§ '( ) (1) A Community Health Council shall be constituted for each District in Wales and
- (a)shall assume in its area, such responsibilities and duties in relation to health matters and services as are undertaken by the existing Community Health Councils;
- (b)shall be invited by the relevant county council to participate in the formulation of Community Care Plans as specified in section 43 of this Act;
- (c)shall seek to co-ordinate the views of relevant voluntary and charitable groups, the recipients of community care and other health services and their carers, and to convey those views to the appropriate county and district councils, district health authorities, special health authorities and the Health Service Directorate of the Welsh Office as appropriate;
- (d)shall monitor the delivery of health and community care services to people in its area, including the complementary provision of social, health and housing services;
- (e)shall issue an annual report on its work;
- (f)shall receive reports from any Independent Inspection Unit to be established by the Secretary of State as may report on services in its area;
- (g)shall issue reports on specific topics from time to time as it sees fit;
- (h)shall be authorised to hold joint meetings to consider such matters of common interest within the terms of paragraphs (a) to (e) above as are set out in the notice convening the meeting and may seek to reach a common view on such topics in accordance with Standing Orders agreed by the constituent Community Health Councils and approved by the Secretary of State.
§ (2)Community Care Services in this section shall be those defined in section 43 of this Act.
§ (3)Districts in this section shall be co-terminous with the areas served by District Councils in Wales.
§ (4)Community Health Councils established under this section shall be treated as successor bodies to the existing Community Health Councils under regulations to be established by the Secretary of State.'.—[Mr. Michael]
§ Brought up, and read the First time.
§ Mr. Alun Michael (Cardiff, South and Penarth)
I beg to move, That the clause be read a Second time.
The new clause aims to offer the individual, that is the patient, the consumer and the community in Wales, a real voice in the Health Service of the future. It aims to protect the interests of elderly, disabled and mentally ill people who are to be cared for in the community. It is logical to give the community health council a role in the two parts of the Bill which affect Wales. Health provision and care in the community must be complementary if the new system is to work.
The care in the community proposals need careful monitoring. Otherwise, they may well prove to be a recipe for neglect in the community, which is the genuine fear of all of us who served in Committee. The Government will simply blame housing authorities, social services authorities and the voluntary sector for any failures, although there is grave doubt whether those bodies will be given the resources that they need. Accusations will fly backwards and forwards unless there is a separate local and comprehensive system of monitoring. The CHC has been just such a watchdog in the Health Service and it would be appropriate for the new CHCs to have an expanded role on a more local level to cover care in the community.
The CHC's traditional role in the NHS will become even more important if the Bill becomes law because there will be a need for a local monitoring system to ensure that the Government's promises are kept. Ministers have rejected our criticisms of the indicative drugs budget, practice budgets and the finance-led planning of their new health system. They claim that no patient will lose out, will be struck off the list or go without treatment. If their claims are genuine, they will want the local, effective, monitoring system outlined in the new clause.
I am surprised that the Secretary of State for Wales and his junior Minister have not responded to our suggestion 311 that the new clause should be accepted as a positive and constructive measure and written into the Bill without the necessity of a long debate.
The new clause sets out to promote the role of CHCs in Wales in several particular ways, based on the special needs of Wales. First, it would enhance the duties of CHCs to advocate on behalf of the users of health and community care services. Secondly, it would co-ordinate such services and discussions about them, particularly community care, at local level. Thirdly, it would monitor such services from the consumer's view and, fourthly, it would communicate its findings to the users of such services at community level.
I emphasise the nature of special needs in Wales. Wales has different and more acute health needs than England. First, more people in Wales develop chronic conditions than in England, particularly young children. Secondly, the male mortality rate is higher in Wales than in England, particularly for heart disease, cerebrovascular disease, bronchitis, emphysema and asthma. The prevalence of disability in Wales is over 20 per cent. higher than in England—even higher than the most severely disabled categories. It seems that the Government do not adequately recognise that.
Many other statistics prove the point, while the reasons for the relatively poor health of people in Wales are well known. They owe a great deal to the industrial and economic history of the Principality. Those differences in health needs call for differences in health care provision. Proportionally more people in Wales visit their doctor more often than in England—particularly young children and people over retirement age. Fewer people in Wales have chosen to make use of private medical insurance. Fewer elderly people in Wales go to make use of private sector homes in retirement, and others are not in a position to exercise any such choice.
A significantly higher proportion of prescriptions in Wales are exempt from payment by virtue of their recipients' financial circumstances than is the case in England. Some important initiatives have taken place in Wales. Heartbeat Wales, launched on St. David's day in 1985, has already achieved much by working with many sectors of the community, including food retailers, industry and the unions. The Lose Weight Wales campaign and several television series have played their part, but the people of Wales, in many unique ways, rely on their National Health Service.
The new clause is partisan in the best sense of the word. It is a serious attempt to maintain the special relationship between the people of Wales and the statutory provision of health and community care. Before moving on to consider the substantive provisions of the clause, I remind the Minister of the commitment that he made elsewhere that he would report as soon as possible on the operation of the joint Welsh Office—National Health Service working group studying the changeover from the steering committee on resource allocation in Wales—the SCRAW formula, which is currently used to determine resource allocation—to the as yet un-named future formula for Wales. The formula contained in the White Paper "Working for Patients" has already been described by the Chartered Association of Certified Accountants as one whichemphasises simplicity possibly to the detriment of equity"—312 in the same way as the poll tax perhaps. Simplicity to the detriment of equity characterises the Government's proposals for the community health councils in Wales.
The unique health needs of Wales, the wholly different service delivery structure—I remind hon. Members that Wales has no regional health authority—and the huge internal diversity of population density, persuaded preceding Ministers to develop formulae that allowed investent related to Welsh needs, rather than a statistical abstract devised in England. We should ensure that the same is the case in the future. We have already seen how standard spending assessments for social services spending relate to the needs of particular communities. We do not want that disaster to be visited upon the elderly, the infirm and the sick of Wales once again.
At present there are structural differences in the Health Service in Wales because it has no regional authority. The Welsh Office fulfils the function of that authority. Therefore, in many cases the Secretary of State is judge and jury in his own decision-making.
Wales has several community health councils per district health authority at the moment—two in South Glamorgan, and three or four in most other counties—whereas in England there is one per district health authority. That is an inappropriate structure for Wales. The district health authorities in England cover a smaller area than in Wales where, except in Pembroke, the authority covers the whole county.
The Welsh Office proposes to merge the present community health councils into one per district health authority—one for Mid Glamorgan, one for Clwyd, one for Powys and so on. The maximum number of members for a CHC will be the same as at present—24—so representation will be reduced in every county in Wales, and that is completely unacceptable.
The only argument that the Welsh Office has put forward in favour of a single CHC per district health authority is that it would speak with a single voice on behalf of consumers in the health authority area. Colleagues may reflect that the interests of consumers in Merthyr and Bridgend or Rhyl and Wrexham might be best served by having different voices that are attuned to the specific needs of those communities and the people who live in them.
The suggested parallel with England—where there is one community health council per health authority area—is inappropriate because the population per community health council is much greater in Wales, on the present pattern of community health councils, than is the case in England. It would be totally inappropriate and far worse were the Government's proposals to be followed.
The proposal in the new clause is threefold. First, the number of community health councils should be increased to one per district council area in Wales, thus allowing a strong and more local voice to be heard on behalf of communities. Secondly, a mechanism should be created to allow a joint meeting or a representative meeting on a district health authority-wide basis—again, apart from Pembroke, that means on a county-wide basis—to consider matters on which community health councils want to speak with one voice because they believe it to be in the interests of consumers. Such matters could include the location of district general hospitals and common aspects of the 10-year health authority plan, where it is appropriate that communities throughout the county area should come together to debate the structure.
313 Thirdly, the role of community health councils should continue to cover Health Service matters but should be extended to cover care in the community, including a joint provision that involves health, social services, voluntary and private organisations, housing and so on. That would provide a much stronger voice for the consumer and the community. It would be locally focused and it would be appropriate to the community-based provision for the elderly, the disabled and the mentally ill that the Government claim that they wish to create.
If the Bill becomes law, the district health authorities will be run by a small board appointed by the Secretary of State. None of its members will be representative of the community and accountability will disappear. In Wales, the Secretary of State is also the regional health authority and the person who gives resources to the social services authorities, the housing authorities and the voluntary organisations. For there to be any monitoring, accountability or representation of the consumer and the community, it is vital to have the strong community health council structure that the new clause proposes to enable them to undertake the advocate's role on behalf of the consumer and the community.
