Lords amendment: No. 1, in page 1, line 6, leave out "Regional Health Authority" and insert
health authority in England and Wales and to each Health Board in Scotland
§ Mrs. Edwina Currie (Derbyshire, South)
I beg to move, That this House doth agree with the Lords in the said amendment.
§ Mr. Deputy Speaker (Mr. Ernest Armstrong)
With this it will be convenient to take Lords amendments Nos. 2 to 8.
§ Mrs. Currie
The prime mover of the Bill, my hon. Friend the Member for Newbury (Mr. McNair-Wilson), first became interested in the complaints procedure in the National Health Service during his serious illness in 1984. This morning he is in hospital as an outpatient on a dialysis machine. I am sure that we all hope that he is feeling much better already and that before too long it will be possible to find a permanent solution for his illness. Meanwhile, I have been asked to move acceptance of the amendments. I feel honoured to have the opportunity to be associated with this important Bill.
As the Bill completed all its stages in the House without amendment on 22 February, and virtually without criticism, I should explain why we are prepared to accept all eight amendments. Without the amendments, the Bill will not do what it is intended to do. It would merely perpetuate the present somewhat unsatisfactory procedure for complaints. As the law stands, the Secretary of State., under section 17 of the National Health Service Act 1977., has the power to give directions to the health authorities, and they must comply. My right hon. Friends who have served as Secretary of State for Social Services over the years have taken this duty seriously.
The result is that we have a plethora of complaints procedures, none of which is entirely effective. The procedures were listed by Lord Colwyn in another place on 17 April. It would be appropriate to read them into the record. Lord Colwyn said:They are: the civil law, with particular relevance to negligence, assault and defamation; the criminal law, with particular relevance to drugs legislation and certification; the General Medical Council and General Denial Council, concerned both with serious professional misconduct and fitness to practice; the ombudsman in matters other than clinical judgment; health circular No. (81)5, which deals with complaints regarding clinical judgments; HM(66)15, which is concerned with methods of dealing with complaints by patients; HM(61)112, which deals with matters concerning the hospital doctor's personal conduct, professional conduct and professional competence; HM(60)45, which is concerned with the prevention of ham to patients resulting from physical or mental disability of hospital staff.We have also the service committee and tribunal procedure which is concerned with the general practitioner's terms of service and under which he can be fined or excluded from providing general medical service. Finally, there are the inquiries set up by the Secretary of State under Section 84 of the National Health Service Act 1977.—[0fficial Report, House of Lords, 17 April 1985; Vol. 462, c. 779.]Recently, the Secretary of State has made use of the powers under that section in the inquiry into legionnaire's disease at Staffordshire hospital. However, my noble Friend missed out several procedures. It is amazing what one finds once one starts digging. There are also letters to 633 the health authorities on complaints procedures of 9 December 1966 and 27 July 1970, health notice HN(78)39 of April 1978. I think that that is an exhaustive list, but I stand willing to be corrected.
The main document in use is HC81(5), issued in April 1981, which makes it clear that it is a "memorandum of guidance" and therefore has no statutory power. If the Bill has any purpose and if these amendments have any value, that gap will be closed. It is vital that we should have, for the first time, a Bill that firmly states:It shall be the duty of the Secretary of State to give to each health authority in England and Wales and to each Health Board in Scotland such directions … as appear to him necessaryto achieve a proper complaints procedure.
I should like to examine the amendments in more detail. If we are to make the Bill work, we must accept all of them. Clause 1 lays a duty on a Secretary of State to exercise his existing power to give directions to health authorities so as to require the establishment and publicising of specified procedures for dealing with complaints in all NHS hospitals. The amendment extends the categories of authority to which such directions will have to be given to district health authorities in England and Wales, health boards in Scotland and special health authorities.
As previously drafted, the Bill covered only regional health authorities, and therefore applied only to England. There are no regional health authorities in Wales and Scotland, and the Bill is intended to apply in both areas. Regional health authorities in England are not the authorities directly responsible for the management of hospitals. The amendment ensures that the directions required by the Bill to be given are addressed to all authorities with hospital management responsibility. The other amendments follow from this proposed change which alters the Bill fundamentally and will make it much more effective.
Under clause 1, without the Lords amendments, there will be precious little improvement in the situation to which my hon. Friend the Member for Newbury drew attention on Second Reading. If the regional health authorities were responsible, nothing much would happen, even with the statutory obligations as laid down in the original Bill. It is worth remembering that my hon. Friend's horrendous experience—when he was treated at three different hospitals, none of which appeared to have a complaints procedure and certainly none of which informed him of one — occurred despite the plentiful supply of circulars and instructions which I outlined earlier. We must do better than that.
The key objective is to pin responsibility firmly on those bodies that run patients' services — the district health authorities. The regional health authorities are remote. In some regions, they cover thousands of square miles. They cover scores of hospitals.
§ Mr. Tony Marlow (Northampton, North)
I am listening carefully to my hon. Friend's argument. It was suggested in the original Bill that the matter should be looked after by regional health authorities, but it is now suggested that district health authorities should be responsible. What was in people's minds originally when they thought that this matter would be better dealt with at 634 regional level? Will my hon. Friend tell the House why that is so, because there may be potent arguments in that direction?
§ Mrs. Currie
I believe that the case was that the regional health authorities were regarded as the prime movers in England and Wales and that my hon. Friend the Member for Newbury had not realised that there were no such bodies in Wales. The main contact between the Secretary of State and the health service in the country at large is through the accountability reviews that he exercises during the year with regional health authorities. The Secretary of State does not normally meet the district health authorities. I believe that that is why the regional health authorities were, before the other place scrutinised the Bill, regarded as the appropriate authorities. However, in my view and that of my hon. Friend the Member for Newbury, they are not the appropriate authorities. I hope that the amendment will be accepted.
The regional health authorities may be funding certain activities — for example, regional specialties such as cardiology and kidney transplantation. However, the district health authorities carry the can for what goes on in the hospitals which they are responsible for running.
