HL Deb 04 March 1953 vol 180 cc945-75

3.17 p.m.

LORD AMULREE rose to call attention to the difficulties imposed upon the work of hospital committees by the implied rigidity of recent instructions from the Ministry of Health; and to move for Papers. The noble Lord said: My Lords, I have been encouraged to put down the Motion which is standing in my name because I have gradually become aware of a considerable amount of anxiety which is felt by members of hospital staffs and of the various committees of management of hospitals in various parts of the country, not only the management committees who work under the regional hospital boards but also the boards of governors of the teaching hospitals. Before I go further into that question, I should like to recall to your Lordships the position in 1946 when the National Health Service Bill was being discussed in your Lordships' House. One of the points made by the Government speakers at the time—I do not in any way wish to suggest that it was not made in all good faith—was that there should be no fixed central control; that there should be no bureaucratic management but that the work should be decentralised as much as possible upon the boards of governors and the management committees by the regional boards.

It was because of those promises that the Bill had, comparatively speaking, a simple passage. As I said, I am perfectly sure that the promises were made in good faith. But after one has been working in a hospital or upon a management committee one feels, from time to time, that the Ministry of Health are showing a de- sire to control more and more the day-to-day running of the hospitals and particularly the staff appointments, both medical and lay—and by "lay" I mean all the administrative staff and all the people working under the secretary or superintendent. That is something which causes us a certain amount of disquietude, for reasons to which I shall refer in a moment. I want to make it perfectly clear that, speaking as a taxpayer, I cordially welcome any attempt to eliminate waste from the running of the National Health Service. But eliminating waste does not necessarily mean that one must maintain a rigid and firm central control.

The matter has been brought to a head, so far as I am concerned, by two circulars which were recently issued by the Ministry and which show great interest in the size and control of hospital staffs. The first one dealt with the medical staff, the second with the lay and administrative staff. I should like first to deal with the circular relating to the medical staff. Before I do so, however I should like to point out that this attempt to control the size and the appointment of the lay and administrative staff seems to be opposed to one of the promises made in 1946: that there would be no financial leading strings, and that each hospital committee would be free to decide, within the limits of an annual budget, how its moneys should be spent. That seemed a fair and reasonable promise, and it was one which we were all very willing to accept; but I venture to suggest that that promise has not been well carried out.

The first request for information about the medical staffs came in February, 1951—two years ago. Then a request came for very detailed information about the consultants, their names, the hours they worked, what people they had working under them, and so forth. For the hospital at which I work, that entailed sending in a return of twenty-nine stencilled foolscap pages. It involved a good deal of work and I should not think it was of very great value when it reached its destination. That was followed by a medical survey. Teams were sent round to the hospitals to review the staff and to make a certain number of recommendations on the appropriate staffing, which it was the intention of the Minister at that time should become "frozen"—I think that is the correct word—on December 6 last. Before that occurred, however, in September, 1952, another demand was received for information on staffing. This was not in quite the same form as the request in 1951, but it again involved a great deal of work. Therefore there were two sets of reports submitted to the Ministry. The circular letter to which I am referring was one which was sent out on September 30, 1952. Noble Lords may have difficulty in tracing it, but the reference at the top is D.G.4 72/201.


That was not the one; it was the last one you mentioned, dated January 30.


The noble Earl is quite right. From the wording of the circular of September 30, it appeared that it was intended that it should be permissible for the board to increase the approved medical establishment in any grade in any speciality only with the Minister's consent. That was the intention laid down in that circular letter. There have been some substantial modifications in that point of view, and it is now possible for the boards of governors to appoint their staffs, under a certain budget; and recently they have been allowed, I think, to appoint an extra consultant over and above that budget. A great amount of trouble and confusion was brought about between September, when that first circular came out, and the final modification which was issued only the other day. It looks as if there was not much in the way of consultation between the bodies involved, and that the Minister was trying to control rather more than he had promised he would control in 1946, at the time when the Bill was debated.

One cannot advise a hospital in detail upon the nature and appointment of its medical staff. One could, perhaps, if people were all exactly the same; but they are not exactly the same and staffs must be carefully chosen so that they will work as a harmonious whole and cover the whole field of operation. A series of appointments, filled without any thought as to the way in which they will work together and of the modifications needed to cover individual peculiarities and exigencies, is bound to result in a dead, dreary, second-rate level of work. I do not wish to blame the Ministry if that should happen, because I do not think it is their fault—it is the fault of a central control. One thing a Government Department cannot afford to do is to take any chance or risk, or make any experiment. I do not mean that unpleasantly at all; but they must go along fixed lines, because if anything goes wrong they stand to lose a great deal. They are also probably frightened of making any new move which would create a precedent and would, in turn, lead to a desire on the part of other people to adopt the same procedure. There are signs of that happening. It is one of the things which is inherent in central control, and that is what I rather deplore at the present time, particularly in view of the promises that were made at the time of the Second Reading of the National Health Service Act.

Since the period of which I have been speaking a further circular entitled "Economy in Manpower" has been sent round. Economy is something which we welcome very warmly indeed. Any attempt to eliminate waste of any sort, either in manpower or in excessive spending in the National Health Service, is obviously to be encouraged, but I am not at all sure that this is the right way to go about it. This circular went to the regional hospital boards, the management boards and committees, and its reference is 52/133. It is dated December 5, 1952. That circular again dealt with both the medical and the administrative staffs of hospitals—all were called, I think, "staff in post"—and the returns had to be made within fourteen days. A considerable amount of work was imposed on the administrative staff in order to get the returns out. Returns had already been made in 1951 and 1952 of the medical staff, and now a second one was demanded in 1952. When all this extra work is entailed, one wonders whether it is really possible to cut down at all on the administrative side. If the noble Earl, Lord Onslow, is in a position to do so, perhaps he would tell me the number of people now employed on the administrative side of the hospital service—those working in the individual hospitals, on the management committees, on the boards of governors, and on the regional hospital boards—compared with the number so employed before the appointed day in 1948. It is not going to be easy to do that, because there is a certain amount of staff from the local authorities who do hospital work, in addition, possibly, to doing something else. However, I hope that we may be given some information on that point.