The Secretary of State has advocated a reduction in the number of community health councils from 22 to nine, but no argument has been advanced for such a reduction. It is not that the Secretary of State is dissatisfied with their work. He acknowledges that the community health councils in Waleshave done much and valuable work in monitoring health care provision and in providing advice and counselling to patients and the public at large.The Secretary of State's declared aim in his review is tostrengthen and focus the community voice.How could he say otherwise? The active participation of the consumer is claimed to be an essential part of the proposed reform of the National Health Service that the Bill seeks to establish.
The White Paper "Caring for People" speaks warmly in paragraph 5 of the need at local level to focus attentionon formulating strategic and operational plans to increase participation and choice by service usersThere are no practical proposals in the Bill to increase participation and choice by service users. Their participation is reduced and will be virtually removed, unless the Government accept the new clause.
The Secretary of State's consultative paper on quality of care looks forward to the development within the National Health Service directorate in Wales of a "genuinely consumer-oriented organisation." How? The mechanism is not there, unless the new clause is accepted.
The Secretary of State's proposals seek to reduce the number of community health councils and also, by limiting the numbers of members of the reorganised community health councils to the number of members who currently serve on CHCs, to reduce further representation with a consequent reduction in overall community health council membership. My proposal would allow an increase in local representation, yet could allow a modest decrease in the numbers on each community health council. If there is a larger number of community health councils to address the needs of local communities, each can have a slightly smaller membership. They will focus on much more local issues.
314 We also provide a mechanism to bring people together on a county-wide basis in order to provide a small, representative group—something that, apparently, the Secretary of State wants. Consumer protection is now a recognised social policy objective except, it appears, in the Welsh Office. A wide range of legal measures in both industry and commerce exist to further that objective. Little else, besides the community health councils, exists to cover social welfare. In fact, until the appearance of this new clause in respect of Wales, there were no proposals recognising that need in relation to care in the community.
The report of the panel of inquiry into the future of community health councils, which was prepared by the Association of Community Health Councils, makes the case for the advocacy on behalf of consumers that the new clause seeks to protect. It says:The crucial difference between consumers of health services and most other consumer groups which requires an active body working on behalf of the former group is that a large number of them are weak and vulnerable and are highly dependent upon the continued receipt of services. This makes it extremely difficult for them to complain personally without support, or to pursue a complaint when the administrative system is less than helpful as is commonly the case.That in itself is a persuasive sign of the need to build the new clause into the Bill.
Community health councils are specialists in consumer representation and advocacy. Their independence, accessibility, expertise and experience qualify them uniquely to speak on behalf of patients. Therefore, Conservative Members should have no difficulty in supporting the new clause, which further develops the claimed intention of the Bill—to work for patients. They may be further inclined to support the clause when they learn that, of the total National Health Service 1989–90 budget of £19 billion, only some £7 million is to be spent on user representation. I am sure that they agree—I invite the Minister to say that he agrees—that it is wholly unreasonable that a sum equivalent to only 0.035 per cent. of the National Health Service budget is devoted to what they say is such an important tenet of the changes that they are seeking to bring about. If they do not accept the new clause, it will be difficult to believe that they are serious about that.
The new clause sets out to establish a community health council in each district council area—not in each district health authority area, as the Secretary of State has proposed. Such an arrangement would not only provide for better community representation in respect of health matters, but would better reflect the administrative structure of Wales, its unique geography, and the very different problems that can arise within the boundaries of a district health authority. Paragraphs (b) and (c) of the clause would give effect to such an arrangement.
In the case of Powys, the area is more than 100 miles long from north to south. Consider the variety of communities in Gwynedd. Even in the smallest county—South Glamorgan—the last time a Government tried to have one community health council, the proposal was rejected. That is why we have two community health councils. That is why, in the smallest county of Wales, which does not have the geographical problems of many other counties, a change to one community health council would be totally unacceptable.
Paragraph (c) gives to the community health councils the function of co-ordinating the views of relevant voluntary and charitable groups and of the recipients of 315 community care and other health services and their carers. Those views would be conveyed to the appropriate county and district councils, district health authorities, special health authorities and the Health Service directorate of the Welsh Office, as appropriate. What Member of Parliament for a Welsh constituency would argue that there is not a need for that function? Which of us has not come across the need for the co-ordination of information and for communication with those services and voluntary organisations?
The co-ordination of those involved in care and service delivery is therefore basic to the new clause and, if the Government's claims are to be justified, should be basic to the Bill. Those two paragraphs ensure that, particularly in relation to community care plans, local needs—and I mean local needs, not just needs on a county-wide basis—are effectively identified, and that resources and services, both formal and informal, are put most effectively to use.
I need not rehearse the arguments, which were put forward and largely accepted by the Government in Committee, about the need for full and effective co-ordination of services. However, I should like to illustrate from my own experience how urgent such matters can be and, thus, underline the main message—that the provision of accommodation for the elderly, the disabled and the mentally ill must be arranged to fit with the community care planning by social services authorities, health authorities and voluntary groups. Housing must be taken into account. The district councils and housing associations in an area must be involved, as well as the county council and health authority functions.
In Committee, many examples were given by hon. Members of cases in which resource allocation and quality of provision were important and flexibility was essential. I spoke in Committee of Colin Griffiths, a constituent, who is now tetraplegic following a tragic accident. He is an extremely couragous and extremely independent-minded young man, something in which his parents support and encourage him. He wants to be as independent as he can be—a desire best illustrated by the fact that he wants to help other young adults who face the same problems and encourage them to fight for an independent and full life and a sense of self-worth. When I spoke to him recently, how he could do that exercised his mind more than how his personal needs could be met.
For Colin Griffiths to have the independence to which his courage entitles him, several factors must be fitted together—appropriate housing and day care, help with mechanical aids, transport and so on. As well as guts, this young man has family, Church and community support with which to tackle his position. Tragically, his circumstances are unique, and not all families and communities can offer the same support to the individual.
We have two responsibilities in this case and in many others involving elderly, disabled and mentally ill people in a variety of circumstances. One is to have an efficient and responsive system of health care and care in the community. The second is to make sure that there is an adequate, efficient and local system, which will monitor that provision, give a strong local voice for the consumer and draw together the different ways of providing for individuals in the community and the community as a whole. That is what the new clause is all about.
I draw the Minister's attention to the comments of the National Consumer Council, which also looks at specific examples. The NCC said: 316Our recent work with elderly people with dementia and their carers has shown that liaison between health authorities, primary care and social services departments is still, in some areas, poor. This has a detrimental effect on those users who may be in need of help from across the sectors and who would benefit from better and more closely co-ordinated planning.This demands a mechanism to monitor and review the service provided, and the new clause provides the way to do that in Wales.
It is not sufficient to anticipate a happy and harmonious unregulated relationship developing between the various local, voluntary and health services. It is true that in Wales such co-operation can exist—one thinks of the all-Wales strategy on mental handicap, for example—but there will be new players in the game in future, the private sector providers of health and social care. I am concerned that the Secretary of State seems reluctant in his review to let even the few community health councils that will survive get too close to National Health Service provision.
In the unlikely event of a hospital trust emerging in Wales—I trust that it will continue to be unlikely—the Secretary of State has been careful to point out that a community health council would deal only with a district health authority and not directly with the trust. Moreover, the community health councils would not have an automatic right of access to routine trust meetings or papers. What is the Minister trying to hide? Are such trusts to remain within the NHS, as Ministers keep telling us? In which case, why have this hand-off to the community health councils? If the trusts are to be within the NHS, why should they be accorded such special treatment? There are important functions for the community health councils to undertake.
We come logically to monitoring. Paragraph (d) would ensure that quality is assessed at consumer level. I pay tribute to the high moral tone and the general worthiness of the comments emanating from the Department of Health relating to independent inspection units within districts and the Welsh Office's "Quality Patient Care" document. However, neither mentions the other and both pay little regard to the consumer.