The Lords amendments to clause 1 have several other effects. They include special hospital authorities. These authorities are a legacy of the reorganisations of the NHS in 1974 and 1982. They mainly comprise certain teaching hospitals. There are eight postgraduate teaching hospital special health authorities, which were formerly run by boards of governors. They are the hospitals for sick children, the national hospitals for nervous diseases, Moorfields, the Bethlem Royal hospital and the Maudsley hospital, the national heart and chest hospitals, the Royal Marsden hospital, the Eastman dental hospital and Hammersmith hospital. There are various other special health authorities, including the Central Blood Laboratories Authority, the Health Service Supply Council, the National Health Service Training Authority, the Prescription Pricing Authority, the Rural Dispensing Committee, Rampton Hospital Review Board and the Mental Health Act Commission. Whether my hon. Friend the Member for Newbury realised that he had left all those out is a moot point, but they will now be included by these amendments.
Current DHSS guidance on complaints under HC81(5) applies to those special health authorities that provide a hospital service to NHS patients. The coverage of the Bill as amended would similarly include special health authorities that provide NHS hospital service.
Not all teaching hospitals are included in the group of special health authorities. The vast majority are run by district health authorities. I have had the privilege of being chairman of the Central Birmingham health authority which had seven teaching hospitals in the midlands, including the celebrated Queen Elizabeth hospital. The teaching hospitals in my area were not covered by special hospital authorities, although there was no technical difference between them. The postgraduate teaching at Queen Elizabeth hospital was similar to the postgraduate teaching at the hospitals to which I have referred.
It is of the utmost importance that our major teaching hospitals are not left out. When a person is acutely ill, when he has a rare condition that is difficult to diagnose or when he is an "interesting case" and liable to be discussed with students or written up as a research 635 exercise, the gap between the patient and the NHS staff, especially doctors, frequently grows too wide. The apocryphal comment sometimes attributed to such centres of excellence is, "The operation was a great success but the patient died." I swear that that comment has been made to me in the teaching hospitals for which I was responsible. That is not good enough. It is essential that the Bill be extended to all such authorities. When the patient is in such circumstances, it is even more important that he knows how to complain, that his family know how to complain on his behalf and that others associated with his care, including his general practitioner, are able to take up the problems. It is essential that a proper complaints procedures should exist and be made available to the patient.
On Second Reading, my hon. and learned Friend the Member for Mid-Bedfordshire (Mr. Lyell) said:It should be a requirement of every medical school that there is at least a significant period of formal training for young doctors as to how to approach the patient." — [Official Report, 22 February 1985; Vol. 73, c. 1381.]I completely agree. I found in the hospitals for which I was responsible that the people in a teaching hospital who benefited most from a properly conducted investigation of a complaint were the young doctors undergoing training. In the middle of all their studies — of anatomy, pharmacology, surgery, anaesthesia and the like — they are not taught well how to listen to their patients. The patient often knows best. As my hon. Friend the Member for Newbury said on Second Reading, he knew that he was allergic to penicillin. The doctors took absolutely no notice, and landed him in hospital for a further five weeks with a dangerous rash.
We all have constituents who have experienced similar difficulties of getting doctors, especially a young doctor, to take some notice of them and to take them seriously when they say where it hurts or what does not suit them, and how they can be better treated. If, by including special hospital authorities, we can take some small step towards avoiding those things happening, we will have done some little good.
§ The Parliamentary Under-Secretary of State for Health and Social Security (Mr. John Patten)
I am following my hon. Friend's argument closely. She is right when she says that patients must be given all possible opportunities to air their complaints against hospitals. Happily, the number of complaints is not too great. Does she agree that, while we are correct to concentrate on ensuring that patients can have their grievances ventilated, we are equally right to stress from time to time that patients also have a responsibility towards the hospitals in which they are treated, and that that responsibility often includes turning up on time, on the right day and at the right place for operations and outpatient treatment? The NHS suffers from a considerable waste of time when patients do not fulfil those responsibilities. There is a social contract between the patient and the National Health Service which both sides should fulfil.
§ Mr. Deputy Speaker
Order. We are in danger of getting back to a general debate on the Bill. We must concentrate on the Lords amendments which are before the House.
§ Mrs. Currie
I am glad to accede to what my hon. Friend says.
636 The third main effect of the amendment is to extend the Bill to Wales and Scotland. I was hoping that we would see some Scottish Members here this morning. It is a pity that there is none. It was always the Bill's intention that it should cover Wales, as clause 2(3) says. However, when my hon. Friend the Member for Newbury originally tabled the Bill, it referred to regional health authorities. It happens that there are no regional health authorities in Wales. The Principality is not covered by a single RHA which answers to the DHSS.
In England, there are 192 health districts organised into 14 regions. In Wales, there are nine health districts answerable directly to my right hon. Friend the Secretary of State for Wales. There is no regional tier. Therefore, 167 hospitals in Wales — that is the figure at 31 December 1983, and I should be surprised if the DHSS does not know of a few more since then — will be covered by the Bill if the amendment is accepted. It would clearly be unsatisfactory if we did not accept the amendment. We would then have two different systems —one for the English and one for everyone else.
§ Mr. Marlow
I take that point. There are ways in which Scottish law and administration are somewhat different from ours and there are good reasons for that. It suits the Scots, us and the Welsh. My hon. Friend has just said that there are 192 health districts in England. I am not sure how many regions there are; perhaps she can advise me. It seems to me a rather heavy job and responsibility for the Minister to have to contact each district. As he is getting in touch with them he has, to an extent, to supervise them to ensure that they are carrying out his instructions. If he makes that connection with the regions, he has a far narrower span of control which is more easily policed and effectively carried out. The regions should be allowed to do the job for which they are in place. My hon. Friend has not yet satisfied that argument.
§ Mrs. Currie
On the first part of my hon. Friend's question, there are 14 regions in England. As to the second part, that is what my right hon. Friend the Secretary of State for Social Services is in office for. I am sure that he recognises that he has that responsibility now, but it is not a statutory responsibility. That is what the Bill will make it. He may give directions, and HC(81)5 is a memorandum of guidance. The health authorities do not have to take any notice of it at all. The Bill, as amended, will insist that the Secretary of State gives those instructions and will then insist that the various health authorities take note.