Following that circular and return, survey teams visited the hospitals again and made certain inquiries and recommendations. The kind of thing that occurs in some cases, of which I can tell your Lordships, makes it difficult to believe that this is not centralised control coming along. One hospital I know had a visit which lasted a whole morning, and the discussion proceeded entirely on the question of whether certain clerks should be in Grade 4, as opposed, I think, to Grade 2 or Grade 3. That seems to me to come very near to detailed control of staffs. A visit was also made to another hospital—I was told about this; the hospital is not one which I myself know—and the recommendation was made there that two extra clerks should be employed. This recommendation was made despite the fact that the necessary work was being done efficiently by the hospital with the existing staff, without extra clerks.

It is hard to see why someone from outside, not knowing much about the running of that particular hospital, should interfere in details concerning the staff. It is as if someone from a Government Department paid a visit to a business office and said: "We think you want two more clerks in your export department" No doubt the person in charge of the business would quickly tell him to go away. The same thing applies in the case of hospitals: they should be allowed to do their work without interference from some central controlling organisation. Hospitals are very much tied up at the present time from the point of view of salaries. Everything is fixed. Fixed limits are laid down by the central authority. This may be a good thing from the standpoint of economy, but one wonders why people, if they have a budget of sufficient size, should not be able to pay out sums, including salaries, which they think reasonable and appropriate within the limits of that particular budget.

Members of the boards of hospitals are appointed, I believe, by the Minister himself. Surely the kind of people who would be appointed would be those who could be trusted to do this work efficiently andproperly. I am afraid that if they are not allowed to do their work without so much control, the time will come when the Minister will find that he will be unable to get people of sufficient responsibility to accept seats upon these boards. That will mean that the control will be forced back to the central department. My Lords, that is all wish to say at the moment. I will not speak at greater length on this subject because there is, I know, a long list of speakers. I beg to move for Papers.

3.33 p.m.

LORD SALTOUN had given notice of his intention to move to resolve, That reasonable economy being of great importance in the National Health Service, rigidity might be relaxed to permit the employment of appliances not less efficient nor more expensive than those of the kind listed in the Drug Tariff. The noble Lord said: My Lords, I think it will be for the convenience of your Lordships if I deal with my Motion now in order to give the noble Earl who is to speak on behalf of the Government a chance to answer the whole matter. Then, if necessary, I can move my Motion formally later.

The Motion in my name originated in the following circumstances. A doctor prescribed for a National Health Service patient, on the appropriate form, two tins of Penicillin Nonad Tulle dressings, 2 in. x 2 in. The two boxes contained seventy-two dressings and cost together 10s. 6d. In due course, after it had been made up, the prescription went to the Executive Council, who refused to repay the chemist, on the ground that these tins of dressings were not appliances coming within the provisions of the Third Schedule to the General Medical and Pharmaceutical Services Regulations. I should perhaps explain to your Lordships, in order to make matters clear, that a doctor, under the arrangement which I am complaining about, can prescribe for any National Health Service patient any drug he chooses; but he may not prescribe what are called appliances. He may not prescribe dressings or a large number of other things—things which are not exactly drugs, but which are equally necessary for a patient—unless they are included in what is called the Drug Tariff. As a matter of fact, this particular dressing is included in the Drug Tariff, but only in sizes of 4 in. x 4 in. or thereby, and the cost is 5s. for a tin of ten or 36s. for the seventy-two dressings ordered by the doctor, in the case to which I draw your Lordships' attention. Presumably, the prescribing doctor thought that the nature and position of the wound required the smaller dressing, and he prescribed accordingly. The chemist was compelled to fulfil the order.

Your Lordships will appreciate at once that a chemist cannot alter a doctor's prescription. He cannot—or at least, it would be a very foolish thing to do—send his customer away empty and so injure his own business. But even if he were willing to do that, how can he let a patient suffer because of a thing like that? Very few chemists would let a patient suffer because of a mistake. Even if it were a mistake, the chemist, usually, would go ahead. I do not think for a moment that the noble Earl would say that the chemist should refer back to the doctor. I would point out that a doctor attends morning surgery, then he goes out on a round, and he is probably absent from home all day. In the evening he again has to take surgery. It may be that he has surgeries in other parts of the borough, so that a chemist would probably be unable to get in touch with him for at least six or seven hours. It might well he that a delay of twenty-four hours would be involved. In fact, in cases which are quite common, to my own knowledge, it would mean a delay of as much as three days. I do not think the remedy of referring back to the doctor is a remedy which the noble Earl would care to recommend, and I do not think that that is the answer I shall receive to-night.

In Scotland, this difficulty could not have arisen because in Scotland the sizes and details of appliances are not specified, and any appliance ordered by a doctor on a proper prescription form is fulfilled and paid for in the ordinary course. I was shocked when this case was brought to my attention because it means that here are a doctor and a chemist working in unison, and they have incurred for the National Health Service a charge of 10s. 6d. avoiding, what they might very well have incurred, a charge of 36s. All that happens is that the chemist is refused payment for the dressings which he has supplied. I have in my possession a considerable list of similar items ordered by doctors, the charges for which have been disallowed. In consequence, I have been at some pains to discover how this situation has arisen, and I think your Lordships will be a little interested in the explanation.

The arrangement is governed by a statutory instrument of 1948, No. 506, of which Schedule 4 gives the terms of the chemist's contract. Paragraph 3 of the Schedule lays down that: A chemist shall supply with reasonable promptness to any person who presents an order for drugs or appliances on a prescription form provided for the purpose by a Council and signed by a practitioner…such drugs and appliances as may be so ordered. I do not think any of us will quarrel with that. Later on, in paragraph 8 (4), it is stated that: Payment will be made for drugs and appliances mentioned in the Drug Tariff at the prices specified therein and for drugs or appliances not mentioned in the Tariff in the manner set forth therein. That is surely quite clear, and I do not think any of your Lordships will quarrel with that. Then Regulation 27 of the same statutory instrument lays down that: The appliances to be supplied to persons receiving general medical services shall be the appliances specified in Part I of the Third Schedule. Part I of the Third Schedule is a generalised list, resembling the chapter headings of a general wholesale drug and appliance supplier. It contains headings like "atomisers, hand-operated," "bandages, calico, crepe, etc.", "rings, cotton wool, etc."—every sort and kind of thing. There are no specifications of size or anything else.