Let us consider the current position in relation to the work of community health councils. I give the example of North Gwent community health council, the work on which it has reported and its representations to the Secretary of State for Wales recently. It describes its work as follows:Members undertake regular and frequent visits to all hospitals, clinics, day centres, etc., where they talk to patients and their visitors, and see conditions as they are. This is considered to be the most important and productive aspect of Members' work.That can be multiplied around every community health council in Wales. The community health council continues:if there were only one CHC with 24 members to represent the whole of Gwent, it would not be possible to fulfil these visits, and, indeed, much of the time would be spent in travelling the length and breadth of the County. The geography is such that the County is divided by valleys, most of which with a hospital as well as other health care premises. The distance may not look enormous, but in reality, mileage would be considerable…it is considered extremely unlikely that anything like the present levels of visits could be maintained.Is it really the Minister's intention to reduce that invaluable element in monitoring the Health Service? Will he really refuse the proposition in the new clause that that monitoring be extended to how that health provision 317 inter-relates with care in the community, such as the social services, housing services and the other services that are needed to give proper provision for people in the community?
The example of North Gwent community health council is not untypical, especially in respect of the independent inspection unit. Do the Government feel entirely happy, despite the arm's length management of such units, that poachers, however reformed, will make the best gamekeepers? The Royal College of Nursing and others have pointed out that the local authority will find itself in a monopoly position on care in the community, with a combination of registration, assessment, procurement and regulatory powers. The community health councils, under the proposals, would provide a meeting place for the noble intentions of the Welsh Office and the independent inspection units of the local authorities, both under the scrutiny of the people who matter most—the patients, the consumers and the community in which they live.
The key point in the communications role of the community health council is as a disseminator of information to people who desparately need accurate and proper information. First, it is difficult to know what services are available. We already see the confusion about that. How does one know that a dog is there if it does not bark? Secondly, it is almost impossible to know what services are available if one does not have direct access to a professional. Thirdly, none of the professionals involved in care in the community has a specific brief to disseminate information and none is required to do so in such a way as to promote access to services. It is only the community health council that can do that. Fourthly, there is after all a proliferation of professionals, all of whom have at best a partial knowledge of the range of services available. Fifthly, most people look for information at a time of crisis. Whether disabled and elderly people receive help depends on their condition, where they live, the structure of the local authority and their luck with professional contacts. We need to guarantee the availability of information as well as services.
The recent report of the King's Fund said:Methods of getting information to parents about formal care facilities are very inconsistent. It depends very much on local developments and the interest and enthusiasm of individuals and professionals who want to be involved.The experience in Wales is that the individuals in the community health councils have that enthusiasm and commitment. With no mechanism in any county in Wales to inform professionals of available services, even carers in regular contact with professionals may be unaware of and, therefore, denied access to support services. They are victims of a vicious circle of mutual ignorance and that applies both to health services and to care in the community.
Paragraph (h) is a serious attempt to meet the apparent need of the Secretary of State for a system once more based on simplicity rather than equity. I hope that he will find the paragraph and the rest of the new clause acceptable. That provision would draw together the community health councils, which would be locally based and well informed about their localities so as to hold joint meetings, and thereby achieve the single voice that Ministers want for the consumer and for communities.
The Secretary of State says that he wants a clear, coherent voice for the consumer. That is a nice idea, but it 318 is not easy to deliver, bearing in mind the danger of oversimplification and distortion. Indeed, it can fairly be said that there is no such thing as a coherent consumer voice. The public at large will always have a variety of views about any topic.
Is it really the role of the CHCs to reconcile those conflicting views, or should they take on the job of ensuring that all expressions of opinion are articulated to the decision-makers in the NHS? Communities will have different interests to be articulated. That is the real meaning of strengthening and focusing the consumer voice. Our proposal in the new clause would achieve that, rather than the half-baked proposal to reduce the number of community health councils in each county.
Strengthening the consumer voice by reducing the number of CHCs in Wales from 22 to nine is a contradiction in terms. There is no evidence that a CHC in a county would give a clearer and stronger focus to the informed consumer voice than does the present pattern of CHCs. Our proposal would strengthen the local element in the representation of the individual and the community.
The new clause would do the job for the Minister because it would strengthen the local community voice and, where needed, create a single voice. It would do what the Minister says he wants to do, and I appeal to him to support it in the interests of consumers and of communities throughout Wales
Until now, health authorities have been run by committees that drew on a mixture of backgrounds, such as medical experts, people elected by the local councils and people appointed by the Welsh Office. In future, much smaller boards will be running the system with fewer medical experts and no local representatives and with all their members being appointed by the Welsh Office. In Wales, unlike in England, we do not have the regional health authority. In future, the budget, policy-making and appointments—all our health authority functions, and much more—will be in the hands of one Minister and his civil servants and there will be no local representation
Where is the voice of the consumer to be heard? How will communities such as Penarth, Merthyr and Bridgend express their views about the type of health services that they need? Who will monitor the way in which the elderly are cared for in the community? Who can listen to the disabled and the mentally ill? The answer is nobody—unless the CHCs can be salvaged from the threat that hangs over them and are made local, effective and coherent, as we propose in the new clause.
§ Mr. Nicholas Bennett (Pembroke)
The hon. Member for Cardiff, South and Penarth (Mr. Michael) said, basically, that community health council areas should be the same as district council areas. It is a pity that he took half an hour to say it.
§ Mr. Ted Rowlands (Merthyr Tydfil and Rhymney)
We have a national health system, but it is also a local health system, and it is vital for us to bear that in mind. The system originated in local community health care. It 'was from the valley communities that the notion of a national health system was created. We must make sure that we achieve the right balance between a genuine National Health Service and a local health service.
319 Since those early days we have developed a complex, specialist service which must now be truly national, in Welsh and in British terms. But there is no reason why it cannot be accountable to the community.
As my hon. Friend the Member for Cardiff, South and Penarth (Mr. Michael) said so eloquently—despite a brief and nonsensical interruption from the hon. Member for Pembroke (Mr. Bennett)—the community health councils have been extremely effective. I can only speak from my own experience, but our CHC has certainly been effective. Mr. Bryn Williams has been active and supportive, raising money and also, on occasion, exercising vigilance and being critical of the service. The Government's notion is to take the word "community" out of community health councils, but, with respect, the community of Merthyr and the Cynon Valley is not that of Mid Glamorgan or some grander district.
Throughout the Bill's passage so far, we have debated—rightly, in my view—whether patient power, or consumer power, can be increased. Opposition Members reject the idea that it can be increased through the creation of a false or flawed system of competition, which is at the heart of the Bill. In the communities that I represent there will be only one health system: only one district general hospital, only one practice or group of practices and only one health centre. There will be only one set of arrangements to which those in need can turn. We do not want to create a divisive, competitive system; we believe that the existing system should be made more responsive.
Although we do not need American-style competition between general practices and between hospitals, we cannot be complacent about the current response of the Health Service to people in need. Certainly I am not complacent: I believe that the system must be more sensitive. I want better care and shorter waiting lists for the communities that I represent, and I agree with many of the criticisms. The answer, however, is not to give people the false impression that they can "shop-around"; we need to develop the present system, making it co-operative rather than competitive, and more accountable and sensitive to the community.
In that regard the CHCs have an important role to play. No one is saying that they are perfect; they are an imperfect vehicle to express the views of a community, to pick up its complaints, to apply pressure and at the same time to be active and supportive. The CHC has been described as a local watchdog, but mine is also a great fund-raiser. CHCs have backed the facilities of the Prince Charles hospital, and helped to raise money to produce the finest technology available in the Heads of the Valley. That is one of the major functions of CHCs. We should not destroy their community base. We should develop the system further. I reject the philosophy behind the Bill—the notion that the way to promote patient power is by competition.
As I have said, we need a new regulatory system on behalf of patients, consumers and the community. There is a case for establishing new performance standards at all levels. In a unified Health Service in a community such as I represent there must be standards and performance levels that everyone, from consultants throughout the system, must meet. 320 3.15 am
The Government have not made that the centrepiece of the Bill because they believe that, in a curious way, competition will deliver that objective, but it will not. The Health Service should be developed by putting more resources into it and it should be made more responsive by establishing new standards and by creating a new regulatory body.
The CHCs could play a vital part in doing just that. The Government's nonsense has no support. The area health authorities, the supposed victims of the CHCs, are against the notion of abolishing them. Whether on the poll tax or education and certainly on health matters and the CHCs, the Government, as always, are on their own. The rest of society rejects them and their proposals.