The regional health authorities will not be excluded by the proposed amendment to clause 1. The Bill will simply refer to health authorities and therefore regional health authorities, district authorities and the other health authorities can be included.
§ Mr. John Patten
Is my hon. Friend aware that, as she said earlier, my right hon. Friend the Secretary of State, my right hon. and learned Friend the Minister for Health and myself regularly meet the chairmen of the 14 regional health authorities to discuss Health Service matters? It is not correct to say that we stop our discussions at that level on complaints or any other related issue, but through regional health authority chairmen we relate to district health authority chairmen. From time to time we meet the various district health authority chairmen in the different regions. There are more than 190 of them. On those occasions we have the opportunity to discuss issues such 637 as Health Service complaints procedures. It is important that the impression is not given that we talk only to the regional health authority chairmen on that point.
§ Mrs. Currie
That is right. I had the privilege of meeting my right hon. Friend the Secretary of State at such a meeting about three years ago.
My hon. Friend the Member for Northampton, North (Mr. Marlow) asked about Scotland. There is no good reason why Scotland should be excluded. There is every reason why Scotland should be part of the Bill. It was the intention of my hon. Friend the Member for Newbury on Second Reading. He is delighted to accept the Lords amendments which will extend the scope of the Bill to all parts of the United Kingdom. I understand that it is my right hon. Friend's intention to move Orders in Council that will make the Bill apply to Northern Ireland as well.
§ Mr. Marlow
I was not saying, forgive me, that Scotland should not be included. All I was saying was that sometimes Scottish legislation is different from that of England, for good reasons. My hon. Friend is beginning to frighten me. She said that there are 14 regions and 192 health districts. She is saying that the Minister will send out his diktat—let me put it more kindly than that: his ideas and instructions — to the districts and to the regions as to how the complaints procedure should be run. That seems like a recipe for chaos, because the chairman of the regional health authority and the general manager of the district health authority will both be waving their pieces of paper from the Minister. The region will be saying to the district, "We do not like the way in which you are doing it." The district will be saying to the region, "Ah, but I have it in tablets of stone from the Minister."
My hon. Friend should study any large organisation. The one that I know best from my background is the services. She will find that the general might tell the brigadier what to do, but it is up to the brigadier how he organises his colonels. If the generals start telling the colonels what to do, there is chaos.
§ Mrs. Currie
Far be it from me to answer for my hon. Friend the Minister, who I know wishes to intervene at some stage, but my understanding is that we will have a process of consultation after the Bill becomes law, if it receives the assent of both Houses. That will be an extensive process of consultation. The instructions that will be eventually issued by the DHSS to the health authorities in the Bill, as amended, will take into account comments that are made. I hope that they will produce something that is effective, and in view of the requirement for publicity, to which I shall come, will cope with all the problems identified by my hon. Friend the Member for Newbury and the difficulties faced by many of our constituents when they are obliged to go into hospital.
As there are no Scottish Members present, I shall deal with the matters relating to Scotland in a little more detail. Without the amendments, we should not be able to extend the Bill to the Scottish Health Service, and that would clearly be unsatisfactory. There are 15 health boards in Scotland — 12 for the mainland and three island authorities for Orkney, Shetland and the Western Isles. There are no districts. One tier, the health board, is appointed by my right hon. Friend the Secretary of State 638 for Scotland. The health boards are directly responsible to the Secretary of State for Scotland, and they cover 365 hospitals.
I have never been in a Scottish hospital. I hope that I never have need of one. My attitude is much the same to all hospitals in Scotland, England and Wales and everywhere else. Any Scottish colleagues who read the Official Report of today's proceedings should not feel discriminated against. The National Health Service owes an enormous debt to Scottish medicine, because there is no doubt that for many years Scottish teaching hospitals have been well ahead of many of their contemporaries elsewhere. Scottish medical schools have led the nation for a long time.
§ Mr. Martin M. Brandon-Bravo (Nottingham, South)
My hon. Friend is treading on dangerous ground there.
§ Mrs. Currie
I have no doubt that my hon. Friend is about to tell us that teaching hospitals in Nottingham will stand with those of the rest of the nation.
§ Mrs. Currie
As many of my constituents are treated there, I agree with him. However, we must recognise that under the Bill, without the amendments, Scottish hospitals would not be included. As the law stands, Scots people would not be assisted by the Bill, unless the House accepts the amendments that I have outlined. They would continue to have the benefit of only the 1977 law and the rather toothless circulars that were sent out as a result. They would continue to have a patchy service with regard to complaints, with some hospitals setting a high standard of producing leaflets telling people what to expect in hospital and how to take up matters that did not satisfy them, and some offering no advice whatsoever and continuing to act as though the patient were merely a case instead of a human being.
That is not satisfactory. By amending the Bill in this way, we shall ensure that patients in Scotland, along with those in Wales in the hospitals under the special hospital boards, as well as in England, will in future have a complaints procedure that is standard across the nation, compulsory and has statutory force. The procedure should ensure that events such as the horrific incidents described by my hon. Friend the Member for Newbury on Second Reading are investigated, put right and dealt with in a manner that can have the confidence and trust of all concerned.
England had 1,923 hospitals as at 31 December 1983. In total, therefore, 2,455 hospitals would be covered by the Bill if the amendments were accepted, 500 of them added by the amendments. Therefore, the amendments are of crucial significance to the many millions of people being treated in NHS hospitals.
An important element in the amended clause 1 would be subsection (1)(b). As amended, the clause will ensure that the Secretary of State will be obliged to require all health authorities to publicise their complaints procedure. My hon. Friend the Under-Secretary said on 22 February:A complaints procedure about which no one knows is of no use to anyone." — [Official Report, 22 February 1985; Vol. 73, c. 1389.]I heartily endorse that. This is the first time that health authorities are being told that they must inform patients 639 about some features of hospital life. It is the first time that my right hon. Friend the Secretary of State will have been obliged to lay that duty on them.
