§ 6.40 p.m.
§ BARONESS PHILLIPS
My Lords, I beg to move that this Bill be now read a second time. On July 5 this year the National Health Service will be twenty years old. The opportunity we have today in debating the Health Services and Public Health Bill is one of the very few occasions in those years when the House has had before it a measure concerning the statutory provisions under which the services operate. Indeed, this is the first Bill whose provisions comprehend the whole range of our health and welfare and public health services that we have had in this period, and that is in itself a tribute to the wisdom and foresight of those who planned and put through the original legislation. But I should not wish to suggest to the House that the measure now before us, although wide-ranging, is designed, as was the 1946 legislation, to transform the organisation of the health services in this country, nor is the spirit of our debate to-day likely to revive echoes of the famous debates which preceded that legislation. For the Bill we are discussing is concerned mainly with making a number of relatively minor improvements to the organisation of services within the terms of reference of the administrative structure set up under the 1946 National Health Service Act, the National Health Service (Scotland) Act 1947 and other legislation, principally the National Assistance Act 1948 and the Public Health Act 1936. Taken as a whole, they should make it easier to provide the patterns of service that are needed to-day and to make the optimum use of the re- 552 sources available within the framework of the services as they now exist.
As noble Lords will know, the Minister of Health has announced that he has set in hand a full and careful examination of the administrative structure of the medical and related services and that he intends to publish tentative proposals in the form of a Green Paper, which will provide full opportunity for public discussion and consultation. The Bill we are considering to-day does not seek in any way to anticipate the results of this review, and of course it would be wrong and premature to introduce through this Bill any major changes in the administrative structure of the health and welfare or public health services. Almost inevitably the Bill contains a large number of miscellaneous provisions. It was rather unkindly described in another place as a rag bag. I prefer to call it a bran tub, with something good in it for everybody. It contains a large number of valuable provisions, and my purpose this evening will be to describe some of the more important of these. Most of the clauses have an application North of the Border as well as in England and Wales; but some of the provisions apply only to Scotland.
The opening four clauses of the Bill are concerned with private patients in National Health Service hospitals. Mention of private practice is apt as a general rule to lead to the instinctive adoption of emotional and partisan attitudes, and noble Lords will doubtless know that these clauses have proved no exception. But I hope that I can satisfy the House that these provisions should in practice prove non-controversial. Clauses 1 to 3 of the Bill replace the existing provisions which are contained in Section 5 of the 1946 Act and the corresponding section of the 1947 Act, except for the transitional matters dealt with in Clause 3. Clause 1 deals with private residential patients or in-patients, and Clause 2 with private non-resident patients; that is to say, out-patients and day patients.
These two clauses make the two main changes. First, they remove the present requirements that accommodation for private patients must be special accommodation set aside. The purpose of this change is to introduce greater flexibility in the use of accomodation for private patients so that within the total amount 553 of accommodation authorised by the Minister at a particular hospital a private patient can be accommodated in that part of it most suited to his medical needs, instead of as at present having to be accommodated in a bed that has been designated for use by private patients—a pay bed. Secondly, the clauses enable pay bed charges to be determined on a national basis for different classes of hospitals. At present these charges have to be based on the cost at the individual hospital with pay beds and calculated for each hospital by the hospital authority according to a complicated set of regulations. Apart from the work involved, the present system can give rise to anomalies in that there may be variations in charges between similar hospitals with similar accommodation, often in the same area. Under Clause 1(3) the Minister will be able to group together hospitals of similar types into classes and determine hospital charges on a national basis for each class.
Since hospital charges for private resident patients are to be fixed on a national basis and not by individual hospital authorities, and since Clause 1 sets out the factors to be taken into account by the Minister in determining charges, there is no longer a need for these charges to be determined under regulations, and accordingly this requirement has been dropped. Similarly, charges for private non-resident patients, dealt with in Clause 2, and for amenity beds, dealt with in Clause 4, are to be determined by the Minister without the need for regulations. Lastly, the power of the Minister to prescribe limits to the fees that hospital doctors and dentists can charge their private patients treated in National Health Service hospitals is not renewed; the actual limits prescribed were removed by the Pay Bed Regulations 1966, with effect from January 1, 1967.