§ Mr. Richard Livsey (Brecon and Radnor)
The rationale behind the Government's and the Welsh Office's thinking on CHCs is to diminish their effectiveness in representing their areas. The proposal in the Welsh Office's consultative paper that the number of CHCs should be reduced from 22 to nine is a direct threat to their effectiveness in representing community interests to the nine district health authorities.
It is important to realise that just when the district health authorities are to be streamlined into a corporate type body with 10 directors, five executive and five non-executive, the CHCs in Wales are being irreparably weakened. All members of the new district health authorities will be appointed rather than elected, and that tells its own story. The communities will no longer be represented on the health authorities. In those circumstances, the community interest will not be protected.
The reduction in the number of the CHCs from 22 to nine and the consequent increase in the area that each CHC covers will fatally weaken the democratic checks and balances in the Health Service in Wales. At present, individual communities are protected by CHCs and new clause 3 will increase the democratic accountability of the Health Service in Wales. The move to reduce the number of CHCs to nine is a cynical and deliberate attempt to undermine the effectiveness of CHCs and the checks and balances.
In Powys, Brecon and Radnor community health council currently has 24 members and Montgomery community health council has 16. The proposals are for one community health council for Powys with 24 members. If we consider that the size of Powys is such that if it were put on its end it would run from the Severn bridge to Hammersmith flyover, we can appreciate that a community health council covering such a distance would be pretty ridiculous. In addition, the population sparsity in Powys—it is unique in that it is the most sparsely populated area in England and Wales by a long way—makes it extremely unlikely that members of the proposed community health council in Powys will know what is going on 130 miles away at the other end of Powys.
If anything is to happen, the special situation in Powys needs recognition, in that it needs at least two community health councils, as at present. If we were to take the new clause to its logical conclusion, there would be three councils—one for Montgomery, one for Radnor and one for Brecon. That would give us proper community representation.
At present, community health council members are often volunteers. Often they cannot spend much of the 321 week travelling up and down the area—in our case, Powys. They would find it considerably easier under the structure proposed in the new clause.
I make a special plea to the Minister—I have already made one to the Secretary of State. At the very least, Brecon and Radnor community health council and Montgomery community health council should remain in place and separate. That is the only way of effectively monitoring the community needs of the Health Service in Powys. In the present circumstances, an all-Powys CHC is not on.
I have received representations from both community health councils in Powys. They wish to keep the present structure. They are representative of the communities. Given the spread of community hospitals, it is vital that there is someone from each community represented on community health councils. That most certainly will not be the case under the Government's present proposals.
The new clause advocates a CHC for each district, based on the district council boundaries. That would be an effective counterweight to the new corporate style health authorities proposed in the Bill. As for the functions of the CHCs in Wales, the question is whether the standard of health service in their areas is properly monitored. Their acceptability to the public and their ability to represent the users of service when changes are proposed must surely be embodied in a greater number of CHCs than is presently proposed by the Government. The question is whether those functions can be better carried out if the number of CHCs is reduced, which seems unlikely. It might be administratively more efficient to have corresponding areas of CHCs and health authorities—nine of each—but it will be much more difficult for the remaining CHCs to carry out their tasks.
The Government are also begging the question whether it is the CHC numbers that should be changed, not the health authority ones. That issue should be closely examined. If my hon. and learned Friend the Member for Montgomery (Mr. Carlile) is called, he will make that point. In parts of Mid Wales, patients may have problems with a health authority that diverts resources away from their areas. We know that patients leave those areas for treatment in other areas.
The last function—that of representing local users—will be well nigh impossible. The needs of some local users may be very different from those in other communities in the same area. Because health authorities and family health service authorities' memberships are to be streamlined to exclude representatives of the community, as well as the professions, it becomes more important, not less, to strengthen CHCs in their ability to do their job. The Welsh Office envisages that local groups will need to be established. That acknowledges the fact that health authorities cover a range of communities. Why not accept that that is the case and have more CHCs—indeed, a CHC for each district? Local groups will not have the clout of fully-fledged CHCs.
It is impossible to escape from the belief that the Government are concerned with quietening voices critical of the way in which the NHS is run. Many of the Government's proposals, such as NHS trusts and contracts, ignore the patient's voice. Reduced numbers of CDCs would be too over-worked and too unrepresentative to be an active and successful patients' champion. Indeed, where hospital closures are proposed, it is vital for those communities that the CHCs based there can make proper 322 representations to the health authority to ensure that the interests of the local community are protected. It is unlikely that that will be possible under the new structure. In fact, it may well be a negation of local democracy in relation to the proposed nine CHCs for Wales. It is not a constructive set of proposals, and it is anti-community.
§ The Parliamentary Under-Secretary of State for Wales (Mr. Ian Grist)
It may help the House if I intervene at this stage.
Hon. Members have spoken knowing very well that we issued a consultation document in November and have only just closed the list, although representations are still being received. They have come from most Opposition Members and from others, and we shall carefully consider what we have been told. We take the representations seriously and are not trying to ride roughshod over people's views. Of course, we believe in the proposals that we put forward in that document. We shall set them against any contrary views. Many hon. Members who have spoken have already let my Department know their views, so although they are not being repetitious in the terms of the House, they may be in terms of my office.
We do not propose any change in the primary roles of the CHCs, which will continue to monitor the quality of services provided, to comment on issues relating to changing patterns of NHS services—which, the hon. Member for Brecon and Radnor (Mr. Livsey) will be pleased to hear, includes closure or major changes to service—anything that has a bearing on the welfare of patients and, of course, anything that provides assistance to anyone who encounters difficulties with NHS services.
The purpose behind our proposals, which would include the replacement—it has been depicted as the notorious replacement—of the existing 22 CHCs by nine CHCs is designed to strengthen and focus the voice of the CHCs within each district and to allow them to take a more strategic view of the services for which each district health authority is responsible. Currently, four CHC's in certain areas cannot possibly take a strategic view of the health authority's proposals and activities within that health authority's area. We strongly believe that they are too localised.
We have made our proposals in the belief that the new and larger CHCs, not least because they will be better funded, should make a far more effective contribution on behalf of patients—for example, by expanding their work in areas such as patients' surveys and commenting on quality of work.
§ Mr. Alex Carlile (Montgomery)
How can the Minister say that a community health council which covers 50,000 people and 900 sq miles is too localised? What a load of rubbish.
§ Mr. Grist
The area health authority of the hon. and learned Gentleman is quite small, as area health authorities go. That is why it does not have a district general hospital in its territory; 50,000 is fewer than the number of inhabitants in my constituency. So I would have said that it was localised.
§ Mr. Michael
The Minister does not seem to be addressing the fact that various communities have different needs. If he does not want to consider Powys, he should take Mid Glamorgan where there are quite a few 323 disadvantaged communities. Do not they deserve a voice local enough to focus on their needs? Has he read the new clause to which he is speaking, which offers a way of co-ordinating views at a strategic level within each district health authority area?
§ Mr. Grist
I think that the hon. Gentleman must have missed my assurance that we are taking the matter extremely seriously and are considering the various points made to us. The points about Mid Glamorgan will be borne very much in mind. He will be aware that there are proposals for the health authority to move its main district general hospital. Therefore, in certain circumstances, with a multiplicity of CHCs, instead of one CHC being responsible for the main district general hospital, wherever it was placed, it would move in and out of different CHCs.
§ Mr. Michael
The Minister seems not to realise that the health authority will be responsible for the district hospital, and the community health council will be responsible for expressing the views of individuals who live within a specific community. That is what he will destroy if the CHC operates at a county-wide level.
§ Mr. Grist
Clearly the hon. Gentleman has not appreciated the point that I was making that CHCs are responsible for looking at the delivery of service and the welfare of patients in the hospital structure as well. Therefore, any proposal for closure or major alteration will certainly be of interest to CHCs.
Community health councils should maintain a close link with their local populations. That was precisely why we suggested—it was just a suggestion—that they might choose to establish local working groups on which CHC members might serve, as would other local people. Those would help the CHC to carry out its day-to-day duties.
The proposals contained in the new clause would further fragment the community health council network in Wales. It is ludicrous to suggest having 37 CHCs. The capacity for the CHCs to be able to watch the activities of the area health authority in any strategic sense would be vitiated. I believe that that would damage the interests of patients.