Regulation 28 lays down that the Minister shall cause to he prepared a statement which shall include the standards of quality for drugs and appliances. If I had not been told that the state of affairs about which I am complaining has always been the rule, and that this is a long-standing grievance, I should have thought the passages I have read out to your Lordships made it clear to us, and to everybody in the world, that payment was to be made in proper cases for appliances which do not find a place in the Drug Tariff. Nobody could believe that the effect of the passages I have read to your Lordships—and they are not modified, so far as I know, by anything else in the instrument—would be that a chemist would be denied payment for a penicillin bandage 2in. x2 in., simply because it does not find a place in the Drug Tariff, whereas he would have been paid for a bandage 4in. x 4in. I can only suppose that the Ministers of the Crown have taken counsel of Humpty Dumpty who, your Lordships will remember, laid it down that words were not to mean what they said but what he wanted them to mean.

I suppose that in some way, which I should be glad to have explained to me, the statutory instrument means something different from what it seems to mean. In fairness, I should say that in 1950 an amendment was made to this instrument, to the effect that die Minister would have to state standards of quality for drugs and specifications for appliances. That might cover this sort of thing if it had not already been provided. But I am bound to say that, when this instrument was laid on the Table of the House, I think none of us could have thought that bore the meaning about which I have to complain this afternoon. I do not for a moment think that the doctor concerned was to blame. The patient had an injury or a wound, and the doctor prescribed on the proper form what he thought was necessary. But whether the doctor was right or wrong, on one thing we can be perfectly certain: the chemist was not wrong in supplying what the doctor thought necessary. If there is a difference of opinion between the Ministry and the doctor, it is not fair to make the chemist pay the penalty or bear the burden of their difference.

I have already said that this is not a solitary case, but I do not want to give your Lordships a long list of examples. I imagine that you will probably be willing to accept from me that there are more instances of this kind—I have given the Ministry of Health a list of them. I submit to your Lordships that a relaxation of rigidity in this matter should be made at least to the extent suggested in my Motion, that if a doctor orders something which is not in the Drug Tariff and which is more expensive than the similar article in the Drug Tariff, the chemist should be reimbursed to the amount in the Drug Tariff. Alternatively, I suggest that it would not do us any harm here in the South to adopt the practice in Scotland, of listing the majority of the appliances in the Drug Tariff in the most generalised form. We are all indebted to the chemist who brought this matter to my notice, because it is an example of a grievance about the administrations of the National Health Service which, in one way or another, is extremely irritating, even though it may not concern a very great amount, and which I am sure is widely felt in the country.

3.46 p.m.


My Lords, we are all grateful to the noble Lord, Lord Amulree, for raising this subject, which naturally is beyond and above Party politics, and is one which from time to time should be looked into and discussed. We are also grateful to the noble Lord, Lord Saltoun, for dealing with his Motion immediately after the noble Lord, Lord Amulree, had spoken. Certainly I am grateful to him for this, because it relieves me from the need to make two speeches, and I am sure the House is delighted that it will not have to listen to me twice. May I, with your Lordships' permission, deal first with the remarks of the noble Lord, Lord Saltoun, as their subject is narrower than the first Motion?

As the noble Lord rightly stated, the Schedule gives a general list of drugs and appliances. But the document on which the chemists and doctors work is the Drug Tariff. I have made extensive inquiries about the Drug Tariff, and I believe that it is almost 99 per cent. fool-proof. There are one or two small things which are not there because they are so rarely used. I can assure the noble Lord that the matter he has raised is being dealt with. In fact, it was already being dealt with before he raised the matter in his Motion, and I assure him that in a few weeks a scheme will be devised with a small enough mesh in the net to catch up those anomalies which result from the structure of the Drug Tariff. The reason why the particular item the noble Lord mentioned is not in the Tariff is that it was considered that that particular size and quantity of penicillin dressing were so rarely used by doctors in general practice (they are mainly used for wounds treated in hospitals) that it was felt that if this particular pack of the dressing were included in the Tariff it might lead to considerable waste. I think this is a sound reason for not including it into the Drug Tariff.

As regards what the noble Lord said about Scotland, we know that from time immemorial noble Lords and their countrymen over the Border have striven to preserve their independence, and that the Scottish way of life, in medical affairs as in others, is different from ours. The original scheme has been reviewed from time to time, but it was felt that if we had the Scottish system in England it would be a great deal more expensive than the system to which we have become accustomed in this country. I am sure that the noble Lord would like to keep his Scottish independence. I hope that I have answered the noble Lord, Lord Saltoun, and, with your Lordships' permission, I will now turn to the initial remarks made by the noble Lord, Lord Amulree.

I should like to say straight away that when the 1948 Act went through your Lordships' House, although on Third Reading we felt we could congratulate ourselves that we had made a better Bill out of the Bill as it came to the House, we were aware that it was by no means perfect. I think everyone realised that an Act which made such great changes in our medical system might have to be revised and amended as time went on. When the Bill was initiated, noble Lords opposite were in power, and I feel sure they will agree that the underlying purpose, so far as hospitals were concerned, was this. There were some hospitals which appeared to have plenty, and many that appeared to have less than their fair share of the country's hospital resources. And the object of the Bill was to gather up these resources and distribute them so that each hospital achieved a reasonable standard. Once that sort of thing is done, public money is more closely involved; and public money must be accounted for, and a watch kept upon its use. It is the old argument of decentralisation or centralisation. If there is centralisation, then the central authority must keep a careful watch on expenditure; though, at the same time, as much freedom as possible should be allowed in day-to-day management—as, indeed, the former Lord Chancellor stated, in the extract from Volume 143 of Hansard, already quoted by the noble Lord, Lord Amulree.

With regard to the two documents from which the noble Lord quoted, the first, BG 4/72/1201, was not a circular, but a letter written to teaching hospitals. Perhaps the wording of it is not quite what the noble Lord would like, but its intention was this. Medical review teams had studied the medical staffing of the teaching hospitals and had made suggestions to the Minister. These letters brought these suggestions to the notice of the teaching hospitals and asked for their views. They were by no means an order to the hospitals to alter their day-to-day arrangements, but they merely drew attention to what the investigating team had suggested to the Minister, and asked for comments. If the hospitals thought they could benefit by this, well and good. After all, a great advantage of the nationalised hospitals, surely, would go by the board if the experience and suggestions of various hospitals and medical authorities were not from time to time pooled and brought to the notice of others, so that all could get the best. That was the point of the first document.