Fears have been expressed, on the one hand, that the changes made by these clauses may be either detrimental to private practice in National Health Service hospitals and, on the other hand, that they will prove unduly encouraging of it. Neither should be the case. Apart from the changes mentioned the clauses make no substantial change in the present position. They neither increase nor decrease the powers of the Minister to control the extent of private practice in National Health Service hospitals and 554 they preserve the existing safeguards to interests of non-paying patients.
I now turn to Clause 5 of the Bill. This clause empowers the Minister to constitute a new alternative form of management for hospitals providing teaching facilities for medical education. Under existing legislation the Minister of Health may designate hospitals providing teaching facilities as teaching hospitals, and a hospital or group of hospitals so designated must be managed by a board of governors appointed by the Minister and responsible directly to him. If the Minister does not designate them as teaching hospitals, then they must at present be managed by a hospital management committee appointed by the appropriate Regional Hospital Board according to the constitution laid down in Schedule 3 to the 1946 Act. Under this clause, the Minister can provide for a new form of administration for hospitals providing teaching facilities by designating them as "university hospitals". Before making such a designation the Minister is required by the clause to consult the university concerned, and while the body responsible for the management of a university hospital will be a hospital management committee appointed by the Regional Hospital Board the order which the Minister will make designating the university hospital may provide for modification of the constitution of the hospital management committee to manage that hospital. The Minister will therefore be able to ensure that the university is adequately represented on the committee. Orders made under this clause will he subject to annulment.
I should make it clear that the Minister is not seeking to create this new form of management because of any dissatisfaction with the existing relationships between Regional Hospital Boards and boards of governors—on the contrary, he is aware that there is close and beneficial co-operation between them. He has made it clear that it is not his present intention to use the clause to make sweeping changes in the administration of teaching hospitals already controlled by boards of governors. However, the Minister believes that he should be free to consider other forms of administration, and in particular he considers that the creation of new medical schools provides an opportunity to link these new centres of 555 medical education more closely with the Regional Hospital Boards who are responsible for the overall planning of the hospital services in their region.
The House will be aware that the Government have approved the creation of medical schools at the Universities of Nottingham and Southampton. At Nottingham both the University and the Sheffield Regional Hospital Board are in favour of the new hospital which will be associated with the medical school being managed as a university hospital, and it is likely that it will be so designated. Southampton may very well also become a university hospital. The title "university hospital" has been chosen to make it plain that these hospitals should have a standing and esteem no less than that of existing teaching hospitals as centres of teaching and research. The fact that through this new form of government they will be more closely associated with the rest of the hospital services in their region will be an additional advantage. The Government are confident that this experiment in hospital management will prove to be a successful and fruitful development.
There are a number of other clauses in the Bill concerned exclusively with the hospital service. I will not describe these in detail, but I should like to mention briefly Clause 65, which was added to the Bill in another place. This clause empowers the Health Minister to give financial help to visitors to patients in the special hospitals or in the State hospital as it is called in Scotland. These hospitals—Broadmoor, Rampton and Moss Side in England, and Carstairs in Scotland—are different from National Health Service hospitals in that they do not serve a local catchment area but admit patients from anywhere in the respective countries. Consequently, in many cases relatives and friends have to make long and expensive journeys to visit patients. At present the usual form of financial assistance available to visitors is in the form of rail vouchers which entitle users to return rail tickets at one and half times the single fare. This clause would enable the Minister to give assistance to visitors travelling by public road services, which many people use because it is more convenient and 556 cheaper. Regular visiting is, of course, very important both for the patient and for his family; this clause will help encourage and perhaps increase regular visiting, and I am sure the House will welcome it.
It would perhaps also be opportune at this stage, before leaving those parts of the Bill concerned with the hospital service, to describe the purposes of Clauses 31 and 32, which relate to the disposal of goods and services produced by the Minister for the hospital service. These two clauses have been viewed with some concern by commercial and manufacturing interests and it may be helpful if I explain their purpose—which has been the subject of some misunderstanding.