§ Mr. Alan Williams (Swansea, West)
Does the Minister accept that there is a genuine difference of opinion? Will he think in different terms to try to understand the point that we are making? Each of the 38 Members representing constituencies in Wales has to carry out on a much wider scale the sort of functions that are carried out in relation to health by the community health councils. I think it would be regarded in Wales as a step backwards—I suspect that the hon. Gentleman would regard it in the same way—if we said that instead of having 38 Members to carry out that function on behalf of all our constituents we should have only nine Members. There can be no pretence that the people of Wales would be better served or that there would be a more localised service. If the hon. Gentleman thinks in those terms, he will see why we are getting angry. We think that he does not understand the personal relationship available through a community health council which my hon. Friend the Member for Cardiff, South and Penarth (Mr. Michael) tried to emphasise.
§ Mr. Grist
The right hon. Gentleman teases me by suggesting that if we were to follow certain devolutionary principles we might end up with nine Members of Parliament in Wales. That is perhaps worth the consideration of hon. Members. The multiplicity would undermine the ability of the CHCs to take a strategic view of the delivery of health service in their areas and it would complicate the working relationship between them and the district health authorities and the family health service authorities. I am afraid that the new clause would end the existing relationship between the CHCs and FPCs, or the new family health service authorities, as they are to be called.
Even more misplaced is the proposal in the new clause that CHCs should be given a role beyond the NHS in relation to the community care responsibilities of local authorities, including personal social services and complementary housing provision. We have made it clear that in carrying out their community care responsibilities local authorities will have a clear duty to work with health authorities, family health service authorities, housing agencies, voluntary bodies, the private sector and users of services in the development and delivery of community care plans. CHCs will doubtless contribute to that process.
However, we regard as fundamentally misconceived the idea that CHCs should have a statutory role in respect of local authority services. Local authorities are directly accountable to their electorates for the provision of services and they will therefore have the duty of ensuring that users' views about services are adequately taken into account. Indeed, we have made it plain that we shall expect the social services authorities to have in place effective systems for users of services and their representatives to make complaints and representations, as members of the Standing Committee will be aware.
I find unacceptable the idea in the new clause that the CHCs should act as ringmasters for a highly bureaucratic process in attempting what I believe is an impossible task—trying to bring together various voluntary bodies, charitable organisations and others to make them speak with one voice. I do not believe that it is possible to co-ordinate those bodies in the way suggested in the new clause.
As I have said, the formal consultation about the Government's proposals ended on 28 February. We are still analysing the responses. The new clause is flawed in the ways that I have described. It is also untimely with regard to the consultation process that is being undertaken at the moment. I hope that the hon. Member for Cardiff, South and Penarth (Mr. Michael) will withdraw the new clause. If not, I invite the House to reject it.
§ Dr. Kim Howells (Pontypridd)
If the Government were to support new clause 3, they would go some way towards regaining a little of the credibility that they have lost during the Bill's passage. That credibility has been lost largely as a result of the Government's refusal to countenance any extension of consultation with those who use and operate the Health Service.
New clause 3 seeks to align community health councils with district councils in Wales and to create a mechanism that would allow meetings of the community health councils to take place on a district health authority-wide basis. I do not understand the Minister's great horror about that arrangement. The proposal that is currently floated by the Welsh Office is that there should be one 325 CHC per district health authority. In Mid Glamorgan—the county with the highest population in Wales—that would have drastic repercussions for the level of representation through community health councils. Instead of the present four CHCs, the 535,000 inhabitants in Mid Glamorgan would be allocated only one CHC.
Under the new clause Mid Glamorgan's CHCs would increase to six—one for each of the district councils of Cynon Valley, Merthyr Tydfil, Ogwr, Rhondda, Rhymney Valley and Taff-Ely. That population of 500,000 would be subdivided into communities that would vary between 60,000 and 160,000, each with its own characteristics, needs and existing resources.
The Minister knows that there are currently about 30 hospitals servicing the county of Mid Glamorgan. They are located in Rhondda, Taff-Ely, Ogwr, Merthyr, Cynon Valley and Rhymney Valley. Those areas and the health requirements of their population are by no means identical. Mortality and illness rates frequently tend to be higher in the older communities, in the central mining valleys of Rhondda, Cynon Valley and Merthyr, and in the Cyntwell and upper Rhymney valleys, and often much lower in the areas that are contiguous to the M4.
Within just one of those districts—Rhondda and Taff-Ely—considerable sensitivity has to be exercised in administering the needs of an older and declining population in the north of the district and of a younger and growing population in the southern part of the district. The CHC's role in monitoring the quality of health provision, if organised on a district basis, could be much more sensitive than at present. Certain critical variables in each of those areas could be catered for if the provisions were based on a district model which in some ways are not catered for now. I am sure that the Minister is well aware of the difficulties of people in Mid Glamorgan in gaining access to the hospitals, especially to the new district general hospitals, such as the Prince Charles hospital in Merthyr, the East Glamorgan general hospital in the centre and the Princess of Wales hospital in Ogwr. People in many of the areas that are served by those hospitals do not find them easy to get to.
One role of the enhanced model that we are proposing in the new clause would be precisely to allow the monitoring service to inform the public of the new arrangements affecting the district general hospitals, such as the new one that I hope will be built to serve the Taff-Ely and Rhondda areas. That would allow much more sensitivity and the input of greater local knowledge about access and people's ability to get to those hospitals. In that way, it would become much more of a two-way process. The decisions would not be being made in county hall, which might not be as sensitive as it should be to the peculiar topography and geography of the valleys in south Wales. It is not asking a great deal to ask that the potential of the expertise of local voices should be tapped by any new arrangement. That local voice should not be diminished by making the decisions more remote in terms of the lack of input of local expertise and information. The Minister seems to be over-reacting dramatically to what is simply an extension of consultation and of people's access to those decisions and the way in which they are made.
I congratulate my hon. Friend the Member for Cardiff, South and Penarth (Mr. Michael) on the way in which he moved the new clause. He has rightly highlighted and valued something about Wales that is unique—our 326 identification with communities. That is something that we should treasure and look after. I advise Ministers that the new clause does just that.
§ Mr. Ieuan Wyn Jones
In supporting new clause 3, may I say that we are discussing the important principle of the way in which community health councils can fulfil their primary role as a public watchdog. We are doing so against the background of a Bill that seeks to reduce the accountability of the district health authorities and all the other bodies that will administer the Health Service in Wales. The Minister will be aware of the criticism of Opposition Members in Committee about the way in which the new constitution of district health authorities and family health service authorities was being radically changed to introduce what the White Paper, but not the Bill, calls a more businesslike approach. In other words, they are being changed to make district health authorities run like businesses and to reduce accountability and the representation of local authorities on those bodies. The accountability and the effectiveness of the body would be reduced. The Government cannot have it all ways
We must make it clear, and the British Medical Association has informed us in its briefing for the debate, that there is widespread opposition to the Government's plans. That widespread opposition must be articulated in a democracy. The people of Wales have rejected time and again the philosophy of change in the Bill. If that is the case, the Government could at least give us an effective watchdog to ensure that the health changes that are being pushed through in the Bill are effectively monitored. That is an honourable argument for Opposition Members to put. There should be an effective monitoring arrangement and system.
The Minister sought to persuade us that, by making each community health council conterminous with the district health authority, he would make them more effective because they would monitor the same area and could make strategic decisions. But the people whom CHCs seek to represent do not see it that way. I inform the Minister, in common with my hon. Friends who have spoken for Mid Glamorgan, South Glamorgan and Powys, that the people of Gwynedd reject the plan for the basic reason that, as my hon. Friend the Member for Merthyr Tydfil and Rhymney (Mr. Rowlands) said, community health councils surely must be based at community level to make sense. That is the way that the people of Ynys Môn see it.
I am in the unique position of speaking for a people who live on an island. They know the sense of community that that involves. They reject the principle that their views should be taken into account in a wider context, particularly being an island people. The people of Anglesey are angry that their CHC is to be abolished under the Bill.
We must also consider the geographical areas which the CHCs, as envisaged by the Welsh Office, would cover. We have heard about the problems of Mid Glamorgan, South Glamorgan and Powys, and I can talk about the problems of Gwynedd. It would be intolerable if we had community health councils which sought to represent the views of people on a county-wide basis. What involves people in articulating their views is what happens to them in their communities. It is not what happens at the other end of the 327 county; it is what happens to their hospital, doctors, friends and relatives. They can empathise with their colleagues and friends within their own villages. They cannot do so with people who live on the other side of the county.
