members at the possibility of further reductions in public expenditure on the Health service in the near future.

7.58 pm

Mrs. Sheila Faith (Beiper)

I am delighted that my right hon. Friend the Secretary of State is to give further thought to the possibility of allowing family practitioner committees to employ their own staff. I know that that will be greatly welcomed, as is the fact that this reorganisation of the structure and management of the Health Service is being embarked upon.

Doctors, dentists and nurses have been demoralised and disenchanted not only because they have seen scarce resources wasted on administration but because they have been smothered by red tape and tiers of bureaucracy. I believe that it is correct that in future, on the whole, the organisation should be in the hands of the smaller district authorities, which will be more sensitive to local needs. These proposals are a positive step towards making sure that the Service will be more personal and responsive to public opinion, However, I should like my right hon. Friend to give further detailed consideration to the future and the organisation of the community dental service, as this may well be more difficult to organise at district level.

It would appear that under the Minister's new proposals there is no provision for a dental officer to be present as of right whenever an item with implications for dentistry is on the agenda for discussion by the district health authority of the district management team. Yet it must be obvious that someone in the dental profession with the status of chief officer should be involved in any new developments and should have a say in the reallocation of the funds. If this does not happen, community dentistry will be taken out of the hands of the dental profession, and this will reflect on the status of the whole profession and there will be a return to the unsatisfactory situation that existed before 1974. when the then local authority dental service was completely dependent on the understanding and sympathy of the medical officer.

It should be obvious that the dental officer should be called on to advise the district health authority on subjects relating to dentistry, for we should bear in mind that doctors are not always well briefed on dental matters. For example, only a dentist really sees and is aware of the suffering caused particularly to children by toothache and will understand the need for fluoridation of water supplies. The subject has been mentioned by the hon. Member for Wolverhampton, North-East (Mrs. Short).

In many parts of the country the dental services need to cover a larger population than envisaged by the new district health authorities. There are fears that community dentists are duplicating services that already exist. In these difficult times for the economy, it is important to see that expensive staff, premises and equipment are put to the best possible use.

An experienced man working in a wider area can monitor these services closely and pinpoint the areas of greatest need. For example, there may be places where there is a shortage of National Health Service dentists working in general practice or where parents are not so conscious of the importance of conservative dentistry for their children.

It is also true that in future community dentistry may have to concentrate more on giving a service to the disabled, the handicapped and the elderly as more of these people are now living outside hospitals. It is policy today to treat more mentally and physically handicapped people in their own homes, and the social services aim to support more of the elderly so that they do not have to go into residential care.

Dentists in general practice are often not able to give up the time that is necessary to treat patients who require extra care and consideration; nor do they have time for domiciliary visits, and more and more of these visits will have to be carried out by community dentists in future.

It is important that the people attracted to this vital work should be of the highest possible calibre and feel that advancement is possible. Because of this and because of the need to pinpoint deficiencies and monitor the service for children and the handicapped over a wide area, in many cases the position of the area dental officer should be retained. He could possibly be employed by one district authority and by others under an agency agreement.

It is often also the case that an emergency dental service providing cover at weekends and on bank holidays could be more easily organised if two or three districts were combined. For example, emergency dental services in Derbyshire are centred on Derby. Of course, larger areas of organisation may not always be necessary in all parts of the country. Not all areas require the same solutions, so flexibility should be allowed, and perhaps some monitored experimentation could be carried out.

I should like my right hon. Friend to give us assurances that he is giving thought to the community dental service and realises that in many parts of the country this service should be organised over a wider area than the proposed district authorities and that access should be given of right to a dental officer to meetings of the new authorities.

I should like to make one further but important point. It is remarkable that in these new proposals little mention is made of financial control. Last year a highly respected small hospital in my constituency was closed, albeit temporarily. It was most frustrating that we could not be assured at that time that there had been any real economies in the bureaucracy. I still see no evidence that the growth of bureaucracy and the cost of administration in the district health authorities will be more closely monitored in future. I hope that my right hon. Friend will give urgent consideration to this matter.

8.5 pm

Mr. Clive Soley (Hammersmith, North)

I shall direct the bulk of my comments to London. I do this for two reasons: first, the circular on the structure and management in appendix 1 states that London has different problems from the rest of the country; secondly—and I make no excuse for this—since I became the Member for Hammersmith, North I have been made increasingly aware of the incredible problems of providing in that area a health service which is in some way linked with the social services and needs of the area.

I recognise that there is a problem with numbers when looking at the London boroughs and that there is a problem concerning the teaching hospitals. But, having said that, I ask the Secretary of State to look again at the possibility of coterminousity with social service boundaries or at least some revision of some of the suggestions that have been made. In the North-West Thames region the only proposal that seems to make sense is coterminousity with the Hammersmith boundary. I say that because the need to link with the social services is important.

I recognise that that would produce certain problems in some areas. However, if we are to have some feeling by the local population of identification with a health area, it needs ultimately to be linked with the local borough. I do not understand the argument that there is no social geography in such an area. The social geography that Hammersmith, North is being asked to accept links it with Ealing and Hounslow, as in the past, which does not work very well, or with Ealing only, which is the current favourite suggestion, about which I am not very happy, or with North Kensington, which I would accept as second best.

Boundaries cause problems. Recently, I was looking into the problems caused for health visitors. I found that some families residing in one district were registered with a general practitioner in another district and visited by one health visitor but seen by another when attending clinics. That is the kind of nonsense that comes to light when we have boundaries that cross each other in this way. There was a suggestion that if they could not be made coterminous with local authority social service boundaries they should be made coterminous with education boundaries, but in London that again becomes nonsense and is difficult to support.

From my contacts with patients, staff, management, trade unions, social services and others, it is clear that there are disadvantages in all this. I would look for coterminousity on the basis of local authority social service boundaries or more tightly drawn boundaries that give some sense of social cohesion. I should regard the second-best alternative for Hammer- smith, North as being linked with North Kensington, although I recognise that that leaves problems for Westminster if it is followed through. I cannot help there, but I fall back on my earlier argument on coterminousity in terms of boroughs.

The importance of coterminousity to an inner city area lies in planning for health and social services. The needs of the social services authority can be linked closely with the health of the area. That can best be seen by taking two examples from the north-west area and, to a limited extent, from the south-west, because it affects that area, too.

In Hammersmith the provision of psychiatric services is abysmally inadequate. Psychiatric patients have to go to Springfield hospital, which is in the southwest of the region. There is a suggestion that ultimately they should go to the Charing Cross hospital. I have heard that suggestion from only one source. I am not sure whether the Minister is in a position to confirm it.

We look to the possibility of providing psychiatric services in Hammersmith, where there are empty wards. I gather that the money is not available for that purpose.

It seems that for a short-term solution we must turn to St. Bernard's hospital. I understand that recently that hospital was not admitting patients, because of a staff shortage.

That is the sort of problem with which we are faced in Hammersmith. As I understand it, it is not dissimilar from the problem that is faced by other areas of London. I urge the Minister to think again about the needs of London.

Hammersmith hospital has the peculiar problem of having had the carrot of modernisation and redevelopment dangled before it for many years. If the programme had been carried out, I suspect that the problems in North-West London would not be as great as they are. The Health and Safety Executive has commented adversely on the state of the mortuary and the X-ray department of Hammersmith hospital. There are grounds for insisting that the mortuary should be closed.

My case is not confined to securing more money for Hammersmith hospital. Redevelopment was discussed in the early 1970s and the hospital staff was given some hope that it might happen during that period. It is only the dedication of the staff that has maintained a standard that has given the hospital a national and international reputation.

I ask the Minister to consider the possibility of ensuring that the region has sufficient funds to enable Hammersmith hospital to provide the services that are the only way of making sense of a region that is based on a Hammersmith boundary, a Hammersmith-Ealing boundary, or a Hammersmith-North Kensington boundary.

It is difficult to consider the problems of London outside the needs of the inner city local authority areas. Whatever the problems concerning numbers, we should give that aspect greater emphasis than it has been given so far.

I do not wish to say any more on cigarette smoking than has already been said. I associate myself with the views that have already been expressed and I am happy to omit what I had planned to say on that subject. One could talk about prevention for a long time and select new and useful areas, such as road safety, stress and low income. I shall refer to only two topics.