Clause 31 enables the Minister to make services available outside the hospital and specialist services. It is already the practice of hospital authorities to sell surplus services. For example, some hospitals provide pathological services for private hospitals or nursing homes, meals-on-wheels for local authorities, laundry services for homes for old people or handicapped people run by local authorities and voluntary bodies, and some provide services of sterile supplies to local authorities and doctors. This clause gives explicit statutory authority to this practice. It was thought desirable to obtain this authority because the 1946 Act provides that services are to be free of charge except where the Act specifically provides for the making of charges. Moreover, as the Act already authorises the Minister to dispose of certain specified services or goods in this way, the existence of these limited powers could be held to exclude a more general power, although such a power is in fact already being exercised by hospital authorities.
Some fear has been expressed that as a result of this clause hospitals may launch out into all manner of activities that might bring them into competition with private enterprise. But I do not think there need be any cause for alarm here. Some examples of the kind of services being provided have already been given and there is certainly no present intention of making any general extension of these arrangements. The clause gives the Minister discretion as to the terms on which surplus services may be made available. This discretion is required since it is conceivable that in some cases it would 557 be perfectly proper to make services available other than at full cost; but it is, and will continue to be, the normal practice to charge for these services on the basis of full cost, including overheads.
Clause 32 will enable the Minister to sell or give away or otherwise dispose of any goods that he produces in the hospital and specialist services and that become surplus to the requirements of those services. This is a simple and straightforward power to get rid of any surplus that may from time to time arise in hospitals. The clause will also enable the Minister to prescribe goods which he wishes to produce in excess of the requirements of the hospital and specialist services, so that he may dispose of them to recipients either engaged on other aspects of the National Health Service or completely unconnected with that Service. This part of the clause, like the previous clause, has given rise to some disquiet lest it be used to introduce unfair competition with suppliers of various items used in the hospital service. The Minister has, however, made it clear that his intention is solely to be able to meet any need that may arise outside the hospital service for special types of articles that may not be readily available from commercial sources in the quantity or quality required. Artificial eyes, sophisticated surgical appliances and specialised components of artificial limbs are the sort of articles that the clause is designed to cover, and the Minister's power to operate will be limited to those classes of goods that he has prescribed by regulations, subject to annulment by either House. As with Clause 31, it will be the normal practice for charges to be based on the economic cost of providing any goods supplied, including overheads.
I now turn to the provisions in the Bill dealing with the local health and welfare services. First, I come to local health services. In the Bill as first published Clauses 10 and 11 provided for the extension of existing National Health Service legislation so as to allow local health authorities to employ midwives, health visitors and district nurses to attend women elsewhere than in their own homes, which is the limit of their existing duty. The purpose of promoting more efficient deployment of staff and encouraging close co-operation between 558 local authority staff and family doctors —for example, by the "attachment" of local authority nurses, health visitors, and midwives to general practice—has been further met by Amendments made in another place which would enable such staff to be used outside the areas of their employing authorities. Clause 10 would now also allow local health authorities to make arrangements with hospital authorities, whether within or outside their areas, so that their midwives might work in hospitals where this would help to provide a better service.
Clause 13 concerns the domestic help service. Its effect is twofold: to make the provision of domestic help a statutory duty and, secondly, to empower local health authorities, in the discharge of their duty to provide a domestic help service, to arrange for articles belonging to the household to be laundered either at the house or elsewhere. The clause also empowers authorities, subject to the approval of the Minister of Health, to recover from persons availing themselves of the service or of the laundry facilities provided, such charges as the authority consider reasonable having regard to the means of the recipient. In practice all local health authorities already provide a domestic help service under existing permissive legislation. In the Government's view, however, it is logical to make the provision of this important service a statutory duty in common with that of similar local authority services.
As a result of a Government Amendment which was adopted in another place, the clause now provides for persons who are handicapped as a result of illness or congenital deformity to be included as an additional category of persons eligible for domestic help. As has already been explained by the Minister of Health in another place, owing to the present economic situation the Government have decided that the implementation of the clause shall be deferred for the present under the provisions of Clause 78 of the Bill. This does not, however, represent any change of intention by the Government.