The other document to which the noble Lord referred was a circular, but again it was not an order. If the hospitals found that they could not comply with suggestions put forward in that document, they were quite entitled to say so. The main intention was to keep a check on proposals for increases of staff, particularly on the administrative and clerical side. Your Lordships are all aware that once a central authority is built up, be it for hospitals, transport or anything else—I personally have seen it in the Army—there is always the danger of overloading the administrative side as against the operative side. The review on which this document is based was started as long ago as 1950. One aim of this particular document is to produce an eventual reduction of something like 5 per cent. on the administrative and clerical side, a target set by the present Minister. But, again, these targets were not orders; they were merely suggestions. I should like to assure the noble Lord that this is part of the scheme to pool information and resources, in order to keep down the cost, and that there is no wish—I emphasise this—to interfere on the medical side, or with the general efficiency of the hospitals or institutions concerned.

The noble Lord asked me for certain figures. I am afraid that I cannot give him figures before 1948, because suitable statistics are not available for the years before that time. However, I can give some figures of hospital staffing in 1948, as compared with 1951. The number of administrative, clerical, and similar staff employed in the hospital service on December 31, 1948, was 21,933, and on December 31, 1951, 29,021. However, these figures are not quite comparable. The increase is not as great as it may appear, since in 1948 a certain amount of the administrative and clerical work of the hospital service was still being carried out by local authorities on an agency basis, whereas now that has been taken away from the local authorities and these people are whole-time servants of the hospital organisation. The number of maintenance, transport, and similar staff employed on December 31, 1948, was 22,803, and on December 31, 1951, 22,125. The figures for professional and technical staff (other than medical, dental and nursing staff) are: on December 31, 1948, 11,825; and on December 31, 1951, 16,631. That includes radiology auxiliaries and similar staff. Where this sort of provision is expanding for the good of the community I do not think anyone will grumble that the figures should have increased. On those figures—and I can assure the House that they are as accurate as figures can be—I do not think one can grumble and say that staffs have swollen too much since the National Health Service has been in existence. I hope that I have answered the main points of the noble Lord, and if I have missed any I am certain that my noble and learned friend the Lord Chancellor will answer them later in the debate. But, as I say, for my part, I hope that I have satisfied the noble Lord, Lord Amulree, and the noble Lord, Lord Saltoun.

4.0 p.m.


My Lords, the noble Lord who has just spoken has given the House a good deal more information than it might have expected to receive, because this is a very difficult subject and the details are buried in documents. I happen to have in my hand at the present time a copy of the document which has been referred to, dealing with the question of economy of manpower. I have no doubt that the noble Earl, Lord Onslow, has a copy, too, as has possibly my noble friend Lord Amulree, but I am not sure. It is very important indeed that these economies should be quite definite. I was glad to hear the noble Earl, Lord Onslow, say to-day that the underlying purpose of the changes made in 1948 was to give fair shares for all in hospital and medical services. That is really the point. I am not sure myself that we are getting that at the present time. I am not sure that we are getting it in the country districts.

For instance, those who have studied this subject in the past have probably read a whole survey of the medical services in the country, and especially those in the south-west region about which I am thinking at the moment. The headquarters of that region is at Bristol, and it extends down to Devon and Cornwall and the neighbouring counties. In the whole of that region there is only one fully staffed hospital, and that is at Bristol. At the present time there may be, and I think there has been, some increase in the specialist and special service arrangements made at different hospitals up and down the area. But I think it is still true to say that the Bristol hospital is the only one which is really first class.

My noble friend Lord Amulree speaks as a member of the staff of one of the London teaching hospitals—one of the best equipped in the world. That hospital is very different from some of the out-of-the-way hospitals one finds in country places. Even this document dealing with economies in manpower, although it contains criticism of over-staffing in some respects, points out that in certain circumstances there is a serious undermanning—for example, in the nursing staffs of some mental and tuberculosis institutions. That is just the kind of institution where we do not want under-staffing.

I hope that this debate will draw attention to the need which still exists to equalise the provision of hospitals and the facilities for specialist treatment all over the country as well as in regions such as London, Edinburgh and other parts, where there are teaching hospitals and where, of course, the provisions for specialist treatment are as good as they can possibly be made. I do not feel satisfied that at the present time we are doing the best we can in that respect. I confess that I am perhaps biased to a certain extent by the fact that for a number of years I have been the Chairman of an organisation which is called the Medical Manpower Committee, which deals with the allocation of medical manpower to the three Services: the Navy, the Army and the Air Force. There we have to be exceedingly economical, because the number of doctors on whom we can call for the three Services is limited. It goes according to certain age groups, as the House knows, and the service has to be one which is ready to enter into battle and to deal with epidemics in any part of the world at any time.

I think we may claim with pride that the medical services of the three Services are certainly as good as, and, one might even think in some respects, better than any others of that kind in the world. But the people who are carrying on that work certainly have placed at their disposal the facilities of hospitals and of a number of consultants, although the total number of specialists is always very much smaller than is needed. However, they still manage to do extremely good work. If we apply the same economy of distribution to the civilian services, we shall be able to cover the whole country much more thoroughly than can be done in the case of the Armed Forces. I am not saying for a moment that the Services have a bad service; they have a very good service; but it works on a very rigorous economic basis.

I hope that, as a result of this debate, the Government will say that they are looking further into the equalising of the provision of medical services all over the country. May I take an actual instance? Suppose a man in the depths of Cornwall has an acute abdominal condition which requires an operation, is there any reason why he should not be as quickly looked after as another man in London? At the present time I do not see that he can be. There is one thing I can say, not from the standpoint of a critic, but perhaps as one who may claim to know something about the service in general. The maximum of liberty is always allowed in every medical organisation with regard to the organisation. There is no question of dictation. It is always a question of consultation, and I hope that that consultation will go on and will improve. The noble Lord, Lord Amulree, works in a luxurious hospital which, I believe, has 1,000 beds and getting on for 200 doctors. That cannot possibly be the case all over the country, because that number of medical staff is very great. I hope that before many years are passed we shall get in all the various parts of the country, services as good as those we have in London, and that there will be a real equalisation of the country's services, as was intended when the original provision was brought before Parliament.

4.8 p.m.