§ Mr. Grist
Does the hon. Gentleman suggest that patients who go to ysbyty Gwynedd would have to be represented by their home CHC? Or does he think that an overall CHC could better track from home to hospital the complaint or worry of a person from Holyhead who goes to ysbyty Gwynedd? Surely that would be better than if the responsibility were split between two CHCs. That is our argument.
§ Mr. Michael
Does my hon. Friend agree that the Minister's intervention seems inappropriate to the new clause because the new clause would provide consideration of the needs of the individual community and co-ordination between CHCs? I hope that the proposals for the break-up of the structure within Gwynedd health authority will not go ahead because that would remove the link between management and local communities.
§ Mr. Jones
Absolutely right. My hon. Friend makes his point effectively.
There could be an improvement in the management structure of Gwynedd health authority. The Minister knows that I have been highly critical of its operations in recent years. Where management is based on geographical breakdown rather than on discipline, there is a case for having CHCs for each geographical area within the county. The Government constantly tell us that we should put the patient first. If the patient is to be rooted in a community and the voice of that community is to be articulated, it should be under a smaller system of CHCs.
One of the new structures created by the Bill is NHS trusts. God forbid that any operate in Wales. I am not aware of any hospital that has announced that it wishes to seek trust status. If one did, the danger is that other district general hospitals may find that they cannot provide the comprehensive health care which they are obliged to provide under statute because of a lack of resources and they may wish to buy in services from neighbouring authorities. We need CHCs locally to consider that.
In fairness I should say to the House that I was impressed with the lobby which the Welsh Association of Community Health Councils organised a few weeks ago. Its message—each CHC area in Wales was represented—was that the Government's plans would be detrimental to the monitoring of the Health Service in Wales and that the measures contained in the Bill would not lead to better services. Therefore, it is vital to have an effective local watchdog.
I am not aware of any body, person or organisation that has expressed support for the Welsh Office proposals in its consultation document. If the Minister were to reply again, perhaps he could tell us whether, as a result of the consultation procedure, any body, organisation or group of persons representing the Health Service in Wales supports his proposals.
§ Mr. Alex Carlile
I listened without surprise, but with accustomed dismay, to the earlier interventions of the Minister. They have confirmed the worst suspicions of people who live in rural Wales.
Apparently, Welsh Office Ministers still consider Wales to be a small place somewhere near Cardiff. As a Member representing a rural constituency, it seems that Montgomery is simply being cast into the Cardiff mould for the decision-making on community health councils. It is too far north for community considerations to be bothered with.
When the Secretary of State limps out of the Welsh Office he will leave quite a legacy behind him—the county councils, which he was responsible for creating during the previous Conservative Government, and which nobody in rural Wales ever wanted. The Government usually find that when a new authority is created eventually people get used to it, and they acquiesce in its existence and get on with the job. However, 16 years after the creation of the new Welsh counties we still do not want them, and we have not got used to them. It is offensive to the people of mid-Wales to have further community facilities and democratic accountability—if there is any accountability in this—ascribed to the same level as those unwanted county councils. When the Secretary of State leaves office we shall still have his unwanted county councils and our representation in health matters in mid-Wales will have been reduced to the same poor level.
In the early part of the 1980s, the Boundary Commission for Wales made a provisional recommendation that the seat which I represent and the constituency of my hon. Friend the Member for Brecon and Radnor (Mr. Livsey) should be merged to form a single Powys seat. There was a detailed hearing of the merits of that before a deputy boundary commissioner, Mr. David Glyn Morgan. After careful consideration of the evidence, Mr. Glyn Morgan came to the sensible conclusion that it was absurd to combine the communities of Montgomery—the old county of Montgomeryshire—and Brecon and Radnor. Why did he come to that conclusion? Because he could see that they are two distinctive communities which require distinctive representation; two geographical areas; two traditional community areas, with traditional community ties; two disparate communities. Therefore, he recommeded, and the Boundary Commission for Wales accepted, that there should be two separate constituencies. Exactly the same arguments apply to the number of community health councils in Powys.
It is a particularly stark fact for the people of Montgomeryshire that we are not as well served by the National Health Service as other areas. We have no district general hospital. Every patient who requires acute treatment has to go elsewhere to a district general hospital—and not to just one but to one of a selection—perhaps in Shrewsbury, Aberystwyth, South Powys, Hereford or Wrexham. It is ridiculous to suggest that a Powys community health council—bearing in mind what my hon. Friend the Member for Brecon and Radnor said about the size of Powys—could scrutinise the adequacy of health services made available to people in my constituency. It is likely to lead to a decline in accountability. We know what the Government are up to in their proposals concerning public bodies in Wales. They are reducing their size. In some cases that may have merit. However, they are being 329 reduced in size so that the Government can carefully put into place those who sympathise with their political views. That is a recipe for patronage.
Wales has been riddled with patronage for at least 80 years. It is time that there was a little less patronage in Wales and a little more democratic accountability. The putting in place of a few Tory business men and business women will not satisfy the people of mid-Wales.
§ 4 am
§ Mr. Carlile
That is a joke and a half. Of course, the Government have left the patronage system as it is at present, but it will be much easier to find six or nine Tory business men than 32 or 34 Tory business men. It will be jolly easy, thank you very much, to pick out the chosen few—the chairmen of the Conservative associations and so on—to fill these jobs. If ever there were a bit of obvious cynical politicking, this is it.
From our viewpoint in mid-Wales—it is a special viewpoint, for the reason I mentioned: that there is no district general hospital within my constituency—it is high time that the Welsh Office recognised the need, which many have spoken of in the past, for a new mid-Wales health authority and for community health councils to be based on the very large district council areas that already exist. I mentioned earlier in the debate the size of my own area. That seems to me as large as one community health council can cover and manage. I pay tribute to the work that has been done in the past by my constituency's community health council. I deplore its passing.
My hon. Friend the Member for Brecon and Radnor was right to refer to the need for checks and balances. The trouble is that the Government do not care about the balances. All that they care about are the cheques—not the kind of checks to which my hon. Friend referred.
§ Mr. Rhodri Morgan (Cardiff, West)
I intend to refer to the problems that constituencies will face if the Government do not accept new clause 3. It attempts to ensure that the community health councils will be able to look after consumers in our constituencies and provide the services that the National Health Service is supposed to deliver.
My constituency will need to call on the services of the community health council in Cardiff. The result of the severe underfunding of the South Glamorgan regional health authority is that it now proposes to close six hospitals, three of them in my constituency—one large and two small hospitals. St. David's is the large one; Glan Ely and the Ely ear, nose and throat hospital for children are the two small ones. The proposal is to close them during the coming financial year.
According to the document that was made public in February by the South Glamorgan regional health authority, consultations will be held on the closure of those hospitals immediately after 1 April. The community health council will take part in the consultations. The Minister said earlier, "If we have countywide community health councils, they will be able to take a more strategic line." That means that they would fit in with the regional health authority's thinking. They would not be so effective in representing the interests of the consumer. They would 330 be able to understand what the management had in mind. They could be persuaded that the offer being made by the health authority—"We shall close down these six hospitals, reorganise the service and reduce the number of beds", and so on—was understandable. Being on the same strategic plane, they would be able to see that the health authority was doing the right thing. Of course, in reality, the Government are reacting to a severe underfunding crisis in South Glamorgan—underfunding to the extent of £7.5 million. They are closing hospitals so that the land on which they stand may be sold. In other words, revenue underfunding in the county is being made good by the sale of capital assets.
The type of problem that we in South Glamorgan face as a result of this clash with patient or consumer thinking is illustrated by the seminar that the NHS in Wales is organising this summer for the purpose of inculcating what it calls management thinking. It will be a wonderful seminar. It is being commended by John Wyn Owen, the director of the NHS in Wales. Indeed, the director has almost threatened that everybody involved in the NHS in Wales ought to attend. In the leaflet of invitation that was sent out on behalf of the NHS in Wales and the Yale university school of management he says:The need for the organisational development and the use of different management methods brought about by theWhite Paper"—
the White Paper "Working for Patients", not legislation—has made the programme of even greater relevance and interest at this time. I unreservedly commend it to you and look forward to seeing colleagues at this event.
§ Mr. Win Griffiths (Bridgend)
Does my hon. Friend agree that this is a serious waste of paper? As American health costs are two or three times those in the British Health Service, it is unlikely that the Yale university school of management will be able to offer us any advice on the provision of patient care at low cost.