The Under-Secretary of State already knows my views on the problem of alcohol abuse. I have recently seen papers that suggest that about one in seven general hospital beds are taken up by those who are not alcoholics, in the sense of being dependent on that drug, but who have as a complicating factor of the condition for which they were admitted a problem resulting from alcohol abuse. From that figure alone it is clear that the costs are enormous. That is not yet a proven statement, as the figures are the result of only one study. However, I regard it as a good study. I hope that further evidence will come forward to support it in due course. I have no doubt that it is a major cause of expenditure.

I am not asking for reductions in expenditure on the Health Service. However, many more advances can be made in medicine by prevention than can often be made by treatment. That is demonstrated by the history of the nineteenth century. That demonstrates that advances can best be made by public expenditure. Many of the advances in health in the past century were made by public expenditure.

A degree of alcohol is beneficial not only to society generally but to the individual. A small quantity can be good for a person. That cannot be said for cigarettes. There is a difference, but it is not so great that we should ignore the immense impact of alcohol—for example, one in four road deaths and a large number of injuries on the road result from people being under the influence of drink.

The general hospital figure that I have quoted ignores the treatment of those who are recognised to be alcoholics in the sense of being dependent on alcohol. It is a problem that has the same stigma attached to it as being anti-smoking. Then was certainly true in the early days.

I do not say that we should not drink in society. I do not speak as an abstainer. However, the problem is becoming so severe that the expense and misery that it causes to the community are out of all proportion. We must take steps to educate and prevent.

A major factor, along with cigarettes and alcohol, is nutrition. When we talk of nutrition we think of malnutrition. As soon as we talk of malnutrition everyone thinks of being underfed. The problem in Britain, as in most western countries, is that of being overfed rather than underfed. Malnutrition really means bad eating habits. The problem is not confined to obesity in the sense of being excessively fat. Bad nutrition generally adds enormously to the burden on the Health Service.

I add my plea to those that have already been expressed and I ask the Minister to reconsider the need for preventive medicine. That branch of medicine can be made effective only if the structure of the Health Service gives some priority to it. I do not see that priority in the present structure, or in any of the suggestions that I have heard so far.

8.18 pm

Mr. Raymond Whitney (Wycombe)

I hope that the hon. Member for Hammersmith, North (Mr. Soley) will forgive me if I do not take up his remarks on the vexed issue of the delineation of the boundaries of London districts, for which I have no locus standi. However, I believe that the House will endorse the principles that he has advanced about the importance of health education and illness prevention.

I hope that when my right hon. and hon. Friends come to consider the organisation of the districts and the allocation of resources they will take into account the problems that have arisen in the resource allocation as it is now applied. My hon. Friend the Under-Secretary of State will be familiar with the argument that I am about to advance. It concerns an issue that has seriously affected Buckinghamshire. Those of my right hon. and hon. Friends who also have the honour to represent constituencies covered by the Buckinghamshire area health authority have raised it with him on many occasions.

I refer to the problems of resource allocation—RAWP—-which arise in an area in which the population is increasing rapidly. Regrettably, we are anything up to two years out of date. This imposes serious inequities. As we travel round the country, it becomes clear to us all that areas such as Buckinghamshire suffer a great many problems. The Secretary of State and my hon. Friend have considered these matters on many occasions. It seems to be outwith the bounds of the present mechanism to overcome the problem.

That is disappointing. We have an expensive and large bureaucratic machine. It is a machine that claims some degree of sophistication. Surely it is not adequate to say that we have to accept figures which are out of date and which create inequities. I hope that this ripple in the administrative framework can be put right before the new district organisation is introduced.

My second point goes far wider than the bounds of beautiful Buckinghamshire. It concerns the National Health Service as a whole. As Members of Parliament, we all have experience of how the Service operates within our own areas. We must all feel deeply uneasy about the present state of the Service. That does not imply any criticism of the many people who show tremendous dedication and who give a high quality of service. We all know that there is something very worrying about the National Health Service, and we must consider fundamental changes.

I should like to suggest one change that has been floated—but, unfortunately, no more than floated. There was a brief reference to it in paragraph 39 of the document "Patients First". My right hon. Friend the Secretary of State also made a fleeting reference to it. I refer to the possibility of monitoring the National Health Service to a greater extent and to having some form of inspection system. I have had the privilege of being a Member of Parliament for two and a half years, and during that time I have come to know a little about the operation of the National Health Service within my area. Inevitably, I have been able to take only a spasmodic and intermittent interest in it, but that interest is deep. Even within the limits of so short a period it has become clear that things are seriously wrong in many areas. In the purest sense of the word, there is an element of irresponsibility.

The Health Service lacks responsible and accountable staff. Perhaps we should return to a method that worked well when our education system worked well. In the dear dead days that are almost beyond recall we were fairly happy with our education system. In those days the pseudo-progressives had not won the victories that they have recently won, and there was a splendid animal called HMI—or Her Majesty's Inspectorate. Inspectors existed until they were turned into things called "educational advisers" and "assessors", with the resulting problems that were found, for example, in the William Tyndale school. In those dear and happy days HMI maintained a splendid standard in our schools.

My right hon. Friend should consider whether a corpus of HMI-type inspectors would provide the answer to the problems of the Health Service. I recognise that my suggestion is open to the objection that it might result in more bureaucrats and yet another quango, but it might prod the Health Service and the many thousands of those who work in it into providing better results and a better service for the patient.

It is with sadness that I mention my last point. Even if my plan to adopt inspectors is accepted as a solution, I have no great hopes that, in the medium term, it will save the National Health Service from final collapse. Although we go on paying for the Health Service, it remains difficult to believe that it does not suffer from a chronic and terminal illness. I hope that I am wrong. There must be a better way of running the National Health Service. Hon. Members have said time and again that things are wrong. Nevertheless, this year we shall have spent nearly £12,000 million of our national treasure on the Service. Given the quality of service that the patient receives, the equation must be wrong.

I urge my right hon. Friend to look overseas, in case there is a better solution. Opposition Members may consider that I have uttered a heresy. However, we must take our heads out of the sand and not just accept that in the best of all possible worlds our Health Service is the best service possible. Let us look overseas, at Germany, France, Canada, the United States of America and Australia. Let us discover whether there are other ways of running a health service.

During the recess I briefly studied the health service in the United States of America. It was conventional wisdom in Britain, and it was also my belief, that every doctor in the United States of America was a millionaire and that everyone who had a tonsillectomy took 10 years to pay for it, but things are changing there. The grip of the American Medical Association is slackening. That great trade union now has only 50 per cent. of American doctors in it, just as the trade union organisation in Britain with which we are familiar has only 50 per cent. of workers in it.

The non-AMA sector of American medicine offers many interesting examples of group insurance schemes. The doctors and nurses and those employed by those schemes are well remunerated. In addition, the patient is blessed with a wider, quicker and more responsive service that is of a higher standard than most of the medical services available in this country. The patient can also exercise a far greater degree of choice.

This is a dangerous and provocative subject, and I have made a radical and bold suggestion. However, my right hon. Friend has the privilege of being a member of a radical and bold Cabinet. I hope that he will take his boldness and his courage in his hands and look at the National Health Service once again.

Several hon. Members

rose—

Mr. Deputy Speaker (Mr. Bryant God-man Irvine)

Order. Six more hon. Members would like to speak before the Front Bench speeches start at 9 o'clock.

8.27 pm

Mr. David Penhaligon (Truro)

The hon. Member for Wycombe (Mr. Whitney) hit the nail on the head when he alluded to the United States of America. If he looks at the statistics he will see that the United States of America spends twice as much as Britain in percentage terms of GNP. If the radical Cabinet that he has referred to were to dare to do that—given the current levels of expenditure—many of the problems of our National Health Service might be solved.

The Government hope to save £30 million. I congratulate them on the reorganisation that they have achieved. Anything that brings decision-making nearer to the patient must be good. I doubt whether they will save £30 million at the end of the day. I am cynical about Government claims and about how much money they will save. However, for once we are not spending money and we may end up with something more efficient. An improvement has been made and I am glad that it has been achieved, although it could have been done last year or the year before that. For some time it has been a fairly obvious requirement.

We should work towards a more democratic system of running the National Health Service. The Liberal Party would like to see a system of regional government. If there were a system of regional government, the health authorities would have to report to it.