We should clarify one or two points about the amended clause. It does not give the patient the right to demand access to his files. It does not challenge hospital security on medical confidentiality. The British Medical Association had some reservations about that in the original Bill. Those matters are being fiercely debated elsewhere, not least later this morning. No doubt the Bill will add to that. However, that is not the purpose of the Bill and the subsection. It says that every health authority must tell patients in all the units for which they are responsible what to do if they are not happy with any aspect of the service that they receive. Up to now it has been said that they "should" tell the patients. Under the Bill as amended, that will be changed to "must". That is a major step forward. It will no longer be possible for the patient to be ignored. It is a most important part of the patients' charter which my hon. Friend the Member for Newbury published last September, and which attracted so many favourable comments at the time. In the circulars sent out under the previous legislation, the Secretary of State has suggested that each health authority should produce a leaflet. The appendix to HC(81)5 made some rather heavy-handed suggestions of what might be included. Paragraph 7 of the circular says:Information booklets should be given to hospital in-patients including, where possible at some suitable time, those admitted through accident and emergency services. These 'hospital booklets' should also be available to patients, on request, in hospital out-patient departments.Note the word "should", not "must". We shall put in "must" as th Bill goes through both Houses and enters into law. Suggested paragraphs for use in the booklets for patients are contained in appendix 1 to memorandum HC(81)5, which reads:If you are seeking information when in hospital, the ward sister will generally be the person to speak to in the first instance"—
§ Mr. Deputy Speaker
Order. The hon. Lady must relate her remarks to the amendments before the House and not go into a general discussion about the Bill.
§ 10.45 am Mrs. Currie
I apologise, Mr. Deputy Speaker. I wish to point out merely that, without the amendments, the Bill would not work. It would simply reiterate and re-establish the existing rather unsatisfactory procedure.
§ Mr. John Patten
Having been correctly called to order once before by you, Mr. Deputy Speaker, I am fearful of being out of order again. I am sure that you will correct me immediately if I stray over the bounds.
The amendments relate to procedures south and north of the border, and my hon. Friend the Member for Derbyshire, South (Mrs. Currie) is speaking to them very clearly. Does she agree that one of the issues raised in the circular to which she referred is the most important issue of monitoring, which is covered in paragraph 8? Authorities will have to introduce, both north and south of the border, systematic and effective methods of reviewing complaints. It is no good just having leaflets available. It is important to have the complaints themselves monitored and reviewed systematically.
§ Mrs. Currie
My hon. Friend is absolutely right. Without such a monitoring system, the complaints 640 procedure has no purpose. It will serve merely to air people's grievances and not correct the problems that led to the grievances in the first place.
My experience supports my hon. Friend in that. I was a member of the old Birmingham area health authority — a teaching authority, which has since been abolished — in the days when the circular to which my hon. Friend refers was published. We did our best to implement the circular, but, with the best will in the world, we had other priorities at the time, such as getting staff in post, particularly on the reorganisation of the Health Service. There are still hospitals in the group for which I was responsible that do not have such leaflets. It is worth emphasising the importance of ensuring that patients all over the country receive appropriate advice on how to complain. The amendment will ensure that that happens.
We had most fun at the Birmingham maternity hospital, a teaching hospital, where I had been a patient twice, in 1974 and 1977, when I had my two children. The hospital had an excellent leaflet. As a patient, I was able to make use of it. Subsequently, as chairman of the health authority responsible for the hospital. I was able to improve it, particularly by choosing better photographs. It may sound trivial to tell a pregnant girl to bring her toothbrush and some change for the telephone, but I assure the House that it felt like good advice when we woke up in the recovery room. We were grateful.
In future, as I understand it, failure to produce an appropriate leaflet will be grounds for complaint, too. I hope that the health authorities do not regard that as too much of an imposition. They should always remind themselves that they run the hospital not for the doctors, not for the convenience of the staff, not alone for the greater gains of medical research or for the reflected glory of being involved with Britain's best-loved institution, but for the patients. The patients are not a nuisance to he kept quiet—they are not a collection of statistics. That is an attitude that we must eradicate.
Amendment No. 4 is concerned with the Health Service commissioner — [Interruption.] There are eight amendments, and as the Bill had its Second Reading on the nod none of those matters was debated then. It is appropriate that we give proper consideration to them at this time. I hope that the House accepts that.
Amendment No. 4 improves clause 2 by ensuring that it extends to Scotland and thus covers the whole country. I accept that this is not the place to debate the role of the ombudsman — I do not intend to do so — but it is important that we do not hamper his work in any way. He was set up under the National Health Service Act 1977, and section 116 limits his powers in the following way:Except as hereafter provided, a Commissioner shall not conduct an investigation under this Part of this Act in respect of any of the following matters—
That is very specific.
- (a) any action in respect of which the person aggrieved has or had a right of appeal, reference or review to or before a tribunal constituted by or under any enactment or by virtue of Her Majesty's prerogative, or
- (b) any action in respect of which the person aggrieved has or had a remedy by way of proceedings in any court of law".
The ombudsman is a most important part of the overall complaints procedure. He deals with about 120 cases a year. He can take up any issue, whether it has a medical content or not. Having been on the receiving end, as a 641 health authority chairman, I know the thoroughness and fairness of his work. He and his staff do a great service to the people and the NHS.
Without the amendment, the ombudsman would be rendered helpless, especially in Scotland. He will effectively be out of a job if he is specifically precluded from operating when any other course of action is open to the complainant, whether through legal action, a tribunal, an appeals procedure or whatever. Over time, as the health authorities obey the instructions set out in clause 1 and introduce a complaints procedure and tell people about it, the ombudsman may be unable to take up cases because the Secretary of State and the health authorities have pre-empted him.
§ Mr. Marlow
I wonder whether my hon. Friend's constituency experience has been similar to my own. Aggrieved constituents have sought my assistance to put them in touch with the ombudsman but in practice he has been able to do very little for them. As often as not, the resolution of their worries has been outside his competence. That is why the Bill and the amendments are so important.