In Clause 59 the opportunity is taken to tighten up the law relating to child minding by amending the Nurseries and Child Minders Regulation Act 1948. At the end of 1949 the number of places 559 for children provided by people who looked after them in their own homes amounted to only 1,744, but over the following 17 years the number shot up to nearly 35,000. Many of these women are providing useful service, but there is no doubt that the standards of others fall short of what ought to be expected. The Government are particularly concerned about some child-minders who do not come within the scope of the Act at present but who clearly need to be supervised by the local health authority, and those minders who, being unregistered, are breaking the law.
The Ministry of Health carried out extensive inquiries of local health authorities in 1965 and 1966 about the operation of the Act, and as a result of these and other evidence—I would mention particularly the Report produced last summer by the late Dr. Simon Judkin, to whom I am sure we should all like to pay tribute for his work for the pre-school child—it is proposed to give local health authorities greater powers of control over child-minders and to increase the penalties for evasion of the Act. In legislation of this nature it is important not to give public authorities greater powers over the individual than is necessary; but the Government are convinced that because of the unsatisfactory conditions in which some children are being cared for they are justified in seeking Parliament's approval to the amendments to the 1948 Act proposed in this clause.
The provisions dealing with local welfare services are found in Part II of the Bill. They are particularly concerned with services for the elderly and would allow authorities to provide places for the elderly and the handicapped in certain commercially run homes; they also provide authorities with a general power to promote the welfare of the elderly. At the moment a local authority can meet its obligation to provide residential accommodation for elderly and handicapped persons by placing them in homes which it runs itself, in homes run by other authorities, or in homes run by voluntary organisations. While the number of such homes is steadily increasing, the demand for places is rising too, and it has been necessary to find new ways of satisfying this demand. Clause 44 aims to do so by permitting authorities to make arrange- 560 ments for the provision of accommodation with the proprietors of those commercially-run homes which are registered with a local authority under the National Assistance Act 1948. It will also enable authorities to provide a wider range of choice for intending residents. An authority making such arrangements will pay an agreed charge to the proprietor and will in turn recover from the resident, in the usual way, as much of the charge as he can afford.
While Clause 44 will, initially at least, have a rather limited application, the general power to promote the welfare of the elderly proposed in Clause 45 will eventually enable large numbers of the elderly to enjoy a much wider range of statutory welfare services, including—and this pleases me very much—preventive services. At present these are limited to meals, whether in a person's own home or at a luncheon club, and recreational or occupational facilities. If the elderly person is also physically or mentally handicapped, as I fear many of them are, he, or more often she, can take advantage of the arrangements made by authorities under their general power to promote the welfare of this class of persons provided by Section 29 of the 1948 Act, as extended by the Mental Health Act 1959. If, however, he is merely suffering from the general infirmity of old age he can derive no benefit from these arrangements. Clause 45 removes these restrictions and will enable authorities to provide for all elderly persons a comprehensive range of services comparable to those available to the handicapped. They will, for example, be able to adapt the home of an elderly person and provide him with services, such as help with gardening or decorating, and personal aids to enable him to cope more easily with ordinary everyday life at home.
They will also be able to give advice to the elderly and to take measures to prevent deterioration in health and living conditions. In particular they will be able to contribute towards the cost of providing warden services in special housing for the elderly—a vital and expanding service, the development of which appears to have been delayed in some areas by doubts about welfare authorities' powers to make such contributions. A further power they will have will be to provide a wide range of visiting services for the elderly aimed at finding those in need of welfare services, 561 ascertaining the services they lack, and providing them with practical assistance and advice. What is perhaps even more important is that authorities will be able to arrange for visits to be made to elderly persons solely with the object of preventing them from becoming isolated from the general community and of retaining their interest in life.
Authorities' arrangements for providing services under the clause will be subject to the Minister's approval. Clearly it will take them a little time to determine what these services should be, and the Minister has no intention of pressing them to make early decisions. Indeed, the present financial restrictions on local authority expenditure will, I am afraid, dictate that the development of these services will come only gradually and in accordance with authorities' own assessment of where their priorities lie.