I have listened to most of the debate—I have missed only about an hour of it. The main issue on which I wish to concentrate has hardly been discussed. That issue is how we, in the long term, satisfy the demands of our constitutents and react rationally to the great breakthroughs in technology that are being made in the health world.

Let us take the current spate of heart transplant operations in this country. In about five years doctors will be able to carry out a heart transplant with 90 per cent. success, giving the person receiving that heart another 15 or 20 years of life. When that day is reached, and clearly it is not far off because medical progress has been quite remarkable, we shall face problems. Our admiration for the genius that is applied in these operations is preventing us from facing up to the sheer impossibility of the situation. I foresee a widespread demand throughout the length and breadth of the country for heart transplant operations. If the technology is perfected, every one of us in the House will have a never-ending queue of people coming to our constituency surgeries saying "How about John, Mary and Bill?" They will all want heart transplants.

In such circumstances the transfer of resources will stop all other medical treatment of every other ailment that we now attack with great success. I urge hon. Members to be far more honest with the people for whom we provide help. How can we provide help and allocate resources? How can we make all these operations universally available?

There cannot be a Member who has not been approached many times in the past two or three years by constituents in their middle or late sixties or early seventies who say that they have been waiting for three or four years for a hip operation. We write letters to the health authority and sometimes such a letter works miracles. I often wonder who gets pushed down the list in order to get someone else to the top. But that is not the point I wish to make. The truth is that many people in their sixties and seventies are waiting for operations and many will never have them because we cannot afford the resources to apply to problems in that age group.

Some argue that the way of allocating operations is to give them to those who can afford to pay. Those who do not agree with that argument, and I am one of them, must come un with a better solution than putting everyone on the waiting list and telling the vast majority that they will never get to the top of that list.

I look at the never-ending escalation of the Health Service budget and the never-ending increase in the numbers of staff and I am appalled by the apparent never-ending increase in the numbers waiting for various operations. By training I am an engineer and it is doubtful whether I have any right to make any comment on the efficiency of the Health Service. But I really believe that there is a strong argument for an efficiency audit of the Health Service to see whether the increased numbers of staff and the increased expenditure are being returned to our constituents and to the British taxpayer. I sometimes wonder about this.

Over the past five or 10 years a concerted effort has been made in my county to close down the voluntary car services and the voluntary ambulance services taking people to hospital in order to set up a bigger and grander Cornish ambulance service. I see no advantage in that operation. I can see that on the whole the ambulance men are pleased with it and perhaps the service is a little more efficient than it was but when one considers the immense cost on the basis of an efficiency audit of what else could be done with the same amount of money, one must sincerely doubt that we are getting value for money. It is beyond my competence to make the final judgment. I simply pose the question. I would like to sec the Government set up an efficiency audit so that these things could be looked at regularly and hon. Members could be far better informed about the various uses of given sums of money.

8.34 pm

Mr. J. F. Pawsey (Rugby)

I shall speak only of my constituency. The background is particularly important in the light of the proposals made by the regional health authority for the West Midlands. Prior to the reorganisation in 1973, Rugby was grouped with Coventry and run by the Coventry hospital management committee. For the seven years prior to that reorganisation only £100,000 was spent on capital projects in the Rugby area. The previous hon. Member for Rugby and I both felt that Rugby had been deliberately starved of resources. Following reorganisation. the situation altered dramatically.

In my constituency we have three hospitals, St. Luke's, which is a long-stay hospital, St. Cross, which is a general hospital and St. Mary's, which is a maternity hospital. Since the reorganisation £1.2 million has been spent. In addition, £800,000 is being spent on the site at St. Cross, a new maternity block is to be started on 8 December at an expected cost of £1¼ million and a new pathology lab at a cost of £1 million is due to be started in 1981. The total value of those improvements in the seven years following reorganisation is £4¼ million. The comparison of the seven years prior to reorganisation and the seven years following is appalling.

As a deliberate policy, Coventry starved my constituency of resources. Money was spent in Coventry to provide a new district hospital at Walsgrave and on improvements and extensions to other hospitals in the area. That was all at the expense of my constituents, who have had enough of Coventry and its biased, selfish attitude.

The reorganisation suggested by the regional health authority seeks to put the clock back to the situation that existed prior to reorganisation. Rugby would be lumped again with Coventry. My constituents do not want that. The proposal is unanimously opposed by organisations ranging from the townswomen's guilds to the local borough council. My constituents have written to me in overwhelming numbers and have forwarded petitions protesting against the recommendation.

To make matters worse, even though the regional health authority says that its paper is for consultation only, it has had the gall to put forward only one proposal and has ignored possible alternatives.

Rugby and the surrounding area are a district authority in the Warwickshire area serving a population of between 86,000 and 100,000. Rugby has the principal virtue of being a clearly identifiable unit. To use the jargon in the paper, it enjoys coterminousity with the local borough council and the constituency of Rugby. It shares the social services department within the borough of Rugby, although it is run by the Warwickshire county council, and we also have an area education office. The significant identity in my constituency is a major advantage. I stress again that local people have no desire to be lumped with Coventry. Coventry has shown its true colours. As was asked earlier, why should we look into the crystal ball when we can read the book? The book with regard to Coventry is printed in large print and legibly.

Rugby wishes to control its own destiny as a district health authority. Not surprisingly in view of past events, there is within my constituency a substantial distrust of Coventry and there is little affinity of interest between Coventry and the West Midlands and Rugby. Coventry is part of the West Midlands metropolitan area, whereas my constituency is part of Warwickshire.

There are alternatives to Coventry. I do not think that it is necessary, but Rugby could be grouped with North Warwickshire and South Warwickshire to form a Warwickshire area health authority with a population of about 469.000—within the guidelines laid down so far by the Secretary of State. I admit that it would be a large authority, but it would at least have the virtue of conforming to one set of local government boundaries and it would obviate the need to cross local authority boundaries. Even more important, there would be an atmosphere of trust, without the suspicion that must colour any discussions or merger with the city of Coventry and the West Midlands.

My constituents and I believe that Rugby, which would handle a budget of about £7 million, would be viable on its own, but we are prepared to consider the possibility that we shall have to merge. If we have to look elsewhere, we should look to our associates in the north and south of Warwickshire and become part of a Warwickshire area health authority. I stress to the House and particularly to the Minister who is to reply that Ruby feels that it has a case to develop itself within its own resources.

On 3 June, the Secretary of State issued a press release headed: We must restore local pride. It is not necessary to restore local pride in Rugby, because it exists already. However, that pride would be lost if we had to merge with another authority. The press release says: We have come to the conclusion that the district concept is broadly right. Of course it is right, and Rugby is a district par excellence. The press release continues that "Patients First" is designed to attack not the people, but the system. It does not attack administrators, but bureacracy and aims at better management.

Rugby would be a small district, with a population of between 86,000 and 110,000, but surely the events of the recent past have shown clearly that biggest is not best. I instance the appalling situation in our great nationalised industries. Does any hon. Member seriously doubt that the smaller units usually give the best form of administration, closer management and better value for money, particularly compared with the large and unwieldy mammoths that are so expensive and that have been criticised by the Secretary of State? Those large organisations are not only expensive but are unresponsive to public opinion.

My hon. Friend the Member for Canterbury (Mr. Crouch) referred eloquently to the importance of bringing democracy back into the NHS. What better place is there to find democracy than in a small district which has an intimate relationship with its population?

The Secretary of State's press release said that the NHS had lost something of the spirit of local pride which used to characterise its service and that, if we could recapture pride, a great deal could be achieved. Let me say to the Secretary of State, whom I am delighted to see in his place, that Rugby has pride in its hospitals and services and we ask him to let us keep that pride.

I turn to a report produced by the West Midlands regional health authority on the consultative document "Patients First". It refers to the ambulance service and states that the authority: welcome the proposal to review functions of the ambulance service, but consider that radical changes should be avoided at the present time in a service which has found great difficulty in settling down since 1974. I visited the Rugby ambulance service station last Saturday. I spent three hours talking to the crews. They are appalled by the prospects of a link with Coventry and the West Midlands. They believe—as the people on the spot they should know—that the only result of such a merger would be to increase the amount of remote control. The ambulance service, perhaps more than any other service, should be a local service able to respond rapidly to demands. To legislate for control of that service to come from some central point, 20 or 30 miles away, completely ignorant of the conditions that exist in my constituency, is a recipe for disaster. From the standpoint of the ambulance service, it is critical that Rugby remains outside the West Midland metropolitan area.