§ Mrs. Currie
Some of the difficulties of dealing with complaints and of getting people to complain correctly and adequately to the right person at the right time were dealt with in the debate in another place. My hon. Friend raises a most important point. Part of the problem is a matter of attitudes. It is surely possible to advise people of the complaints procedure before they go to hospital for planned surgery or treatment. They should receive a leaflet in advance including advice on what to do if they are unhappy or have questions to ask. That advice should cover not just the patient, but his family, his general practitioner, his other medical advisers, and so on. If the patient has that information before he goes to the hospital he is likely to ask the appropriate questions at the right time and the people treating him are more likely to regard him as a human being whose fears and anxieties have to be allayed, not ignored. We must make that point very firmly today.
As for the powers of the ombudsman, it is worth reflecting that more than 5 million outpatients and, I believe, more than 600,000 inpatients are treated every year. Under the guidance of the Ministers concerned, record numbers of patients are being treated, but there are only about 9,000 written complaints per year which have to be investigated, and the ombudsman deals with only 120.
§ Mr. Deputy Speaker
Order. The hon. Lady said that she did not intend to talk about the ombudsman's duties. She must deal with the amendments.
§ Mr. Marlow
On a point of order, Mr. Deputy Speaker. If the ombudsman is prevented from fulfilling the purpose for which he exists and from meeting the needs of complainants, the question whether the situation is best dealt with by the Minister issuing instructions to regional health authorities or directly to district health authorities would seem to be germane to the debate. To that extent—
§ Mr. Deputy Speaker
Order. That is an interesting question, but it is not one for me. It is for the Chair to decide whether a matter is in or out of order.
§ Mrs. Currie
With regard to amendment No. 4, the law is a little hazy. It is not clear whether the ombudsman would be ruled out of court by the Bill as it stands, but we do not intend to find out the hard way. The clause is especially defective in relation to Scotland. In this context, we are pleased to note and to support their Lordships' amendments, which will ensure that the ombudsman's work in Scotland will continue on exactly the same basis as in the rest of the United Kingdom and that the benefits to which my hon. Friends have referred will be assured.
In my view, the Lords amendments greatly improve the Bill's effectiveness and are to be welcomed. Under the existing legislation it was possible for my hon. Friend the Member for Newbury to visit three different hospitals without being given any information about complaints procedures and to be a patient for months on end without realising that the Secretary of State had written to all health authorities years earlier advising them to set up a complaints procedure and to tell everyone about it. Indeed, other patients turned to him as a Member of Parliament to take up complaints on their behalf. In other words, the powers that be were able totally to ignore the myriad circulars sent out and the advice of the Secretary of State to the effect that they should have a complaints procedure. I am sure that my hon. Friend the Member for Newbury was surprised to read all those circulars and no doubt that was the basis of his determination to make the procedures statutory and mandatory so that no hospital could make the excuse that it did not have time and had not bothered to establish the necessary procedures.
This little Bill, with these important amendments, will be a step forward in patient care. My hon. Friend the Member for Newbury has asked me to thank all the staff at the DHSS for their assistance at all stages of the Bill. I also thank them for their very effective briefing to me in recent days. My hon. Friend has also asked me to thank all hon. Members who have assisted in the passage of the Bill in both this and the other House, especially the Under-Secretary of State, my hon. Friend the Member for Oxford, West and Abingdon (Mr. Patten) who must be singled out for special praise as he has taken a close personal interest in the Bill.
Finally, I am sure that the whole House will join me in thanking my hon. Friend the Member for Newbury for bringing forward the Bill. We congratulate him on his success in the ballot and we recognise the courage and dignity with which he presented his case and with which he continues to combat his illness. We wish him good health and we hope that he will never have occasion to set in train the procedures that he has established in the Bill.
§ Mr. Marlow
The Bill is very welcome, but it is important that it should be coherent and that the amendments should be properly considered. As my hon. Friend the Member for Derbyshire, South (Mrs. Currie) has said, it is important to include Scotland and Wales—and potentially Northern Ireland as well—so that the whole United Kingdom can benefit from this boon.
At present, the Minister has power to issue instructions but is not required to do so. In the light of my experience of real constituency problems in this area, I am anxious that the Minister should give the instructions to the right people. The House is frequently concerned with human rights issues, but what happens in the Health Service is not just a question of human rights — sometimes it is a matter of life or death. Those who survive the sad death 643 of a loved one are rightly deeply concerned about the circumstances. Sometimes, they fear that something which should have been done was not done or that the concerns of the bereaved have not been properly considered. A constituent whose mother died in a hospital outside the area sought an investigation into the circumstances in the belief that the right treatment had not been given. That may well have been so. The doctors do a tremendous job, but to err is human and mistakes happen. We must consider how complaints of that kind are best investigated in the light of the real burdens of sadness and distress that many of our constituents face.
Where do we go from here? Do we, as the Bill suggests, require the Minister to send to every one of the 192 district health authorities in England an elegantly phrased edict — knowing my hon. Friend the Under-Secretary of State, it will be both elegant and eloquent —as to how they should proceed?
In Northampton, but not in my constituency, a young girl was recently misdiagnosed and, sadly, died of appendicitis. There was a great deal of publicity and anxiety about the case, and people feel that questions have not been answered.
Is my hon. Friend the Minister required, in regard to the complaints procedure, to pass his instructions to district health authorities or to regional health authorities? If he gives instructions to DHAs, that means that he is responsible for ensuring that they are carried out. If he gives his instructions to RHAs, he has a proper responsibility to ensure that they are carrying out his instructions, but there are 14 of them. Some of us have been in the Army, industry and management and have heard about something called the span of control. The ideal span or number under a chief is eight. I am aware that my hon. Friend is beyond the realms of normal human beings. He is a gifted and gracious man and I am sure that he could cope more than adequately with a span of control of 14. Nevertheless, I wonder whether, in his heart of hearts—for, despite his great skills, my hon. Friend is a modest man — he feels that he could administer and supervise 192 DHAs.