My Lords, I think few people will complain about the need for adequate supervision, scrutiny and direction over the spending of public money. The question which I think might be debated, and is being debated, is: in whose hand should the direction of spending be placed? It goes without saying that the Ministry of Health must lay down at least general lines for the direction of the management committees and boards of governors as to how the money allocated to them should be used. The difficulty of the situation arises, and has arisen just now, because the direction and the policy has been made too detailed and too rigid. What, in effect, is being done is to negative the efforts of those patriotic men and women who are giving so much time and thought to implementing the requirements of those parts of the National Health Service which come under their purview. If the authorities are too rigid or too detailed in their directions, it removes the initiative, the enthusiasm, and the imagination from those workers; and that is not good. There are already people on these hospital committees who are saying: "What is the use of my giving my time to these committees when the directives are so detailed that they can be carried out just as well by the permanent staffs?" In consequence we are risking the loss of some of our most vigorous men and women. It may be, and probably is, true that this feeling of frustration and uselessness is greatly exaggerated—I am quite prepared to admit that. But we must remember that the belief exists. The annoyance exists; and the damage is done. I could give many examples of what is happening. I know a very enthusiastic committee which has worked in close co-operation with its public-spirited staffs and which, as a consequence, will probably save this year £15,000 on its budget.

But think of the consequences of the refusal of the authorities to allow a small increase in the staffs of these hospitals in order to save the hard work which the officials, medical, nursing, and administrative, are putting in. Here is one instance. The Ministry desire, and rightly desire, an inventory to be made in these hospitals. The workers of these hospitals have been treated as so many of the keenest and most patriotic people are treated when the Government demand that something should be done. They were amongst the first to cut their requirements to the bone, and in consequence their requirements for 1948 (I think that was the year) are now taken as the basis of their needs to-day. The Ministry say, when a demand is made for two extra clerks to do the inventory, "You must get on with your own staff: that is quite adequate." These two additional clerks would be required for two years only; they would have specialised in this work and have become very efficient in it. In consequence of the refusal of the request by the hospital committee, the existing staff, already worked to the utmost, will have to work overtime; and I am assured that it will probably take them six to seven years to do this work. The fact that these extra clerks have been refused will mean that the work will not be done quite so efficiently, because it will be done after hours, when the people doing it are already tired. All this is very frustrating to the administrative staff and to the management committee.

Let me give another instance, in another hospital; it concerns the nursing staff in the operating theatre. In this hospital the theatre sisters have to work very hard indeed. It is true that, to some extent, if they have to work a great deal of overtime, they are compensated by time off; but that is not good enough. The situation could well be eased by allowing the appointment of an extra sister. That, again, has been refused. Is this real economy? Is it economical to act in this restrictive way? There is a good deal of indiscriminate restriction, and what I am pleading for is that the management committees and the regional boards should be given very much more elbow room, so that money saved in one direction could be used in another direction. In the end this would be good business and good economy. A satisfied and happy staff, working with enthusiasm, will give very much better results; the most vigorous and enthusiastic men and women, who, after all, are devoting their time for nothing, will not be frozen out. I am asking that this greater elbow room and elasticity should be granted by the Ministry, and that the life and humanity of the hospitals should be preserved, rather than that everything should be submitted to the frustrating and killing effect of finance. I hope that no one will take my observations as a criticism of the officials at the Ministry. In all my dealings with them I have always found them courteous, understanding and very desirous to help. I rather suspect that they act as the unfortunate buffer which has to take the blows of what I can only call an inhuman machine—a machine one of the duties of which is to be tough.

4.17 p.m.


My Lords, I am glad to follow the noble Lord who has Just sat down in making a plea for elasticity, and in expressing the hope that we may see, in place of the rigidity which is referred to in the Motion on the Paper, a little more flexibility. I do not propose to keep your Lordships long. I entirely agree with the noble Lord, Lord Amulree, about the danger of over-centralisation. I think this danger has existed at times and I was very glad, therefore, to hear from the noble Earl who spoke earlier on behalf of Her Majesty's Government that this certainly was not intended. I hope that if this debate does nothing else it will keep that danger before us, so that it may be avoided. With regard to the question of finance, I should like to assure the Minister that we who have responsibility for watching hospital finances are doing our level best to carry out the economies which the Ministry are asking of us—though it is certainly difficult, because so many of the expenses that we have to face are outside our control. The amount of such expenses forms a very large proportion of the whole. However, as I say, we are doing our best. I should like to remind Her Majesty's Government that hospitals are not just static units. They have to go forward; and I think there will have to be a great deal more progress in all our hospitals all over the country if we are to tackle successfully the ever-increaing work of giving everybody immediate and proper attention.

With regard to elasticity and flexibility, I hope that it will always be remembered in the Ministry that each hospital unit is different from the others. It seems to me it is quite impossible to frame something that will fit everybody or every unit. No framing of either legislation or directives is likely to fit all types and sizes of unit. But if (and here I entirely agree with what the noble Lord who has just sat down has said) there could be laid down a general policy on matters concerning hospital administration in its wider sense, this would allow each unit to place its own interpretation on that policy. If that were done, I believe that things would be much happier, and certainly very much easier, for boards of governors and others. It would, at the same time, give greater authority to those boards and not make their members feel, as I have sometimes known them to feel, "Well, we cannot do much about this because we are told exactly what we have to do and we have not much choice." If the boards were given greater authority, it would impress upon them that the Ministry were showing greater confidence in them.

4.21 p.m.


My Lords, I am sure that we must all be grateful to my noble friend Lord Amulree for raising this matter this afternoon. I am very pleased indeed to follow the noble Lord who has just spoken. May I suggest to your Lordships that there are two separate issues. The first is: should cuts be made at all? The second is: if cuts are to be made, are the Ministry not acting, too rigidly? My noble friend Lord Amulree has dealt more particularly with the second issue. While yielding to no one in a desire for genuine economy, and not for one moment suggesting that here and there in the hospital services there may not be some wasteful expenditure which should be eliminated, I suggest to your Lordships that, taking an overall view, for the hospital services even to maintain the standards of two years ago in the present background of rising prices and increased wage and salary rates, is impossible without increased Exchequer grants. Therefore, on the Government's present policy there can be only one result—inevitably lower standards of service.