The final sentence in the regional health authority's report says: The Regional Health Authority fears that the turbulence that the Government's proposals portend will far outweigh the benefits that Ministers ambitiously seek to achieve. It is not for me to remark on Minister's ambitions. I am surprised that the regional health authority should try to do so. If, however, Rugby merges with Coventry and the West Midlands, I have no doubt that turbulence will occur. My constituents oppose positively and absolutely any merger with the West Midlands. If the West Midlands regional health authority is genuinely concerned about turbulence, it should not pursue this proposal further. On page 4, the consultative paper "Patients First" states: As Napoleon said, 'morale is to material as three is to one.' Change for change's sake must be avoided. If the Minister believes what he has written—I know him to be an honourable man and I have no doubt that he means every word—I ask him to allow Rugby, despite its administratively small size, to become an independent district within its own right. Within my constituency morale is high, but the damage caused by a link with Coventry would be very great. The report says that the district of Rugby might be small but adds that certain of the services could be supplied on an agency basis. This would answer most of the objections that might come forward. Because of the coterminousity of boundaries, Rugby's link with local government is particularly strong. There is a clear identity of need and of direction and, above all, a common purpose felt within my constituency.

The document is rightly entitled "Patients First". If a proper regard is to be given to patients, Rugby should become a new district authority. Rugby's patients would then be coming first and not a poor second best as was the case when we were last linked with Coventry. An earlier predecessor of mine in the House was Mr. Roy Wise, a man, who I know, Mr. Deputy Speaker, was known to yourself. Roy Wise described Coventry as an octopus of civic imperialism. That phrase is as valid today as it was on the day he first used it. My constituency has no desire to be grasped by the tentacles of that octopus.

8.50 pm

Mr. Alfred Dubs (Battersea, South)

The hon. Member for Rugby (Mr. Pawsey) will forgive me if I do not follow him along the highways and byways of the Health Service in the Midlands.

Several hon. Members have referred to the recently published report on inequality in health, which I do not want to go into in the detail that I had originally planned. The report makes clear that many of the alarming inequalities in health care and health standards can be attributed to factors outside the Health Service, such as the environment, work accidents, overcrowding, poverty and deprivation. I hope that before too long the Secretary of State will separate those inequalities due to deficiencies in the Service from those that are due to other factors so that we can properly attribute blame.

The report makes it clear that at least some of the inequalities in health are due to cigarette smoking. Without going into all the details of the argument that other hon. Members have already put before the House tonight, I say simply that there is no excuse that lack of resources prevents the Government from taking action to prevent cigarette advertising and reduce the amount of cigarette smoking. It is a test of political will, and political will alone. I hope that the Government will say whether they have the courage to exercise political will or whether they will seek refuge in some other excuse.

The next few years will be particularly difficult for the NHS, which will have to absorb yet another reorganisation. In principle, I agree with what is intended, but there will be the traumas of absorbing the difficulties for the staff and the structure of the Service. In addition, there will be difficulties due to increased pressure on resources—the pressure that the Government have put on the NHS already and the extra pressures that are apparently in the pipeline because of further cuts, not only in London but in other parts of the country.

A third difficulty will be that imposed by the Government on the NHS: their intention to increase the private sector, which is demoralising for the Health Service and makes life for NHS administrators and doctors that much more difficult. The new structure will cause tension and stress for those working in the NHS, for whom there is plenty of tension and stress already. Just outside my constituency recently there was the closure of St. Benedict's hospital, a typical example of where the relationship between the Health Service and the local community was made worse by Government imposition on the area health authority.

Several hon. Members have spoken tonight of the need to introduce democracy into the Health Service. Some have suggested that small districts—and there is certainly an advantage in them—are equivalent to democracy, but that need not be so. Democracy does not necessarily follow from having small units of organisation. The need to make the new districts accountable to their local community will depend on other matters, including the regrettably small number of elected local authority members. I wish there were more.

I turn to the subject of resources generally and a matter that has not been mentioned so far. It seems to me that a fair bit of responsibility for resource allocation within NHS authorities depends upon the way in which doctors exercise their powers, that for all the administrative decisions, for all the decisions officially made by members of the old AHAs and by members of the new district, a fair bit of responsibility for resource allocation will rest upon the doctors themselves. I should like the Secretary of State to accept that as a genuine statement of the problem and to make suggestions about whether the present way in which resources are allocated through the power of the doctors can be made more responsive to democratic needs and pressures.

The structure of the regional health authorities is closely related to the way in which resources are allocated. There is a link between structure and resource allocation. In London, in particular. because of the wedge-shaped pattern of the regional health authorities from the inner cities, through the suburbs and to the green fields, a tension in resource allocation is imposed upon each regional health authority, with which authorities find it difficult to cope. I hoped for some words of comfort from the Secretary of State that would lead to a better system.

It is not surprising, where there is so much emphasis on hospital services, that health authorities are less interested in the arguments in favour of coterminousity than the local authorities, which place more emphasis on community-based services. It is not surprising that local authorities are the champions of coterminousity. I hope that the Secretary of State will not be over-influenced by certain arguments but will consider carefully the valid points in favour of establishing the same boundaries for the different services. particularly because of the advantage that that would have for the elderly.

I have examined carefully the initial report by the London advisory group published in the DHSS circular in July. The group states clearly why London requires different treatment, but its conclusions are a little tame and not the direct result of the arguments in the report. We are talking about a new structure for the Health Service in London, when one of the key factors—the future of medical education in London is still an unknown quantity. I hope that the university of London will finalise its view of the Flowers report and that the Secretary of State will come to a decision soon enough to influence the new structure for the Health Service in London. If that does not happen, we shall have some inconsistent authority boundaries, possibly without hospitals.

It is over-optimistic to assume that the new structure and the definition of responsibilities for members of the new district councils alone will result in the level of efficiency we all wish to see. I speak as someone who believes fervently in the public sector and who would like to see it as efficient as possible. That is why I welcome the tentative suggestion made by both sides of the House that we might take a leaf out of the education book and appoint the equivalent of inspectors of education. That might help hard-pressed health authorities to learn from each other.

I urge the Secretary of State to consider advising the new health authorities to introduce a method of monitoring efficiency. The pressure will be such that cuts in the money made available to local health authorities and the difficulties of reorganisation will mean that they will not have time to consider efficiency. A monitoring system should be established so that the efficiency of service is kept under scrutiny.

Above all, let us allow the National Health Service to get on with the job. Compared with other countries we have a service on the cheap but it is still worth while, and we should be proud of it. I hope that the Secretary of State will do all that he can to improve morale in the Health Service. The staff have taken a severe battering in recent years. Let the Health Service get on with it and provide the service that it wants to provide for the people of Britain.

9 pm

Mr. Roger Moate (Faversham)

In one minute I shall endeavour to make two points. First, I warmly welcome the proposals, essentially because they will introduce a vitally needed element of democracy into the National Health Service. Like many other hon. Members, I speak as one who, in recent years, has been involved in endeavouring to obtain more resources for a deprived district. I and other Members have felt acutely the lack of democratic structure in our existing Health Service. It is significant that there has been such a general welcome for the proposed changes. There are arguments about detail, but in broad principle people accept that our Health Service should be based on strong districts. The districts must be more democratic.

I think that my right hon. Friend the Secretary of State was wrong to say that there should be only four elected members serving on the new authorities. I am not saying that having extra elected members is the answer. It is not. It clearly does not work in such bodies as the water authorities. It is not a complete answer, but there is no other way to achieve such democracy. I urge my right hon. Friend to reconsider his proposals and to introduce as many elected members to the new strong districts as can be sensibly accommodated.

Secondly, I wish to make a brief point about the ambulance service. Kent has gone through a traumatic experience in recent times. I am not blaming anybody for that, but it is a fact. It was the result of an attempt to centralise the ambulance services. It proved conclusively to me, and to most other people involved directly in the ambulance service, that the new Service should be based on the districts. I hope that when my right hon. Friend replies he will say something more about his thinking on that matter. It is wrong to contemplate dividing the ambulance service between those dealing with emergencies and those dealing with community transport. They are one service and should be kept as such.

No areas will remain, so some new structure for the Service must be concluded. Obviously, it is illogical to base that on the region, because it would have to re-think a new structure. The district is the natural and proper unit. Those responsible for the large districts, and the large number of hospitals within the districts, should also be directly responsible for the ambulance service.