Finally, may I say that in developing their services in the directions to be permitted by the clause, authorities will have to rely very heavily, probably much more even than they have done in the past, on voluntary help. Visiting the elderly is a field in which the voluntary organisations are already doing a tremendous amount. Any extension of visiting on the scale now envisaged must clearly draw extensively on the valuable experience they have gained, and must depend very largely on the services that trained volunteers can contribute. It is only fitting, therefore, if I may anticipate matters slightly, that the existing powers of local authorities to assist voluntary organisations—both financially and by making premises, equipment and staff available to them—should be consolidated and extended by Clause 64. This gives authorities a wide ranging power to assist such organisations operating anywhere in the local health and welfare field.
If I may continue on this tack for a little longer, may I mention that Clause 63 gives the Minister, for the first time, a complementary power in the same field. This will put on a statutory basis the payments he is already making to voluntary organisations in the field covered by the local health and welfare services and enable him, again when the financial climate improves, to extend the range of his assistance.
I come now to those Parts of the Bill concerned with what are often called the 562 executive council services—the services provided by doctors, dentists, chemists and opticians who are in contract with executive councils. Clauses 16 and 19 and Schedule 1 are concerned with the ophthalmic services. These are currently designated "supplementary ophthalmic services" because in 1946 they were expected to fulfil a merely temporary role until hospital ophthalmic clinics could take over all testing of sight and supply of optical appliances. In the event the hospital eye service has concentrated on meeting the more specialised requirements, whilst the "supplementary ophthalmic services" have catered for the bulk of our ordinary needs. The Bill recognises that they will continue to do so permanently and renames them, in consequence, "general ophthalmic services".
No changes in the scope of these services are involved, but there are necessarily some in organisation. In the 1946 Act provision was made for the ending of these executive council ophthalmic services in each area as the extension of the hospital service made them redundant. Until then they were to be controlled by special ophthalmic services committees acting as agents of each executive council. In Scotland there are particular reasons for retaining the joint ophthalmic services committees, but in England and Wales it is appropriate that the ophthalmic service committees should be abolished and a permanent service should be controlled directly by executive councils, with the three groups of practitioners involved represented on the councils themselves. This, together with consequential additions to retain the balance of membership, is the reason for the changes in the membership of executive councils proposed in Schedule 1.
As long as the ophthalmic services were considered to be on a temporary basis there was no need to authorise their provision in health centres; Clause 18 now proposes that this should be possible. This brings me to a number of provisions relating to health centres in Clauses 18, 19, 21 and 22. Since 1949 it has, been possible for doctors to practise privately in health centres, and experience has shown the advantage of a limited degree of private practice in certain circumstances. It is possible that similar extensions to the other services provided 563 there might prove beneficial to the patients attending a particular health centre. When it is possible to provide ophthalmic services at a health centre, it may be felt that they will operate at a considerable disadvantage if, for example, a patient finds that he is obliged to go outside in order to purchase a spare pair of spectacles or a private frame.
Similarly, a patient might find a health centre less attractive if after he had been given a private prescription by his doctor there, he could not have it dispensed at the centre pharmacy, or if he had to go outside the centre in order to obtain the ordinary household remedies which we encourage him to buy for himself. Consequently the Bill makes it possible for dentists, opticians, and pharmacists to engage in private practice at health centres if the Minister so determines in the case of a particular centre, and to such an extent and under such conditions as the Minister determines in each case in the light of local consultation.
Ophthalmic services have not, as I have explained, been provided in health centres previously, and the only pharmacists there have been employed by the local health authorities, even though they are providing executive council services. The professional representative bodies concerned have indicated that they would find it more appropriate for persons providing general ophthalmic and pharmaceutical services in health centres to be in contract with the executive councils, and the Government have thought it right to respect their wishes in this, and put them on a par with the doctors and dentists. Consequently, Amendments were made in another place precluding the employment of both opticians and pharmacists by local health authorities for the provision at health centres of services under Part IV of the 1946 Act, but with a saving clause for those health centres where pharmacists are already so employed.