Even two years ago in many directions the standards were hopelessly inadequate. Waiting lists, even in general hospitals, bad as they are in some places, are kept to the present level only by a rigid selection of patients, while for an elderly person to get into hospital even with an acute illness is as difficult as the entry of the rich man, in the parable, into the Kingdom of Heaven. In this connection, may I quote a few sentences from the official journal of the Institute of Hospital Administrators? It states: So long as the present shortage of beds continues we shall have with us the waiting list and all that it implies. Besides mental defectives, the aged and infirm and patients suffering from chronic conditions, where the problem may be as much social as medical, there is a large and heterogeneous group of cases, mainly surgical, which can take their turn on the waiting list without grave risk of the patient's life being immediately endangered. Yet even as regards this latter group of cases we all know that, even if the patient's condition is very far from endangering his life if untreated, it may yet be important, both on grounds of humanity and on social grounds, that he should have prompt hospital treatment. That is an official diagnosis of the position existing in our hospitals to-day from The Hospital, dated January, 1953—an up-to-date survey of the position.

If, however, the need for cuts in hospital expenditure is accepted—and I do not accept it in the background which I have endeavoured to indicate—then there is still the question of rigidity raised by my noble friend Lord Amulree. For example, the recent Ministry circular demands 5 per cent. cuts in hospital staffs other than the nursing and medical staffs and, as I understand it, excluding administrative and clerical staffs, who are to be subjected to reports by investigating teams. I suggest that that circular is stupidly rigid. It takes no account of whether any particular hospital or group of hospitals has already been run with the utmost economy. Moreover—and this is most important—it takes no account at all of the impact on the patient, which may be altogether out of proportion to any possible saving.


I do not want to interrupt the noble Lord unnecessarily, but I think he is slightly mistaken there, because if a hospital feels it is running as economically as it can there can be no question of asking it to reduce expenditure in any way.


I was coming to that point. I am glad the noble Earl hasintervened to re-emphasise the point he made in his speech. A little later in my speech I was going to give him full marks for that statement and to say that I hope that it will receive the widest possible publicity. Because, as one who is going in "on the ground floor" again and serving in quite a humble capacity on a hospital management committee, I can assure him that the edicts from the Ministry of Health are not regarded as being drafted in that kindly and sympathetic way which the noble Earl has indicated this afternoon. If this debate has served no other purpose than to have that authoritative statement from the noble Earl, it has been well worth while. I was going on to say that if cuts took place in the domestic staff—presumably, if the circular is rigidly interpreted, that is one field of a possible cut—it would mean that the nursing staff would get back again to those bad old days when the nurses did almost all the domestic work in our hospitals, to the neglect of their proper work as nurses.


My Lords, I do not want to interrupt the noble Lord, but he gives a false impression of this circular. Let me read one passage: In no case should reductions be achieved by transferring domestic work to nursing staff.


That is a sort of ideal suggestion. It is not transferring the domestic work, but it is cutting down domestic staff. What is to happen then? The work has to be done, and I ask anyone engaged in hospital administration what would happen if the domestic staff were cut down as I am suggesting may be the case.


May I put a point to the noble Lord? I regard the noble Lord's statement as rather a reflection upon those of us connected with the voluntary hospital system, as I was for forty years. I was for thirty years chairman of a hospital. The noble Lord's suggestion that the domestic work of the hospital is done by the nurses is quite inaccurate.


It may be in the happy circumstances to which the noble Earl referred, but I can assure him that in the voluntary hospital that I know, and in municipal hospitals, too, before some of us came into a position of responsibility for those hospitals, a great deal of the domestic work was done by the nursing staff. As a matter of fact, in the 'thirties and onwards we had specially to employ people for that work. I cannot go back quite so far as the noble Earl, but the 'thirties is a fair way back.

I said I would give full marks to the noble Earl, Lord Onslow. My last point is again a quotation front The Hospital, which further endorses, shall I say, the considered view of an institute comprising the most responsible men and women in the profession. If these responsible men and women get the impression which is conveyed in the short extract which, with your Lordships' permission, I will read, your Lordships will see how important it is to get the assurances we have had from the noble Earl. This is what the journal says: Lastly, it cannot be too strongly stressed that the new measures viciously continue the lamentable process of increasing centralisation and rigidity of control. The measures now ordered are at complete variance with the spirit, if not with the letter, of the 1948 regulations setting out the respective functions of boards and committees. They in fact make a complete mockery of any idea of decentralisation of administration in the hospital service and represent the most flagrant whittling down of functions and responsibilities of management committees which has yet occurred. They cannot but arouse antagonism and aggravate unrest and distrust throughout the service, and may well cause friction between boards and committees. Whatever the ostensible reductions in staff which may be achieved as a result, the real effect of the measures will be costly to the efficiency and economy of the service…Measures of this kind constitute precisely the wrong way to go about securing a healthy, efficient and economical service. That is a fairly stiff statement in a journal like The Hospital, which speaks with the fullest sense of responsibility. If the noble and learned Lord on the Woolsack repeats, as I hope he will, the assurances that these are suggestions and not mandatory, then I am sure Lord Amulree and many others will be very glad that this debate has been initiated.

4.34 p.m.


My Lords, as another member of a hospital management committee, I think it is only fair to say that probably nine-tenths of the troubles from which we are suffering lie in the lack of money, and the birth pains of a new system. Either costs in the system are too high in relation to what is being done, or too much is being attempted with the funds available. In any case, a study of costs must come first, and a careful survey should be carried out with a view to reduction. Thereafter, if funds are still inadequate, those in authority will either have to declare openly for lower standards in some quarters or adopt some means of supplementing income, however unpopular that may be.

I feel certain that the original plan for administering the hospital service was wise. It was based partly on voluntary and partly on full-time personnel, and the units of administration were to be as free as possible to work within a common policy and a pre-determined budget. The personnel side still operates, and we have the benefit, without cost, of expert advice and a wealth of experience given by many public-spirited persons, some of whom have devoted themselves for years to the cause of hospitals. We also have a certain continuity with the past. On the question of freedom, we have undoubtedly moved a long way from the original concept. Whether or not this is temporary, I do not know. It goes without saying that all appreciate the need for economy—none more than the hospital management committees. They are, I think, now prepared to accept a certain curtailment of their authority, in view of the urgency of the national need. But they should be assured, if such is the case, that this curtailment is temporary and that the original plan will be restored.

Hospitals are exceedingly complicated units. Each is an individual problem, as is each case. I doubt whether any two hospitals are comparable. Two facts, therefore, follow. The first is that in any organisation such as this, where experts abound on all levels, those most closely in contact will probably know how to get the best results from the hospitals in their group. Secondly, no rigid system will ever apply uniformly to every hospital—there will always be a certain deviation and a corresponding need for flexibility. And this, I feel, should be reflected in the administration.