Even if I were not one who has taken advantage of the emergency service in recent weeks, with immense appreciation of its skills, I should still say that in my area we feel that confidence has been undermined in the ambulance service itself, among those who administer it, and among the patients, by the changes that took place. Let us return the ambulance service to the districts. There might be variations in certain areas, but as a general rule I hope that the Government will lay down a guideline that the ambulance service should be administered by district authorities.

9.3 pm

Mr. Roland Moyle (Lewisham, East)

We have had a wide-ranging debate this evening. I hope to reply to many comments quite apart from those on the pending reorganisation of the National Health Service, about which, of course, I shall have something to say. Many of my remarks, especially in the opening part of my speech, will not be entirely unfamiliar to the Minister of Health, because I made them often in Committee on the Health Services Bill during the early part of this year. I make no apology for repeating the points, because we have not yet received answers to some of them. By continuing to pound away from time to time we force the odd glimmer of light out of the Treasury Bench, which helps us to feel our way forward in the surrounding gloom.

It is necessary to state the attitude of the Opposition to the reorganisation. We believe that it is necessary to improve morale in the Health Service and to attain greater administrative efficiency. The scheme adopted by the Government is broadly that which was recommended to them by the Royal Commission on the Health Service, which we appointed. The administrative efficiency that is likely to accrue could be overstressed and exaggerated. For example, one result of the reorganisation will be that the links between the local authority social service departments and health authorities will be more complex than in the past.

There was some virtue in the suggestion made by my hon. Friend the Member for Brent, South (Mr. Pavitt) that social service directors should automatically be made members of health authorities. The link between the existing area health authorities and family practitioner committees is tenuous. One might say that they are almost independent fiefdoms within the kingdom. It will become more tenuous as a result of the reorganisation, because, instead of one health authority relating to one family practitioner committee, several health authorities will usually have to relate to one family practitioner committee.

Surgery of a sort will be applied to the Health Service, rather than any less drastic therapy. In those circumstances. I believe that the Government have a great responsibility to the staff, because at the end of the reorganisation the fundamental problem of Health Service costs will not be touched at all. That fundamental problem is the application of economically uninformed therapies by the medical profession. That will be left untouched. The staff will bear the burden of any reorganisation and any savings, but the essential problem will be left untouched.

The Government also aim to make financial savings. Here comes the advantage of battering away. because we are grateful to the Secretary of State for at last authoritatively setting out the figures on job losses. Job losses will be about 4,500 to 5,000. As a result, the right hon. Gentleman is aiming to achieve savings of £30 million—I assume at the moment that these are 1979 figures, although they might have to be updated by about £5 million or £6 million for inflation—over a five-year period. That means that savings will accrue to the Health Service at an average rate of about £6 million for each year over the next five. That will therefore mean a very minor saving on the NHS budget altogether.

What is happening in the Health Service at the moment—and I thought that the hon. Member for Belper (Mrs. Faith) gave clear expression to it—is that many medical people are looking forward to the cutting out of many administrative jobs, in the hope that large sums of money will accrue to various therapies in the Health Service, most of them administered by the medical profession. As a result of what the Secretary of State has said, it is now clear that that will not happen. No one will notice the degree of saving that comes to the Health Service, particularly—as I shall demonstrate in a few minutes—when substantial costs will have to be met in the initial period of those four to five years.

Even though the Secretary of State has given us the information that he has provided today we are still in a quandary, because the basis of his information is flawed. The basis of the £30 million figure is something that we have been seeking for the best part of 10 months. The best basis that we have is the remark made by the Under-Secretary of State during the Committee stage of the Health Services Bill, when he said: My hon. Friend the Minister for Health, with his vast personal experience of the Health Service, believes that more than that can be achieved, and has set the target at 10 per cent."—[Official Report, Standing Committee G, 12 February 1980; c. 102.] He was talking there of management costs. That is the basis.

We have already had one quotation from Napoleon, so I shall mention the other one while we are at it. He said: Beware the voice of experience", and added that all that any of his grenadiers saw of Russia was the knapsack of the man marching in front of him. I pay an unsolicited tribute to the Minister for Health, which is that there are few greater authorities in this world on the provision of child psychiatric services at Guy's hospital than the hon. Gentleman. That being said, the House ought this evening to be given a more scientific basis for the calculation of £30 million, which we have been seeking solidly for 10 months.

Are the Government saying "We shall use the reorganisation to save £30 million", or are they saying "We have a better system of administration as a result of the advice of the Royal Commission on the Health Service, and as a result of applying that we shall save £30 million"? From the Opposition side of the House it looks very much as though they will save £30 million by hook or by crook, no matter where it might come from.

We have established that there will he reorganisation costs. Conservative Members did much of the probing in Committee. There will be the painting of various new signs, an increased number of authorities, and so on. At present there are 90 authorities with members, which have to be administratively served. In the future there will be 170 or 180 such authorities, which will mean increased costs. There will be an increase in the costs of what I call euthanasia—the quiet putting down of various people who will lose their jobs—and salary protection for those who will lose their present responsibilities and have to accept lower jobs. There will also be the friction costs of reorganisation. The administrators will concentrate not on the effective, economic administration of the Health Service, but on putting into effect the reorganisation, and on wondering what will happen to their personal jobs and futures. That will incur increased costs.

What will the costs be? In Committee the Minister said: We have had warnings that it could he expensive. We have also been advised that it need not be expensive."—(Official Report, Standing Committee G, 4 March 1980; c. 391.] That was 10 months ago. The Minister has had 10 months to reflect on the cost of reorganisation. I drew to the attention of the hon. Member for Truro (Mr. Penhaligon) the fact that we must not assume that the Government will not spend money in this exercise. If this degree of imprecision in their estimate of the costs remains, they may ultimately spend more money. It the reorganisation goes amiss, that quotation will certainly hang around the neck of the Minister like a millstone.

Further, all the figures that we have are last year's figures. The figure of £30 million was first mentioned in 1979. We are now in 1980, with an intervening period of inflation, often at 21 per cent. Must we now update the 1979 figures to £35 million? Those matters are crucial to the well-being of the National Health Service and the staff.

The Government have an overwhelming responsibility for the welfare of the staff. It is because of the Government's incompetent previous reorganisation that the present reorganisation has to be undertaken. Broadly speaking, the people who will be dismissed from their present jobs in the next two years are those whom the Secretary of State and his hon. Friends put there in 1973 to do the jobs that they are now doing.

It seems to Labour Members that this reorganisation will be carried through without the benefit of any anaesthetic. The Secretary of State has refused to give a "no compulsory redundancy" undertaking. There has also been a withdrawal of the Crombie code of compensation for public servants at the crucial moment when that code is desperately needed by everyone in the Health Service. The staff must be reassured that they will have as good a code to replace it.

In Committee the Minister for Health said: … redundancies—I know that that is a point that the hon. Member for Wood Green (Mr. Race) is concerned about—but I suggest to him that taking time, not doing these things in one burst overnight, will enable staff changes to be made with the minimum of disruption and will reduce the number of redundancies considerably "—[Official Report, Standing Committee G, 4 March 1980; c. 393.] In view of the fact that as a result of this reorganisation we are moving towards an appointed day throughout the National Health Service when all these changes will be synchronised—certainly outside London—what effect will that one rapid D-Day have on the number of redundancies? The clear implication of the Minister's remarks in Committee was that the number of redundancies would be reduced with the operation spread over a long period. Therefore, the number of redundancies will be substantially in- creased if the appointed day procedure is adopted.

The staff have constantly asked for a staff commission to protect them. We have argued the case in the House and in Committee for a staff commission to protect the staff who will undergo the reorganisation. The Secretary of State has persistently refused to appoint such a commission. We have done our best to warn him. One of the prime objects of this exercise is to improve staff morale. The staff commission approach is a tried and trusted remedy that has been applied in countless public reorganisations in the past couple of decades in all spheres of activity. If the reorganisation goes sour and the staff get disgruntled, it will be on the right hon. Gentleman's head, because he will not have provided the sort of support that the staff want.

Then there are the functional officers. Their careers have been organised on a functional basis from area health authority downwards. They are mostly laundry, catering, personnel and works officers and some nurses organised on a divisional basis. Even if they remain in the National Health Service the right hon. Gentleman will have destroyed their careers, because most of the steps in those careers will go.