§ Mr. Morgan
I could not agree more. The cost of this seminar in Llandrindod Wells will be £1,500 per person attending. How many holidays in Llandrindod Wells could one normally get for £1,500? In addition, there is £225 VAT. This is to enable people from Yale to teach us something. But, as my hon. Friend says, in terms of National Health Service administration costs, we could teach them something. We could teach these professors from the Yale university how to run a health care system with very low administrative costs. The NHS in Wales is trying to inculcate this sort of management bunkum, whereas what we want is more money for the system. We do not want whiz-kids uttering buzz words; we want more medics delivering health care. Unfortunately, the elimination of community health councils will hardly help. It will lead to a culture in which management methods are finance-oriented—a culture in which, in the end, health care systems work for profit rather than for patient care. We need community-based CHCs to prevent that.
I listened very carefully to the Minister's remarks. I always find myself accepting that he is very sincere. He has an outgoing personality. If the electors of Cardiff, Central have anything to do with it, we shall discover at the next election just what an outgoing Member of Parliament he is. We in Wales do not want a transatlantic takeover. We do not want to be deprived of the ability adequately to resist the closure of hospitals. We want to be able to put forward the case for keeping the hospitals that we have. We do not want to see Ministers indicating to senior 331 management staff of the NHS in Wales that we are heading for a finance-oriented system full of accountants and involving lots of expenditure on management conferences and new computer systems. We want a system whereby the CHC at community level represents the interests of the ordinary consumers of the NHS. If they want hospitals to remain open that the management wants to close, they should have the right to put their case as effectively as they can.
If the Minister thinks that he can get South Glamorgan health authority to close St. David's easily, he has another think coming. There will be an almighty row. We are not willing to accept that, suddenly, because of revenue shortfalls, health authorities will be panicked into making short-term hospital closure decisions. That will be the rocky road to ruin. It will mean that health authorities are left with no alternative but to sell their capital assets to make good the shortfall in money that the Government should provide.
§ Mr. Win Griffiths
We have had quite an interesting debate in the early hours of the morning. If we look at the Government's proposals once again—heaven knows, we have done so often enough—we see that they are based on a theory that has already been discredited in practice in many countries. In the United States, Switzerland, France and Germany, where there is much more of this so-called competition, average health costs are double those in the United Kingdom. The Government wish to bring into our Health Service market principles that are supposed to make the service more cost-effective and more sensitive to consumers' needs, but no health service in the world can support those claims.
On the basis of that discredited theory, the Welsh Office has already agreed to inject an additional £5 million into the Health Service to provide it with the information technology needed to enable the market system to operate. If the Government genuinely want to ensure that the new system is sensitive to the user's needs, a substantial increase will be needed in the resources made available to the community health councils. They are the statutory bodies charged with representing user and community interests in the NHS.
Instead, there has been a Welsh Office consultation paper in which the Secretary of State for Wales proposes to reduce the number of CHCs from 22 to nine. The Minister suggested that the Welsh Office would listen to all the responses, but he suggested also that our new clause, which is much more along the lines of the existing system than is the Government's proposal, is not to be countenanced. It seems as though the issue has been prejudged and that this is a deliberate attempt by the Welsh Office to remove a genuine local focus for anxieties about the NHS in Wales.
My CHC in the Ogwr district of Mid Glamorgan, which is superbly serviced by Mr. Chris Johnson, its secretary, does a tremendous job monitoring developments. There is no way that that CHC, translated into the county of Mid Glamorgan with the same number of people, could possibly monitor the entire Health Service in the county; it is out of the question. I hope that the Minister, in reviewing the responses he has received, comes to realise that that is the virtually unanimous opinion of all the people and all the organisations that have responded.
332 Under the proposals, this extremely good community health council is destined to be swallowed, along with the three other community health councils in Mid Glamorgan, into one body with the same number of members—24. It cannot do the same job across the county as each of the present councils does in one district of Mid Glamorgan now.
In competitive business, commercial companies often take steps to ensure consumer satisfaction. There may be a move towards encouraging district health authorities, family health service authorities and service providers to assume more responsibility in this area themselves. However, in the commercial world, it is in the interests of the providers of goods and services to undertake that work in an objective manner. One cannot get such work done in the same way within the structure of a health authority. Patients do not have the same purchasing power as consumers have in the outside world. The two cannot be equated. In the National Health Service, purchasing power will lie with the procurers of the service, such as the district health authorities and the GPs who hold their own clinical budgets, rather than with the patients or the public at large. The imperative for the service providers will be to satisfy health authorities and GPs rather than patients. If patients benefit, it will only be by chance.
Community health councils as statutory and independent bodies must be recognised as having a primary responsibility for insisting on and measuring user satisfaction. They must be properly resourced to enable them to undertake that task effectively. Much of that input depends on the work of volunteers within the structure of community health councils. To imagine that the 24 good men and women will be ranged up and down the county of Mid Glamorgan—and this will be even less true of counties such as Powys—is to place a responsibility on them which cannot be sustained. We must look to community health councils that genuinely represent communities. Perhaps the Government do not fully appreciate that the councils are not only good at the provision of information, advice and assistance to individual members of the public, but are often the only groups performing such a task across the whole area of a health authority.
That part of CHCs' work is likely to increase substantially with the more complex pattern of services that the Government intend to introduce through the Bill. The Government are, unfortunately, seeking to introduce a far more market-style National Health Service. They will reduce the number of people who will provide an information service to patients seeking help in the Health Service. So far, community health councils in Wales have done an extremely good job with minimal resources. I should like the Welsh Office to review their work to see how it could be done more effectively, but merely to make a proposal to cut the numbers is wholly out of keeping with any form of providing an improved service.
The consultative document issued by the Welsh Office gives no confidence to the public that the CHCs will be able to do the job better when their numbers are slashed. The Department should accept that the CHCs will be even more important as part of the complex system that is being introduced.
Should the Bill pass unamended, we will move first to the commercialisation of the NHS and then to its 333 privatisation. In other words, this measure represents the first step towards the privatisation that the Government are trying to avoid having tagged on to them. The public at large know that that will happen, and it worries them.
The type of care that will be provided will be a precursor of what is now happening in America. We must face the fact that the more we introduce competition and the concept of cost-effectiveness in patient care, the sooner that American type of care will be on our doorsteps. Patients will become customers, cash will be king, cost-cutting will have a greater priority than patient care and access to treatment will be enhanced by personal payments.
The Government frequently say that they are spending more on the NHS. They are hiding behind the facade of the retail prices index, which has no relationship to the real cost of providing health care and meeting the expanding needs of the NHS, faced with our aging population.
§ Mr. Grist
I have been listening to this farrago for long enough—[Interruption.] The hon. Gentleman will appreciate that the vast bulk of the cost of the NHS is made up of pay, which is set against the cost of living index and therefore has a direct bearing on that index. Health authorities do not pay mortgages, which feature largely in the cost of living index. In other words, those issues have a great effect on the index.
§ Mr. Deputy Speaker (Mr. Harold Walker)
Order. All of that is a considerable distance from the substance of the new clause that is being debated.
§ Mr. Griffiths
Community health councils play an important role in seeing that health authorities are properly funded so that patients get the care they need. Despite the Government's claims about putting extra money into the NHS, hospital waiting lists continue to lengthen and, because of the aging population and the stress that many people face due to high unemployment and more costly mortgages, greater use is being made of the NHS.
Not for the first time, I was confronted this week with a case that many other hon. Members will have faced. An old-age pensioner telephoned me almost in tears saying that he had been discharged from hospital into his home without anybody to look after him. He said he could not cope and was feeling unwell. I had to contact the health authority and social services to ensure that that old gentleman was not left to his own devices.
Such people are not being pushed out of hospital because they are considered to be well enough to manage on their own; they are having to leave to make beds available for others who are seriously ill. The CHCs, by monitoring developments of that kind, can highlight the need for a better-funded Health Service.
Why are health authorities in Wales—and, indeed, all over the country—crying out for cash for patients, when operations are being rationed? At Christmas last year, the Princess of Wales hospital in my constituency stopped all non-urgent operations for three weeks when waiting lists were growing. That is a scandal, and the Bill does nothing to deal with it.