§ Mr. John Patten
I am naturally loth to intervene in this agreeable flood of compliments, and I hope that my hon. Friend will not feel that my intervention should cut him off from continuing in that vein. Does my hon. Friend agree, however, that there are great difficulties in Health Ministers involving themselves in detailed management, including management of complaints procedures, in 192 DHAs? Does he further agree that it is therefore important that we should issue general instructions to all health authorities, as my hon. Friend the Member for Derbyshire, South (Mrs. Currie) said, in so doing trying not to intervene unnecessarily beyond the span of control in the running of those 192 DHAs, or that we should approach the task through our regular contacts with the 14 RHAs?
§ Mr. Marlow
I am beginning to be reassured. Perhaps I might bore the House with my experiences in uniform. When I was in the Army, we had things called Defence Council instructions and Army Council instructions, which were sent throughout the service to every unit, however small, The War Office, as it then was, and the chiefs of staff were not directly responsible for or in control of each unit. I should be worried if I thought that my hon. Friend had to manage the 192 DHAs directly.
644 It is instinctive for a professional body to look after its own. Disasters are bound to occur in the Health Service, and when they do there is a closing of ranks. There is little controversy about that. If prime responsibility for dealing with the complaints procedure rests within the DHA, responsibility will lie precisely where the ranks will close. It could be advantageous for responsibility to be vested in the higher tier. With responsibility in the lower tier, internal politics and knowledge of individuals—
§ Mr. John Patten
I am a bit worried about what my hon. Friend is saying. Is he entirely ignoring the introduction of the new management structure, the appointment of the general manager, Mr. Victor Poge, general managers for RHAs and for DHAs and the appointment of managers at units of management level? Does my hon. Friend agree that that provides a line of management which will enable complaints procedures to be dealt with managerially and outwith any closing of ranks, which my hon. Friend suspects might happen?
§ Mr. Marlow
My hon. Friend says that I suspect it might happen. I am not suspecting anything in a nasty way; I am reflecting on human nature and how things happen in organisations and institutions. The new management structure is a tremendous step forward. Like him, I believe that it will be massively helpful for the Health Service as, at last, there will be somebody at each level with whom the buck will stop.
We have a police complaints procedure, and one of the criticisms of it is that it is in-house. The police are involved with people's civil liberties. The Health Service—
§ Mr. Deputy Speaker
Order. Will the hon. Gentleman tell me to which amendment he is addressing himself? I see no reference to these details in the amendments.
§ Mr. Marlow
The thrust of the amendments is the inclusion of all health authorities as opposed to just regional health authorities. I am seeking justification for my hon. Friend sending his instructions to each hearth authority rather than, as the Bill originally provided, to RHAs.
§ Mr. Deputy Speaker
Order. The hon. Gentleman must address himself to that argument. I have not heard it deployed yet.
§ Mr. Marlow
There is anxiety that the police complaints procedure is in-house. I am saying that we should be more careful in the Health Service because we are dealing with matters of life and death. As we are having a complaints procedure, we must ensure that it operates at the proper level. I feel instinctively that the main responsibility could quite properly lie with the RHA, although I accept that, as with Army Council instructions and Defence Council instructions, it is right for my hon. Friend to send his eloquent, elegant and well-written instructions to every health authority in the realm.
I am sure that my hon. Friend will have a good reply to that question. What is the best method for ensuring that my hon. Friend's instructions are carried through?
§ Mr. John Patten
Ultimate responsibility lies with my right hon. Friends the Secretaries of State for Social Services, for Wales and for Scotland. Responsibility for the complaints procedure therefore devolves downwards through the health authority network and management structure in the three different countries. I do not see that 645 my hon. Friend has a point to make, because the line of responsibility goes up to the three Secretaries of State involved.
§ Mr. Marlow
I respect my hon. Friend's point, and I am sure that later he will provide further details that will satisfy even my mind.
In the NHS my hon. Friend has a management structure, just as ICI, BP, Shell, and Guest, Keen and Nettlefold have a management structure. If, as a supplier or receiver of goods, one had a commercial complaint against any of those firms and wrote to the chairman or managing director, there would be a tendency within the firm concerned to close ranks. That is why we have consumer protection legislation. Splendid though the general managers in the Health Service are, if complaints are made relating to their area, are they the best people to operate the complaints procedure, or would it be better done at a higher level? That is the question that I leave with my hon. Friend.
§ Mr. Brandon-Bravo
In case the crowded Benches in the House this morning should give the public at large the wrong impression, I should like to make a brief contribution in support of the Bill in general and the amendments in particular.
In the 17-line explanation of the purpose of the Bill there are 19 words that we are considering this morning to which the amendments are specifically addressed. Those words are:to establish and publicise, as respects each of the hospitals they are responsible for managing, a procedure for dealing with complaints made by, or on behalf of, patients at such hospitals.Given that that is the kernel of the Bill, I do not think that anyone could reasonably suggest that the amendments do anything but emphasise and underscore those objectives. It is right and proper that we should have one law in the United Kingdom to deal with a hospital complaints procedure. Many of us — even after two years in this House—still cannot come to terms with the fact that we do everything three times — first for England and Wales, then for Scotland and then for Northern Ireland. The public must also be puzzled that we have to multiply our legislation in that way. If the Bill simplifies the procedure, I am sure that that is all for the good.
I do not think that the analogy of generals bypassing their brigadiers and talking to their colonels, in the manner suggested by my hon. Friend the Member for Northampton, North (Mr. Marlow) is fair. Indeed, if that is how they operate, I can understand why the management structure of the services was in such a mess in the first world war. I think that the point that my hon. Friend was trying to make was that perhaps our worthy colleagues in the DHSS should talk only to the regions and not to the districts.
There are only 14 regional health authorities. My authority is Trent. They are vast organisations. The public might think it more appropriate that the Minister should write direct to the district councils, which are nearer to the grass roots and much more in contact with local people and local Members of Parliament. The Trent region stretches from Sheffield in the north to Leicester, or even further south. Those vast regional authorities employ thousands of staff.