I raised this problem on 23 July when the right hon. Gentleman made his statement about the future organisation of the Health Service. He said that he would negotiate protection. So far no protection is emerging, and if some of these people read in management documents that the future organisation of their jobs is "a matter for conjecture at this stage" it scarcely serves to reassure them about what will happen under reorganisation.

In summary, therefore, the surgery that the right hon. Gentleman and his Friends are about to apply to the Service shows every sign of being conducted not with a scalpel but with a chopper, and without the benefit of an appropriate and adequate anaesthetic.

Another problem concerns London, to which my hon. Friend the Member for Battersea. South (Mr. Dubs) referred. It is a highly complex problem. The Royal Commission has advised the Secretary of State what to do about London, which is to hold a comprehensive inquiry into the health services with a view to promulgating a proper policy for those services and—this is important—to take the people of London along with him when he is composing a reorganisation. We have supported that approach as being the right one.

Again, the right hon. Gentleman has ignored all advice. He spoke this afternoon of machinery for planning and various committees, but he did not explain how the people of London would be involved in the planning and be taken along with the future reorganisation of the London health services. We in the Opposition regard his approach as irresponsible. We regard it as within our sphere to support opposition to those policies in London, and we shall do so. That means that battles on behalf of Westminster hospital, and other such hospitals, and King's College pre-medical year can be and will be fought by us because the right hon. Gentleman and his colleagues have not done the job that they should be doing in promulgating proper health services for London.

Throughout the discussions on "Patients First" there has been constant criticism of the Government for having treated district health services as an afterthought. The hon. Member for Belper made this point. The Government have denied the accusation. The Black report had a tremendous amount to say about the provision of district health services and the role that they will play in the future of health services.

The Government's attitude to the Black report reinforces the charge that they are disregarding the district health services. They are saying that here is an organisation that suits hospitals and that they think that it might well do for district services as well. I criticise that approach, and I believe that the Black report will prove to be one of the most important Government social documents of our time.

I reiterate that it will become one of the basic policy-making documents of the Labour Party in the run-up to the next general election, yet the Secretary of State embraced it with the friendliness of a boa constrictor embracing its victim. He embarked on a badly bungled attempt to manipulate the news to ensure that discussion was suppressed. Only recently prominent journalists have made the point that that is what the Government have been doing again and again.

Mr. Patrick Jenkin

I apologise if I am interrupting the right hon. Gentleman before he has made his case. We sent 100 copies of the report to national, provincial and specialist newspapers. In those circumstances, to argue that we are trying to hush up the thing is absurd.

Mr. Moyle

In that event, why did the Daily Telegraph, for example, not have a copy of the report on the day of the press conference by the working party? Why did not most of the regional health authorities have copies? Why did my hon. Friend the Member for Birmingham, Perry Barr (Mr. Rooker) have to send a cheque for £8 to the Department to get a copy so that he could consider it?

The report was received in April and published—if "published" is the word—in August week, some months after, when it was no doubt assumed by the right hon. Gentleman that most Members of Parliament and journalists would be on holiday. It was not given to Her Majesty's Stationery Office to print and publish; it was photostated in the basement of the DHSS. Its publication—

Mr. Patrick Jenkin

rose—

Mr. Moyle

I have already given way once to the right hon. Gentleman. Its publication was made the responsibility of such a junior official in the press department of the DHSS that it took all Professor Peter Townsend's research acumen to trace his telephone extension. Finally, the original time of publication was supposed to be midnight—to make sure that everybody knew about it. In fact, it was brought forward to a reasonable time of day only because the working party announced that it was going to have its press conference. In that way, it forced the hand of the Department. Of course, the Secretary of State did not deign to have a press conference on the matter.

It must be a record in callousness, even for this Government, to be told that 30,000 of our fellow citizens are needlessly dying every year and for the Government to turn their back on them. The right hon. Gentleman is not responsible for the creation of that problem.

That problem evolved before the National Health Service was established, as a result of optimism, complacency and inadvertence. But, now that the right hon. Gentleman and his right hon. and hon. Friends have been told that the problem exists, they become responsible.

The right hon. Gentleman turned down the recommendations on the ground of cost. I have today put down about two dozen questions on the costs of the recommendations in the Black report. As the right hon. Gentleman has turned them all down because of the cost factor, I shall expect precise answers on the costs of those recommendations, because he has had from April to August to work out the excessive cost, as he would say, of turning down those recommendations.

Fortunately, we are now getting more copies of the report. The TUC is to produce a pamphlet that summarises the report, and that pamphlet will be printed in large numbers so that people will have access to it.

The right hon. Gentleman did himself less than justice when, during his opening speech, he sneered and said that it would cost £2,000 million to apply the dreams of Professor Peter Townsend. That is not the sort of approach that is required. If the dreams of Professor Peter Townsend are not applied, it will probably mean 30,000 avoidable working-class deaths per year. That is what the right hon. Gentleman is trying to brush under the carpet, and it is not good enough.

How much would the Black recommendations on smoking cost? On 9 May last the House of Commons debated policy on smoking. It was almost uniformly critical of the current position regarding the sale and promotion of cigarettes. That concern was based on the best available advice that cigarette smoking was the single largest avoidable cause of ill-health among our people. At the end of that debate a resolution was approved, without a Division, that called on Her Majesty's Government to make new initiatives to alert the public to the dangers and costs of smoking and also to agree measures with the tobacco industry which will lead to a reduction in the promotion of cigarettes to the young. At the time that that resolution was passed, the second in a series of three- year agreements that would gradually restrict the cigarette industry was already two months overdue. Nevertheless, the motion was approved by the House on the basis that there was sufficient good will in the tobacco industry to reach a voluntary agreement. That was certainly the basis on which the Labour Opposition proceeded. The Secretary of State said: So long as progress by agreement is possible, it would be wrong to introduce legislation".—[Official Report, 9 May 1980; Vol. 984, c. 783.] As my hon. Friend the Member for Brent, South said, the three-year agreement is now nearly eight months overdue.

The view of the Labour Party is that the attempt to proceed by voluntary means has collapsed. The Government must legislate. We hope that in doing so they will put the Opposition's policy into effect. If they do not do that, they should at least write their own policy on restricting the tobacco industry and enact the Bill. It is clear that there is no good will in the tobacco industry.

I was going to say that I would urge one of my colleagues who is fortunate in the Private Members' Ballot to introduce a Bill restricting the cigarette-smoking activities of the industry and promotion in all its aspects. I now have a definite offer from my hon. Friend the Member for Brent, South, who says that he will introduce such a Bill. It is now a race between the Government's Bill and a Private Member's Bill introduced by my hon. Friend. In view of the debate that took place on 9 May, I wonder whether the Government have enough political clout to be able to stop such a Private Member's Bill if they really want to do so.

One or two other matters have arisen as a result of "Patients First". First, there is the hospital building programme. A district health authority is supposed to be an area that can support a district general hospital. Until now, 209 districts have been supposed to be able to support a district general hospital. The number of districts is now to be reduced to about 180 or 170. Those are districts that are also supposed to support a district general hospital. That in itself arouses the deepest possible suspicion.

This issue was raised when the Health Services Bill was being considered in Committee. We had some weasel words from the Under-Secretary of State to the effect that the reduction in the number of districts would not involve a reduction in the number of hospitals that would have been built anyway. When we couple the number of districts with talk about preserving small and well-loved local hospitals—a phrase of that sort appears in the Government's consultative document on the hospital building programme—it is clear, in our view, and in the view of most of those who are involved in the Health Service, that the hospital building programme will be substantially and savagely cut. It ill becomes the Secretary of State to talk about cuts in the capital building programme when he talks about the previous Labour Government.

There is a quiet resistance building up in the Health Service to the Government's urging to subcontract. The hon. Member for Harrow, Central (Mr. Grant) was right to draw the Secretary of State's attention to the quiet resistance to the circular that is building up in the Health Service. Most of the subcontractors find that they cannot do the job that is required by the Health Service. The administrators lack control over the operation once they have put it out to private contractors. Over the next two or three years they will be so involved in reorgianisation that they will not have time to worry about that sort of thing anyway.

Mr. Anthony Grant

rose—

Mr. Moyle

No, I shall not give way. I am coming to my conclusion.