§ Mr. Alan Williams
I did not intend to speak, but I want to respond to one or two points made by the Minister. As he knows from my experience with my local health authority—he has been of great assistance in that regard 334 —I have as great an interest as he has in devising an effective method of controlling what could otherwise be arrogant and arbitrary authorities, although we may disagree on how that is to be achieved. There is no health authority in Wales more arrogant or arbitrary than that in West Glamorgan, as the Minister knows from the case of the Singleton casualty unit. We start from the same premise: we want an effective monitoring system that represents public interests vis-a-vis the policy decisions made by health authorities.
Nevertheless, I find it somewhat worrying—indeed, virtually grotesque—that a Bill that will change the system more drastically than it has been changed since the Health Service was established, so that even doctors are afraid that patients will be rendered into units of account by the budgetary system for GPs and the best-buy approach towards hospitals, also does something very different: it releases into that depersonalised system the very people who are least able to fend for themselves.
As a barrister, the Secretary of State for Health will remember—as will some of my hon. Friends—that, when the House first debated the abolition of the death sentence, one of the arguments against a life sentence of more than 10 years was that people who had served a sentence of 10 years or more became institutionalised. A week ago, a gentleman came to my surgery having just spent 30 years in a series of mental institutions. Now, in the community, he will have to survive as an individual, against the changing background that the Government are trying to introduce. He will find himself desperately dependent.
The Minister said that there would be no alteration in the CHCs' primary role of monitoring the changing pattern of the NHS. As I have said, however, this is a time of the most rapid change since the establishment of the service. As my hon. Friends have said, at the very time when monitoring is most needed—particularly in rural areas—it is being reduced. We are in danger of making the CHCs more inaccessible, not more accessible; more remote, not more available; and more difficult to find and approach.
Sitting alongside the Under-Secretary of State is the Secretary of State for Health, who has not enjoyed the greatest of eulogies in the past few months. But he at least is creating smaller CHCs in England than his colleague is seeking to impose on Wales. The Government are reducing the number of CHCs from 22 to nine, at the same time as they are halving the number of people who will be involved in them, and so halving the number of people available to the public and to carry out the very monitoring that he has admitted remains their primary role.
The Under-Secretary must ask himself how CHCs will achieve their primary function on much diminished individual resources. There just is not the manpower. There is no logic, other than on paper, in saying that there should be one CHC for each health authority. In Wales, except in Dyfed, the Minister is saying that there should be one CHC per county. If that is what he wants, it would be more logical—but not necessarily the best thing to do—to say that rather than create a special quango we already have representative organisations at county level. They are called councils. If he thinks that a county basis is correct, a machinery already exists that is more democratic than the one that he is seeking to impose.
§ Mr. Grist
The right hon. Gentleman will appreciate that we are not proposing to cut the amount of money going to CHCs. Therefore, the nine that we propose would be better resourced and so better able to carry out such work as patient surveys, which they may find beyond them at the moment. There is a pay-off there. It is difficult to know how 37 would be financed, particularly with a standstill on overall finances.
§ Mr. Williams
The Minister says that he will halve the number of people and give them the same resource. If he is cutting back on the number of people, it would be logical to increase the resource in order to enable the smaller number of people to use more up-to-date techniques to achieve his and our objectives.
§ Mr. Williams
But the point is that it is the same money, not more money. Therefore, the financial resource is the same. There are just fewer people to use it and to take advanatage of it. But the Minister does not understand that. That is where he has gone wrong. I hope that he will listen instead of laughing.
The Minister said at the outset that he approached the debate in an open-minded manner, but he does not give that impression and I am saddened by that. This need not be a point of great principle between the two sides. If there is genuine consultation, he should be willing to listen and not take a pre-set position. He should not sneer when someone is putting forward an argument in a reasonable way. I could make a completely different speech, which I would much more enjoy giving and which the hon. Gentleman would much less enjoy listening to, if I wanted to make a political speech. Atypically, I have tried to be eminently reasonable in the debate with the Minister and his colleagues.
The Minister started at the wrong end. He talked of bureaucracy but he brought to us a plan drawn up by bureaucrats for bureaucrats. He started with the system instead of with the people. He should have started not with the number of individual health authorities, but with the 2.5 million patients. He should have asked himself, "What is the correct structure to enable the interests of 2.5 million people to be properly monitored, sounded and represented by and to the health authorities and the Welsh Office?"
The Minister should remember that we are talking not just about policy decisions, but about monitoring local implementation and the results of those decisions. That is what matters to our constituents. That is why I said that he started at the wrong end. I return to the parallel that I put to him earlier; I am not suggesting that there should be 38 councils. He seemed to misunderstand my point.
There is a parallel to be drawn. In Wales we have 38 Members of Parliament, representing 2.5 million people. Does the Minister seriously think that we would do our job more effectively if we each represented two or three times as many constituents as we do at present? If he thinks of his surgery and daily caseload, does he seriously believe that he would do the job more effectively if he was responsible for two or three constituencies? That is what he is saying about the health councils. He wants them to become more remote and more difficult for the public to 336 get to, yet they are supposed to be more representative. He is actually creating the reverse of what, I am sure, he genuinely wants to produce.
Will the Minister not be set and predetermined in his responses? There will be no crowing from the Oppositon if he says, "We have listened to the arguments and we think that some of the points that you have made were right. We reject other points, but on this particular point we think that the Opposition—not just as a party sitting on the Benches, but people in Wales, including the doctors, those in the Health Service, and the patients—are right. We acknowledge that we put forward a proposal in good faith, but on analysis it has proved to be wrong. Therefore, we shall be big enough to step back".
§ Mr. Michael
I had hoped that the Minister would respond to the generous invitation of my right hon. Friend the Member for Swansea, West (Mr. Williams) who was right to point out where the attention should be focused in this debate and to suggest that the Minister should start with the people, patients and the communities in which they live. That is what the debate is about and what the Minister has simply not understood.
Conservative Members have failed to respond to a constructive proposal. It is deeply disappointing that the Minister has been so negative. The Conservative party, generally, has been pathetic in this debate. We had a single sentence from the hon. Member for Pembroke (Mr. Bennett), who has otherwise been conspicuous by his absence. Apart from that, the Minister has been the single, lonely Conservative Member, rejecting the one opportunity open to him to build into this deeply unpopular and dangerous experiment with our National Health Service in Wales the representative of consumers in the community. As a Cardiff Member, I am ashamed of the Minister's response. The city of Cardiff, like every other community in Wales, rejects his plan and needs the new clause. His majority is not very large, so he will not be in the House much longer.
The Minister suggested that the CHCs—and there will be fewer of them—would be better resourced. They have an impossible task. The hon. Gentleman is trying to emasculate them and largely to eliminate the voluntary commitment that they attract and on which their work depends. I was amazed to hear his extraordinary claim that the new clause would fragment the community health services in Wales. That is complete nonsense because it is his proposals that will destroy them.
I regret that the Minister demonstrated his ignorance of the commitment and effectiveness of people in the local community if they are supported and encouraged to help a service in which they believe. The new clause offers a mechanism to co-ordinate the views of the more local CHCs that the hon. Gentleman proposes so that, where appropriate, a single view can be expressed across a county or district health authority area. That mechanism is built into the new clause, so why is the Minister rejecting it?
The Minister suggested that the link between the CHCs and what are now called family health service committees would be removed. That is untrue. The hon. Gentleman could not have read the clause. Paragraph (a) states:shall assume in its area, such responsibilities and duties in relation to health matters and services as are undertaken by the existing Community Health Councils.No element in the work of the existing CHCs will be removed if the new clause is accepted. It involves representation in the development of plans within a county 337 council area because care in the community cannot simply be carried out by the local authority. We cannot ignore the overlap between the social services department, the health authority, the housing department and so on.
The new clause is an intensely practical recommendation. The Minister's response is impractical because he ignores what is done by CHCs—the regular and frequent visits to all hospitals, clinics and day centres; the fact that members of existing CHCs talk to patients and their visitors; the fact that they see conditions in Health Service provision as they are. That is what we want on a more local basis, taking into account the development of care in the community, and co-ordinated countrywide to provide the single, coherent voice that the Minister says that he wants.
I regret that I have to conclude from the debate that the Minister does not believe in giving the consumer a voice; that he does not believe in co-ordinating services in a way that involves the community; that he does not understand how communities tick. He has proposed a plan that will render the representation of the consumer in the community meaningless, and he had better think again.
§ Question put, That the clause be read a Second time:—
§ The House divided: Ayes 55, Noes 140.338
§ Question accordingly negatived.