§ Mr. John Patten
My hon. Friend is pressing me, as I have been pressed hard by my hon. Friend the Member for Northampton, North (Mr. Marlow), on the question of devolved responsibility. Will my hon. Friend accept from me that it is our intention, should the Bill become law, that while all health authorities will be given identical instructions, we regard our relationship as being initially with regional health authorities on the general conduct of business, of which the complaints procedure is but one part, and thence onwards to the district authorities, as laid down by law?
§ Mr. Brandon-Bravo
I accept my hon. Friend's point without reservation. I am sure that the Bill will be accepted in its present form. I welcome and support it.
§ Mr. Clive Soley (Hammersmith)
In the unavoidable absence of my hon. Friend the Member for Holborn and St. Pancras (Mr. Dobson), I confirm that the Opposition welcome the Bill as a step in the right direction.
Congratulations are due to the promoter, the hon. Member for Newbury (Mr. McNair-Wilson), who is not very well and cannot be here today, and to the hon. Member for Derbyshire, South (Mrs. Currie). We must not only congratulate the hon. Lady but you, too, Mr. Deputy Speaker, for your forbearance during a speech lasting 40 minutes in which Scotland was referred to only half a dozen times, when every amendment relates to Scotland. I am not sure who deserves most congratulations—you for your forbearance, Mr. Deputy Speaker, or the hon. Lady for getting away with it.
The hon. Lady also deserves congratulations for striking fear into the heart of the hon. Member for Northampton, North (Mr. Marlow). That is not an easy thing to do. Perhaps it is a forerunner of what may happen when we deal later with the Sexual Offences Bill.
The Hospital Complaints Procedure Bill is a step in the right direction and we commend its extension to Scotland. We do not need to have separate legislation for each part of the United Kingdom; that is neither necessary nor desirable. The fundamental argument is that there is a need for a proper complaints procedure in the NHS, and that it should extend to all parts of the United Kingdom.
It is regrettable that there is still no proper democratic system for running the NHS, and that matter needs to be examined carefully. From time to time I receive complaints which can be taken up with the area health authority or the regional health authority and I do not always receive satisfaction, despite the good intentions of those involved. In many cases there is no proper way in which to follow up complaints. I know that from time to time the Minister receives letters of complaint about the procedure and he must appreciate that it is not effective.
I should like to see the involvement of local councillors who are directly elected. I commend the efforts of Councillor Hugh Thompson in my own area. He has started the first advice surgeries for people with complaints about treatment in the NHS. They are held on a regular basis so that people have someone to whom they can air their grievances.
I shall be writing to the Minister in due course on another matter which does not fall under the legislation before the House. There are plans in Hammersmith, which is a special health authority area, to close seven wards for the month of August. I have already received several 647 complaints from people who will not be able to enter hospital and will suffer extra pain because of the month's delay. The reason for closing the wards is simply to save £100,000. That is the nature of the problem, yet a few moments ago the Minister intervened to say how much the Government were spending on the NHS. The public recognise that there is a real undermining of the NHS taking place and a deterioration in the services provided.
The Bill is a small but important step towards a proper complaints procedure, and will put firmly on the statute book a recognition of the principle that some form of national complaints procedure is required. But sooner or later the House will have to examine in more detail the administration and control of the NHS on behalf of the people who make use of the services. We should also consider whether it should be separate from local government.
§ Mr. John Patten
Our interesting short debate has been notable for the fact that the affairs of Scotland and Wales have been debated without many hon. Members from those countries being present to consider the amendments.
I join the hon. Member for Hammersmith (Mr. Soley) in paying tribute to my hon. Friend the Member for Newbury (Mr. McNair-Wilson). I described him during Tuesday's debate on the NHS as our valiant hon. Friend —and valiant he is. I know that he wished to be here today, but is unable to be present because he is having hospital treatment. He certainly intends no discourtesy to the House by his absence. He has an adequate and elegant substitute in my hon. Friend the Member for Derbyshire, South (Mrs. Currie).
The amendments have been fully examined. Most involve the extension of the Bill to other parts of the United Kingdom, though there are also important issues involving the Health Service Commissioners.
Clause 1 lays a duty on the Secretary of State to exercise his existing power to give directions to health authorities requiring the establishment and publicising of specified procedures for dealing with complaints in all NHS hospitals. Lords amendment No. 1 extends the list of authorities to which such directions will have to be given to district health authorities in England and Wales, health boards in Scotland and special health authorities wherever they are located. That provision greatly exercised the mind of my hon. Friend the Member for Northampton, North.
My hon. Friend the Member for Derbyshire, South went into the amendments in detail and I complimented her on her speech, which I followed with great care. We are sometimes a little too free with our compliments in the House, just as we are sometimes a little too free with our abuse of each other. When I read what I had said about the hon. Member for Oldham, West (Mr. Meacher) at the end of Tuesday's NHS debate, I was a little ashamed of myself. I referred to his possible future as a Front-Bench spokesman and used the words of a well-known first world war song to express my regrets that the hon. Gentleman might not be on the Opposition Front Bench in the future. Perhaps I went a little far and, therefore, perhaps I have been a little restrained in my compliments to my hon. Friend the Member for Derbyshire, South.
As drafted, the Bill covered only regional health authorities and therefore applied only to England. There are no regional health authorities in Scotland or Wales and it is now intended that the Bill should apply in both those 648 countries. My hon. Friend the Member for Nottingham, South (Mr. Brandon-Bravo) complained about our legislative diversity, but the countries that make up the United Kingdom express that diversity in their organisation of the NHS and in other ways, and we have to make appropriate legislative provision for them. However, I understand why my hon. Friend feels that the process takes up much of our time.
Regional health authorities in England are not directly responsible for the management of hospitals. Lords amendment No. 1 will ensure that the directions to be given are addressed to all authorities that have hospital management responsibilities. I made that point two or three times during interventions in the speech of my hon. Friend the Member for Northampton, North. I am grateful to him for having given way because we had a useful debate about the responsibilities of the various health authorities.