This is a reorganisation that will be carried out without the resources that are needed to fund it. We have established that it will cost money, and none of that money is forthcoming. The reorganisation will be imposed on an anaemic Health Service. The previous Labour Government were criticised for reducing growth in the NHS. Possibly that criticism was justified. However, the Government have introduced a new concept into the NHS, namely, that of absolute shrinkage of the Service. They have done so in defiance of their most obvious and specific manifesto commitments to maintain spending on the National Health Service.

In page 6, paragraph VI of the third report of the Select Committee states: Current spending on the hospital and community health services, in volume terms at 1979 survey prices, was £160 million below the total planned in Cmnd. 7439, the last White Paper published by the outgoing Labour Administration. In addition, capital spending was £44 million below the Cmnd. 7439 figures for 1979–80. Overall, real expenditure on the National Health Service was less than in the previous year. That is the first time since 1948 that it has been possible to say such a thing in any public document about the National Health Service. This is the first Government to introduce shrinkage as a concept in the administration of the National Health Service. The Secretary of State admitted as much when giving evidence to the Select Committee.

The National Health Service is being sacrificed. Until now the Government have maintained a fairly twisted and tortuous logic, to the effect that the National Health Service will be sacrificed so that the burden on private industry can be relieved, thus enabling it to earn lots of money that will in time provide extra resources for the NHS. That argument has no appeal to the Labour Party. It is a tortuous and twisted argument that has a fantastically convoluted logic of its own.

Nobody with eyes to see or ears to hear can maintain such a case now. Conservative Members must face the fact that after 18 months of Conservative Government the message is clear. The National Health Service is being sacrificed so that the ICIs of this world can also be sacrificed. The Government are on a course that cannot give rise to hope. They are in an untenable situation, and we shall fight them all the way.

9.33 pm

The Minister for Health (Dr. Gerard Vaughan)

Until the closing remarks of the right hon. Member for Lewisham, East (Mr. Moyle), which were particularly vicious and misplaced and which did not do the debate justice, I would have said that this had been an interesting and wide-ranging debate. I welcome the opportunity to answer as many individual points as possible. Earlier this year the Opposition asked whether they could have such a debate. They felt that it was essential that the House should consider what was happening in relation to restructuring. We were happy to agree.

Since 1974 the Opposition have consistently criticised the structure of the National Health Service. Throughout the period in which the Labour Party was in government, they criticised it. The previous Labour Government set up the Royal Commission. However, during their five years in office they did nothing to correct what they saw as major faults.

Mr. Ennals

is the hon. Gentleman suggesting that we should have immediately gone back on the reorganisation that had already been carried out? Is he suggesting that we should not have waited for the report of the Royal Commission? Does he further suggest that we should have taken action before we were ready to do so, which would have created further disturbances in the National Health Service?

Dr. Vaughan

The right hon. Gentleman knows perfectly well that I am stating an historical fact. The previous Labour Government endlessly criticised the situation and spoke about the damage that had been done to the National Health Service, but they did nothing to put it right. It has fallen to us to take the action that virtually everybody agrees is necessary. We are having to take such action at the same time as we are having to restore the vitality of the National Health Service.

I wish to comment on the background which is very relevant to the pace at which we have been able to proceed with the restructuring. We have had to keep in mind that we are asking a great deal from the staff. This was referred to by the right hon. Member for Lewisham, East. We are asking the staff to continue running the Health Service for patients at the same time as dealing with the reorganisation and the restructuring. This fact has played an important part in our consideration of the pace of any changes.

We inherited a cumbersome and top-heavy structure with too many committees. I noticed that the hon. Member for Wolverhampton, North-East (Mrs. Short) talked about the time wasted by professional staff on committees. I agree with her. This is something that we intend to stop. We inherited too much paperwork. The previous Administration increased the number of administrators from just over 82,000 to just over 100,000 during their time in office. So much for their views on the need to cut down the amount of administration. We also inherited too much delay and too much frustration.

At every hospital I visit I make a point of meeting the representatives of the staff. Over and over again I find that it is damaging to morale at the grass roots of the Service that there should be this delay in the implementation of any suggestions they might make. This leads to frustration. It is not surprising that we inherited very low morale in many places.

The winter of 1978 saw the most appalling scenes of industrial unrest. That was, to a considerable extent, the result of the indecision and confusion that occurred under the previous Administration over the direction of the Health Service.

We inherited the longest waiting lists in Western Europe. They had increased by a quarter of a million in the previous four years. I do not wish to dwell on the distress, pain and suffering that this causes to large numbers of people.

Mr. Pavitt

rose—

Dr. Vaughan

No, I will not give way at this point but I will in a few minutes if the hon. Member still wishes to intervene. In those years 280 hospitals were closed and a further 31 closures were in the pipeline.

I find it very difficult to follow the right hon. Member for Salford, West (Mr. Orme) and the hon. Member for Brent, South (Mr. Pavitt) when they talk about cuts. This talk is so fashionable in the press, but in five years under the Opposition's control the capital spending of the Health Service was radically reduced by one-third.

Most of all I deplore the drift and indecision in the National Health Service. Hospitals were actually closing down because they could not get clear answers about their future and staff were leaving because they felt that their careers were in jeopardy. Hospitals were losing staff on a huge scale and falling into disrepair, not only because of shortage of money but because of this indecision and drift. That is one reason why we wish urgently to see a more local service which is able to respond to the needs of the local community.

When considering the restructuring, I never believed that it would have to be in the context of such a fall in standards and so much confusion of purpose in the Health Service. That is what we inherited and hon. Members know that it is true. More than this, although it was clear early on that many of the new hospitals being built were hopelessly wrongly designed and in some cases were not even needed because the hospitals they were intended to replace had been refurbished, and although it was clear that some of them would be excessively costly to run and staff, our predecessors did absolutely nothing to stop the process. Now we have. I am grateful to The Daily Telegraph for drawing attention to the problem. We now have a long list of new buildings that cannot be staffed and cannot easily be run.

Mr. Ennals

They cannot be staffed because the Government will not provide the money.

Dr. Vaughan

It is not only a question of money. There is a difficulty in staffing. That is the background against which the restructuring has to take place.

Since taking office we have had systematically to set about reducing the chaos, and I believe that we are succeeding. Morale is rising. One has only to tour the country to realise that. It cannot be denied. I was especially pleased the other day when some of the voluntary organisations said that for the first time for years they feel they are welcome when they try to assist in hospital procedures.

We are steadily reviewing hospital building policies. The week before last we announced a new low energy hospital design. It makes no sense to have a hospital that, like a cuckoo, eats up resources endlessly.

As the House will know, waiting lists are falling. It was suggested earlier that waiting lists are three times larger. That is not so. They are falling. The hon. Member for Wolverhampton North-East mentioned the distress involved in hospital waiting lists. In March 1979, 752,000 people were on the waiting lists; in June the number was 740,000; in September, 698,000; in December, 677,000; and in March of this year. 662,000. Waiting lists have come down by 90,000. I am not saying that they will not go up again, but I believe that this important downward trend will continue.

Mr. Ennals

The hon. Gentleman is making a comparison with the period at the height of the industrial disputes. During almost the entire period of the previous Labour Government waiting lists were well below 600,000, but the figure is now in the upper half of 600,000.

Dr. Vaughan

I do not know what the right hon. Gentleman is trying to tell us. Throughout the period of the Labour Government waiting lists increased steadily. If it is true that all that has happened is a fall off in the waiting lists that built up as a result of industrial unrest, lists would level out and not decrease. In the past year we have not only been catching up on the waiting lists built up during the industrial unrest but dealing with the new people coming onto waiting lists.

The right hon. Member for Salford, West made a sincere but somewhat misinformed speech. When listening to his comments on the Black report I could not help thinking of his comment not long ago that the National Health Service is the jewel in Labour's crown. if so it is beginning to look very tarnished.

The right hon. Gentleman made a completely misguided point about "Patients First". He said that there was no great reference to community services and the social context. Of course not. That is not what the document is about. It is about the changes that we consider necessary in the administrative structure, mainly in the acute hospital section of the Health Service, in order to pull this end together and transfer the resources that we hope can be saved into preventive and community services.

The right hon. Gentleman was right when he said that we must not continue a hospital priority service. Before Christmas there will be a strategy document from the Government on our priorities for preventive medicine and improving community services. I ask the right hon. Gentleman to await our document before he makes any more such comments on "Patients First".