It is notoriously much more easy to criticise than to construct, and it would be sheer hypocrisy to suggest remedies which are impracticable. I would therefore confine myself to some very modest suggestions. First, I can see that early, positive results are needed from the conferences which I understand have recently been taking place with regard to the institution of accosting system. Nobody appreciates more than I do the difficulties, but an early start and a gentle introduction would give confidence, make for a certain uniformity, and assist estimates and discussions. Secondly, freedom must be restored to the hospital management committees, in the form of block grants and flexibility in the use of the money. Thirdly, and simultaneously, a careful survey of the whole system should be carried out, with a view to economy by the elimination of redundancies and waste through alternative or improved methods.

Fourthly, since administration is so obviously expensive, I feel that a realistic survey of the activities of the regional boards should be made with a view to the prevention of overlap between them and the hospital management committees, and the possible restriction of their task to policy and planning. Lastly, I think it would help those administering the service if the proportion of the total health money voted to this service, as opposed to other calls on it, were made much more clearly known to the public. No doubt there are many further points, but the adoption of some of these that I have suggested would, I think, help to obviate the necessity for instructions, which I trust are as distasteful to give as they are vexatious to receive and frustrating to carry out.

4.38 p.m.


My Lords, it falls to me to wind up this debate on behalf of Her Majesty's Government. This is not an occasion upon which your Lordships will expect any pronouncement upon policy or anything of that kind—indeed, I think my name was put at the bottom of the list as a matter of courtesy to noble Lords who intended to speak, so that I should, so far as I could, take up any points which were made by later speakers and which had not been answered in advance by the noble Earl whose duty it was to reply on behalf of the Government.

Perhaps your Lordships will allow me these general observations. First of all, let me assure those of your Lordships who have spoken that what they have said will be brought to the notice of the Minister of Health, who will most gladly give weight to their suggestions, and in particular if I may say so to the very able and interesting observations of the noble Lord, Lord Milne. Your Lordships will, of course, bear in mind this: that the Minister of Health is faced here with the eternal conflict between, on the one hand, a proper supervision where national finances are concerned, and, on the other, the requisite delegation of authority. And nobody realizes better than the present Minister of Health how important it is to delegate authority, so far as it can be properly delegated—and for this, if for no other reason: that he realises how much importance is to be attached to the voluntary services of those citizens who give so generously of their time to the work of the hospitals and of the regional boards. Anything which suggested that they would be frustrated in their work and would feel that it was not worth their while to continue with it, would, I am sure, hit him very hard; for, as I say, he realises how important it is that they should continue to make the contribution which they have made to the full performance of this service.

That is the first general observation I would make. The second is this. Your Lordships will realise that the initiation of this great National Health Service involves the Minister in, I think, three very important considerations. He has, so far as possible, to see that there are fair shares for all. That is a matter to which the noble Lord, Lord Haden-Guest, referred. The noble Lord speaks, if I may say so with the greatest respect, always interestingly, and with accepted authority, on these matters. That is a matter which the Minister has to bear in mind. For that reason he will feel it very difficult, I think, to subscribe to what Lord Amulree said about allowing each regional board or hospital authority to pay whatever it thought fit to pay. Clearly, that would mean that one hospital could, by offering higher rewards, draw from another services which the latter hospital required. The second matter which the Minister has to bear in mind—and this is a national matter—is that, so far as possible, equality of conditions should be observed. That is really complementary to what I said just a moment ago. Bur it does demand a certain amount of supervision. The third and overriding consideration is that the Minister is responsible for the money that is spent. When your Lordships realise that for hospital services alone the Health Service is now demanding annually a sum approaching £300 million, your Lordships will realise how essential it is that that supervision should be strict—I avoid the word "rigid."

These are the considerations which the Minister has to bear in mind. When your Lordships realise that that is the position, I do not think you will consider that the circular which has been the subject of criticism really deserves any harsh criticism, at any rate. Let me remind your Lordships of this point, because, if I may say so, I think the noble Lord, Lord Burden, introduced a somewhat new note into the debate by quoting and using as his own such adjectives as "vicious" and "stupid." As I say, he introduced a somewhat new note and in doing so, I thought, he might have given a somewhat wrong impression of the circular which has been the subject of criticism. May I read the opening words of this circular—it is called a memorandum—to which reference has been made? It begins by saying: This memorandum stresses the overriding need in present circumstances for economy in hospital running costs, and asks Boards and Committees to review their staffs and achieve reductions wherever possible. It also requires Boards and Committees to obtain approval before increasing the total number of staff employed, the staff being for this purpose divided into certain broad categories. Are there any noble Lords who think it wrong that, at the present moment, in the interests of economy, a review should be instituted? If so, let me remind those noble Lords that the Select Committee of the House of Commons, in July, 1951, reported in favour of a review of the Health Service costs and the hospital costs upon a national basis. And that has to some extent now been done.

Let me now read your Lordships another paragraph from this circular: It is known that in recent months a number of Boards and Committees have carried out reviews of their establishments, and that in some instances it has been found possible to reduce the number of staff employed. All Boards and Committees are now asked to undertake such reviews with the aim, wherever possible, of making similar reductions, the Regional Board participating in the reviews undertaken by the Management Committees in its area. Is that not a laudable request or direction? The circular goes on to deal with increases, and while permitting increases—I must put this as accurately as I can—for the purpose of considering such increases it divides staff into certain categories. The total number of staff within each category is not to be increased without permission, but within each category there is complete flexibility. For instance, within the category which embraces some of what I might call the domestic staff, and a number of other branches as well, a reduction may be made in one class of service within the category and an increase made in another. So there is a considerable amount of flexibility. There is not to be a total increase of staff without consent, but there is no reason to suppose that, if a proper case is made out, consent will not be forthcoming. I will not weary your Lordships by reading the whole of the circular, but it would give an entirely false impression, I think, if it were suggested that absolute rigidity is imposed, that there is no flexibility, and that there cannot be an increase in staff where an increase is desirable.