Lords amendment No. 1 extends the Bill to Wales and Scotland, but not to Northern Ireland. In an enjoyable and all too brief speech, my hon. Friend the Member for Nottingham, South told us his views on legislative diversity and said that he always liked to see one law for the United Kingdom. For two and a half years I was Under-Secretary of State for Northern Ireland and I was often here at two o'clock or three o'clock in the morning debating Northern Ireland issues. I know that if the right hon. Member for South Down (Mr. Powell) were here today, he would give a "Hear, hear" to the sentiments of my hon. Friend the Member for Nottingham, South.
The amendments are technical, but they are important to Wales and Scotland. They are designed to ensure that the Bill can have its intended effect, and the Government support them wholeheartedly. For my right hon. Friend the Secretary of State to be able to make directions which will bite on the relevant authorities, the Bill must specify the authorities correctly. As originally drafted, it did not do so.
Clause 1 refers only to regional health authorities. As has been pointed out time and again in the debate, those authorities exist only in England. There is no regional tier of management alone in Scotland and Wales. Moreover, as my hon. Friend the Member for Northampton, North mentioned in his powerful speech, regional health authorities in England do not directly run hospitals. That is the job of district health authorities and of special health authorities to which my hon. Friend the Member for Derbyshire, South referred at length, though I should have liked her to develop her comments on special health authorities, because they are neglected bodies. I fear that all too often the public do not appreciate the relationship between district, special and regional health authorities, particularly in London.
In Wales, district health authorities are the relevant authorities, while in Scotland the health boards run hospitals. The amendment would include those authorities in the Bill. In addition, to the extent that regional authorities are responsible for elements of the management of hospitals, the Bill will bite on them. My hon. Friend the Member for Northampton, North referred to that. I see that he has moved to the Opposition Front Bench; I hope that that is only a temporary aberration.
The Bill was originally intended to apply only to England and Wales, but the Government and my right hon. Friend the Secretary of State for Scotland, who has had to give his assent. have agreed that it should apply north of 649 the border as well. My hon. Friend the Member for Newbury has said that he wishes the Bill to be extended as widely as possible and the Government support that objective. There has been no dissenting voice from England, Scotland or Wales during the debate.
Lords amendment No. 2, which is also a technical amendment, will include a necessary reference to the legislation governing health boards in Scotland. It will permit equivalent Scottish legislation to be applied in the issuing of directions to health boards north of the border. I commend the amendment.
It is important briefly to consider amendment No. 3, which provides for references to health boards in Scotland to be included in the Bill. It is consequent upon the previous two amendments and ensures that the Scottish health boards are referred to in the Bill where necessary. The Government support the amendment. The issue was of great concern to my hon. Friend the Member for Northampton, North, who, I am relieved to see, is now crossing the Floor, back to his rightful place below the Gangway on the Conservative side of the Chamber. I was worried to see him on the Labour Front Bench consulting the hon. Member for Hammersmith.
Amendment No. 4 is interesting and ensures that the Health Service Commissioners are not precluded from carrying out investigations, under part V of the National Health Service Act 1977, into cases that have been investigated under any procedures laid down in the directions to be made by the Secretary of State in pursuance of the duty conferred on him by the measure. Those directions should not in any way interfere with the work or the jurisdiction of the Health Service Commissioners. The amendment makes equivalent provision for Scotland, which the Government wholehear-tedly support.
The offices of the Health Service Commissioners, which will be affected by the amendment, provide an important avenue for an independent review of complaints. Certain criteria must be met before the Commissioners can investigate, but they are not onerous and are intended to ensure that justice is done to both the complainant and those complained against. Although my hon. Friend the Member for Derbyshire, South made that point, I am sure that the House regrets that she did not speak at greater length on it. The Bill is not intended to restrict the Commissioners' powers, and it is important that that is widely recognised.
A strict interpretation of the legislation governing the Commissioners' activities may well have caused 650 problems. Therefore, section 116 of the National Health Service Act 1977 prevents any investigation of an action where the complainant has a right of appeal, reference or review by a tribunal constituted under any enactment. If the section were not specifically exempted, it might bite on the procedures to be laid down as a result of the Bill. That is not the intention of the Bill and, therefore, clear provision is made to allow the Commissioners to investigate complaints and to exempt the Commissioners' investigations both north and south of the Border.
Amendments Nos. 5 and 6 are technical amendments to ensure that the interpretations of the provisions applying to Scotland are included. Just as there are different legislative provisions north and south of the Border, so Scotland and England are at times divided by legal language. If my hon. and learned Friend the Member for Perth and Kinross (Mr. Fairbairn) were present, he would say, "Hear, hear," to that, and stress that it was desirable. The amendments ensure that the Bill will be understood on both sides of the Border, and include necessary references to Scottish law. The Government support them.
Amendment No. 7 refers to clause 2(3) and deals with the extent of the Bill. It deletes references in the Bill which exclude Scotland. The amendments that we have so far discussed render redundant the exemption of Scotland from the Bill, and this amendment brings Scotland fully within the Bill's scope.
Amendment No. 8 deals with the long title, which it is important to get right. At present it refers only to regional health authorities, and the amendment provides for the inclusion of references to district and special health authorities in England and Wales, and health boards in Scotland. As drafted, the long title reflects the previously limited scope of the Bill, but thanks to the advocacy of my hon. Friend the Member for Derbyshire, South we have extended that scope. The amendment ensures that the long title accurately reflects the amended Bill's contents, and parallels the wording that has been agreed for clause 1(1) in its references to health authorities in England and Wales and health boards in Scotland. We support the amendment.
I hope that the House will approve the amendment and that the Bill will pass into law. My hon. Friend the Member for Newbury, ably and strongly supported by my hon. Friend the Member for Derbyshire, South, has advanced the rights of patients to have complaints against hospitals thoroughly investigated within and by the NHS. The Government wholeheartedly welcome the spirit in which the Bill was introduced in February, and hope that the measure will eventually pass into law.
§ Question put and agreed to.
§ Lords amendments Nos. 2 to 8 agreed to.