My right hon. Friend the Secretary of State dealt adequately with the comments on the important Black report.

It is totally untrue to suggest that we restricted its distribution. We do not underestimate its importance as the right hon. Member for Norwich, North (Mr. Ennals) suggested. I share the right hon. Gentleman's view that we should not talk about social class 1 and social class 5. They are all people living under different conditions. I also share the right hon. Gentleman's view that we must do more for those who have fewer environmental provisions than they need.

However, we must consider not only the relative differences between groups, though they are important and it is a matter of great urgency that we do something about them. The actual improvements in all social groups are also important. I concede that those improvements have not taken place as quickly as we should like. I ask the right hon. Member for Norwich, North and the hon. Member for Wolverhampton, North-East to accept that we recognise the importance of the report on perinatal mortality and we shall shortly be commenting on it.

A number of hon. Members, including the right hon. Members for Norwich, North and for Lewisham, East and the hon. Members for Wolverhampton, North-East and Brent, South, raised important questions on smoking and health. I say only that it takes two to make an agreement. We have set our minds to reaching an agreement. The Opposition would be the first to complain if we did not come up with an agreement that met our proper obligations.

My right hon. Friend the Secretary of State has said: So long as progress by agreement is possible, it would be wrong to introduce legislation, for instance on advertising, although no Government could rule that out for all time."—[Official Report, 9 May 1980 Vol. 984, c. 783.] That is the position on which we stand.

Mr. Orme

Is the Minister prepared to set a deadline on how long the Government will negotiate with the tobacco industry? We have waited 12 months and the House is entitled to a specific date.

Dr. Vaughan

The right hon. Gentleman will know that specific dates can be helpful in negotiations, but they can also be damaging. Our aim is to get a voluntary agreement with the industry which will work. That is what matters. As a Minister and a doctor I am as aware as any hon. Member of the appallingly high figures of mortality from smoking.

In passing, I cannot resist congratulating my hon. Friend the Member for Harrow, Central (Mr. Grant) on giving up smoking.

Mr. Anthony Grant

And without legislation.

Mr. Pavitt

Is the tobacco industry arguing as one group, or does the battle that is being waged between British American Tobacco and the Imperial Tobacco group mean that the Government are negotiating with two groups?

Dr. Vaughan

The hon. Gentleman knows that it would be wrong for me to comment on such points. We are carrying on responsible negotiations and we are determined to get an agreement. Labour Members would be wise to leave it at that.

The right hon. Member for Salford, West and my hon. Friend the Member for Peterborough (Dr. Mawhinney) asked about the ambulance service. It is because we share the concern over the ambulance service and the anxieties about its working situation and its future that we set up a special working group on the ambulance service. We are now awaiting its report, which I hope will be available soon. I regard the report as very important.

A number of hon. Members have talked about London and our view that the Royal Commission's recommendation that there should be yet another inquiry was misplaced. As Opposition Members know, we do not agree with them on this matter. We think that there is already a wealth of information on London. The need now is for decisions and a clear programme for London's services. That is why we set up the London advisory group. On community health councils, we are looking urgently at their membership and their role. We shall be bringing a document before the House this autumn.

A good deal of anxiety was expressed by the right hon. Member for Salford, West and for Lewisham, East and the hon. Member for Brent, South about local authority representation. There is no doubt that local authority work has increased to such an extent that many local authority members find increasing difficulty in doing their local authority work and also, for example, serving as a member of a health authority. We concluded that it would be much better to have a smaller number of people able to devote the enthusiasm and thought to the health side of the Service than a larger number who were unable to do so. We hope that the chairman of the social services commtittee will be a member of the health authority wherever possible.

Much was said about democracy.

Mr. Moate

My hon. Friend gave the impression that the Government have decided to limit the number of local authority members to those recommended in "Patients First". Is he rejecting any recommendations or arguments that are put forward? Or will he respond to the requests to increase the number?

Dr. Vaughan

We have received some 3,500 recommendations and views on "Patients First". We have weighed them carefully. My right hon. Friend has stated that we shall proceed with reducing the number of local authority members.

The right hon. Member for Salford, West talked of wholesale sackings. I have no idea what he means. We are seeking to keep on health authorities people with a genuine, on-going interest in the Health Service. We are only replacing people who, clearly, have no real interest in the Health Service, are too busy, or, for various reasons—health grounds and things of that kind—are no longer suited. Under our restructuring, we are removing not one tier but two tiers—the area health authority and the sector tier. We shall watch carefully any recommendations of an administrative structure being put between the new district authorities and the unit organisation.

My hon. Friend the Member for Harrow, Central made the point that simply to pump more money into the National Health Service was not the sole answer. I believe that he is right. Regrettably, unlimited money can all too often lead to almost unlimited waste and extravagance. I share my hon. Friend's views. Many people with great experience in the Health Service say that we could make much better use of the money that is available. I share my hon. Friend's views on the value to the National Health Service of collaboration—I think that is the word—and partnership between the National Health Service and the private sector. Contracting out can offer great value to some parts of the Service. I am having discussions with representatives of various organisations.

The right hon. Member for Norwich, North suggested that we were on a wild goose chase. I do not understand what he means by that. I believe that there can be real savings in many cases as a result of restructuring, and that it makes sense.

I was glad that the right hon. Gentleman supported us by saying that it would be a mistake to have a single appointed day. I wish that he would talk to some of his colleagues about this matter. We do not think that it is in the interests of the staff as a whole to have one day of national change, although it may be desirable to have a set day within the whole region or a local area. We wish all our administrators well, because we are asking a great deal of them.

The right hon. Gentleman went on to talk about the Westminster hospital. I understand his preoccupation with the hospital and the medical school, because he has a great deal to thank them for personally.

Mr. Pavitt

So have we all.

Dr. Vaughan

Of course, but we have the whole hospital service of London to consider, and the medical schools are the university's direct repsonsibility. I suggest that we wait until we hear the university's recommendations. They will be settled by the court of the university, which does not meet on this matter until 5 November.

Mr. W. R. Rees-Davies (Thanet, West)

I do not share my hon. Friend's view on this matter. It is essential that we maintain the medical school at Westminster, which is immensely successful.

Dr. Vaughan

I am grateful to my hon. and learned Friend for stating his view. It is an admirable medical school, but I suggest that we wait until we hear the recommendations of the court of the university. We recognise that any changes in the medical school would have repercussions for the hospital as a whole, but we have never envisaged that this great hospital would close or cease to do acute work. I ask hon. Members who are present to reassure other hon. Members about that.

My hon. Friend the Member for Canterbury (Mr. Crouch) talked about the need for a more local service, and I agree with him. What we have asked of the regional chairmen is that they should look for the smallest size of health authority that will be viable and be able to run an efficient Health Service. That is why we have given the range of size for health authorities in "Patients First".

The hon. Member for Brent, South made a number of important points. For example, he talked about drug costs. I share his anxieties about this matter. That is why we have asked the profession to come to us with views on self-regulation and what we can do about it. We are treading into clinical freedom here, and I think it best first to hear from the profession what it thinks should be done about it.

The hon. Gentleman also made some comments about general practitioners and accommodation and other facilities for nurses. I am very aware of the problems of nurses. That is why I am holding for the first time for many years discussions with the nursing groups about their careers and future in the NHS.

A number of hon. Members raised other topics. I apologise for not having reached all of them in the time available, but I shall be glad to take up detailed matters in writing. I think particularly of my hon. Friend the Member for Belper (Mrs. Faith), the hon. Member for Hammersmith, North (Mr. Soley) and my hon. Friend the Member for Wycombe, (Mr. Whitney).

The hon. Member for Truro (Mr. Penhaligon) posed a very difficult question—the dilemma of how far to go with new technology, how many resources should be put into something that to begin with may not have the best of returns but tomorrow may be a matter of everyday procedure in the Health Service. That is why we went for the £100,000 funding for the Papworth heart unit.

This has been a useful debate. The Opposition should not try to escape from their own record. They criticised the National Health Service structure but did nothing to put it right. We on this side of the House have grasped the nettle. We are simplifying the structure. We are starting not at the point of administrative convenience but at a point of service to the patient—

Mr. Walter Harrison (Wakefield)

rose in his place and claimed to move, That the Question be now put.

Question, That the question be now put, put and negatived.

It being after Ten o'clock, the motion for the Adjournment of the House lapsed, without Question put.