There is another matter to which I wish to call attention, because it has been the subject of some comment by one noble Lord. What I have particularly in mind is this paragraph: Applications for increases in these maximum numbers should not subsequently be made"— that is after the review— without the most careful consideration by the Board or Committee concerned. Before applying, they should be fully satisfied that the increase is justified by exceptional circumstances such as serious under-manning (as, for example, exists in the nursing staffs of some mental and tuberculosis institutions).… So that the Minister there recognises that increases may be made and, indeed, suggest that they ought to be made in that class of institution.

Then the circular, or memorandum, goes on to deal, in considerable detail, with what is proposed and suggested, and ends up with a summary of action required, which I venture to read to your Lordships. It states: (i) Boards and Committees should make an immediate return of their staff numbers. The present numbers"— that is, the numbers at December 5— are to be maxima not to be exceeded without approval.

  1. (ii) Applications for increases should not be submitted or approved without the most careful examination.
  2. (iii) Boards and Committees should review their present numbers and make reductions wherever possible.
  3. (iv) The reductions should broadly counter-balance approved increases.
  4. (v) A 5 per cent. reduction in category D staff"—
that is, the junior staff, the lowest grade— should also be aimed at. (vi) Progress returns are requested. Of course that request involves a degree of trouble for hospitals, but where we are dealing with the expenditure of vast sums of money I venture to think that a not unfair balance is struck between the two things which are prerequisites of any national service—all the supervision that is possible over finance, and all the flexibility of administration that is also possible. A number of points have been made by noble Lords. The noble Lord, Lord Kenswood, referred to faulty administration in some hospitals. I do not know their names. The noble Lord may not have considered it proper to give their names, but if there is any question of maladministration I hope that the noble Lord will give the necessary information to the proper authorities and it shall be dealt with. But I am not in a position to deal with the matter here to-day.

If I may for a moment revert to the noble Lord, Lord Saltoun, who dealt with a specific point, I think he hardly did justice to the position. There is a so-called Tariff which has been drawn up after the most careful consideration with the general practitioners. It contains a list of those things which, in instructed opinion, it is proper that the general practitioner should order for home use, as distinguished from what might be used in hospitals. The conclusion of those concerned to draw up that Tariff was that it would not be right to include packages of pads of a certain dimension as a thing which could he ordered by a general practitioner, partly because they are a class of article which a general practitioner was extremely unlikely to require to order and, secondly, because, if he were able to order them, it would result in a great deal of waste. Although I am not pledging myself one way or another, I think that even after a full consideration of the particular case to which the noble Lord referred, it may still be thought wise not to include that article amongst those which it is proper for a doctor to order. That matter, of course, will be considered, in view of the representations which the noble Lord has made; but a doctor should be, and I believe perfectly aware of what are the things which he is entitled to order, and if he chooses to order something which is not on the list he runs a grave risk in so doing.


My Lords, the noble and learned Lord will forgive me if I interrupt. Perhaps he could say something a little further. I took the penicillin bandages only as a case in point. There are a great many other things which would not fall under that stricture. But what I was anxious to know was, when a chemist is presented with such a prescription, what is the proper course for him to pursue?


I feel a difficulty in answering that question. Am I to assume that the chemist knows that the doctor has no right to order the article in question?


Yes, of course.


I am afraid that I do not know what would be his right course. Obviously the chemist runs a serious risk, and he runs into it because the doctor has done what he ought not to have done. He has to take his chance, I think.

The particular case to which the noble Lord referred will be looked into but I submit that, as a general principle, whatever may be the position in Scotland, where I think people are traditionally more cautious, in England it is not thought desirable to give a free rein to doctors to order and chemists to supply whatever appliances they think fit. There is a broad range of appliances which are useful in hospitals and which are not on the list of those which doctors may order and chemists may supply. That is a policy which I do not think will be, or ought to be, departed from. I think I need say no more about this special point which the noble Lord raised.

Generally, I will end where I began. The Minister is as anxious as anybody can be that there should be a continuation of the voluntary service of generous citizens. It is obvious that the Health Service could not continue without their aid, and anything that he can do that will encourage them to continue in their fine service will be done. At the same time, he has to bear in mind the need to supervise all expenses at a time when our national economy is so greatly strained. Bearing these two things in mind, he will proceed as best he may in the performance of his duty.

4.57 p.m.


My Lords, I should like to thank cordially the two noble Lords who replied for the Government. The answer which received first of all from the noble Earl, Lord Onslow, satisfied me in regard to a great many of the points I raised, and the noble and learned Lord on the Woolsack has satisfied me on the other points. I am surprised to realise that the noble Lords regard this as a mild document. I think they have little experience of the terror which the mandates of the Ministry of Health inspire in the bosoms of hospital committees. But I am glad to know that it is meant to be such a gentle and encouraging little document. It has a nasty sting in the tail, where it says that returns have to be made four times a year and that there can be no increase in staff without permission. But it would be unkind and ungracious of me to proceed further, in view of the replies which I have received, and therefore I beg leave of the House to withdraw my Motion.

Motion for Papers, by leave, withdrawn.

4.58 p.m.


My Lords, after the very kind and friendly answer which I received from the noble Earl, Lord Onslow, I do not propose to move my Motion, but, with your Lordships' permission, I should like to make three short observations. I should like to thank the noble Earl very much for the good news that conversations are taking place. I hope he will allow me to ask later on how they are progressing. In the second place, I should like to urge the Government to consider a little the position of the chemist. I frankly acknowledge that since 1913 he has been in the position of a whipping-boy between the doctor and the Ministry, in this matter of prescriptions. The chemist gets an order from the doctor and then the Ministry say that he is not allowed to supply it. His situation is not pleasant. I believe it is unjust and the Government need to have this matter cleared up.

I am very glad the noble and learned Lord the Lord Chancellor did not suggest that the chemist should send the patient away uncatered for. In conclusion, although I spoke only of penicillin pads, there are many other things excluded from the Drug Tariff. For instance, ventilated elastic adhesive bandages are not allowed under the Drug Tariff, but non-ventilated elastic adhesive bandages are. If a man has a colostomy and has a particular kind of appliance, he gets pads; but if he has another kind of appliance, he cannot get the necessary pads. There are many other things and the particular example I gave does not really matter. In spite of the fact that noble.Lords think things are so much better in England than in Scotland, I may say that in the Scottish Drug Tariff we do not attempt to give detailed specifications. The ordering of drugs and appliances is left to the discretion of the doctor and there is no obstacle to his prescribing the required drugs and appliances. If that is the rule in Scotland, it should be the rule in England, also.