Clause 24 will enable executive councils to supply goods and materials to persons providing general medical, dental, pharmaceutical and general ophthalmic services under the National Health Service Act 1946. As the clause has given rise to some anxiety among the professions providing the family practitioner services, 564 and indeed among certain of the industries supplying goods to the National Health Service, it may be helpful for me briefly to explain its purpose and scope. The clause is primarily designed to remove any doubt as to the legal basis of the present arrangement whereby disposable sterile syringes and needles purchased by the Minister of Health are supplied by executive councils to medical practitioners. This arrangement has been generally welcomed by doctors, and I am confident that they will be glad to see it now placed on a firm legal basis. The clause will also enable councils to supply such other goods and materials to practitioners in the future as may appear necessary or expedient to the Minister. No extension to the existing arrangements is in fact intended at present, but there may be a case in the future for supplying additional items in order to improve standards or to save cost by centralised purchasing arrangements.
My Lords, the powers conferred by the clause may be exercised only by the laying of regulations, which on every occasion would specify the class of goods to be supplied and the category of person (whether doctors, dentists, chemists or opticians) for whom they were intended. This of course means that there would be full opportunity for prior discussion, and if necessary Parliamentary debate, before any class of article were listed for provision to practitioners by executive councils. There is, moreover, no question of the clause imposing an obligation on practitioners to apply for or to use such goods as might be supplied. I hope that what I have said will allay the anxiety which has apparently been expressed that the powers conferred by Clause 24 might be used to compel practitioners to make use of centrally supplied goods or materials of a nature or on terms which would be unacceptable to them.
Before leaving that part of the Bill which deals with executive council services, I should like to refer briefly to Clause 25. This clause was included at the Report stage in another place. It was not proposed by the Government, but the intentions of the clause were acceptable to the Government and the Minister recommended its acceptance on that basis. Clause 25 applies various provisions of the Patents Act relating to the Crown use of patented inventions, in particular 565 Section 46, to the services provided under Part IV of the National Health Service Act 1946 and the comparable Scottish Act. Part IV services are those administered by executive councils. The main purpose is to enable the Health Departments to authorise, for the purpose of the general medical and pharmaceutical services, the purchase of patented drugs bought from unlicensed sources, the terms for the use of the patent being subject to either agreement or determination by the court. The Health Departments already have a comparable power in relation to drugs and other patented inventions supplied for the hospital service, since it was decided in the Pfizer case that the latter was a service of the Crown.
In its review of the relationship of the pharmaceutical industry to the National Health Service, the Committee of Inquiry, under the chairmanship of the noble Lord, Lord Sainsbury, concluded that the Health Departments needed to have a procedure to which they could resort if negotiations on prices of pharmaceutical products failed, that Section 46 of the Patents Act 1949 was an appropriate instrument for this purpose, and that it would be right to extend its application to the general medical and pharmaceutical services. The Committee hoped, as do the Government, that revised arrangements for regulating prices will greatly reduce the chances of Ministers having to resort to the use of these powers, but we think it right that they should be available, on the basis envisaged by the Committee, as a procedure of last resort. It was primarily because of this that the Government were prepared to accept the clause. Since then, the Government have had the opportunity to look at it more closely, and I think I should tell noble Lords that as drafted the clause does not entirely meet its purpose. The Government will accordingly be proposing Amendments at a later stage of the Bill to get it right.
So far, my Lords, I have dealt with provisions in the Bill concerned with the personal health and welfare services provided under the National Health Service Acts and the National Assistance Acts; but the House will have noticed that the Title of the Bill refers also to public health, and it is to some of its provisions in this field, mainly that of notifiable 566 disease and food poisoning, that I now propose to refer. For England and Wales, the majority of the new provisions are those set out in Part III of the Bill. I will not attempt to describe all of them—there will be opportunity at Committee stage for this—but will, instead, confine myself to two of the clauses.
Clause 47 deals with the definition of "notifiable disease". The present definition of "notifiable disease" in the Public Health Act 1936 includes a number of diseases to which, because of advances in medical knowledge, it is no longer considered necessary to apply all the precautionary and preventive provisions of Part V of the Public Health Act 1936—as must be done in respect of all diseases included in the statutory definition of "notifiable disease". For this reason, the Minister proposes that membranous croup, erysipelas, scarlatina (or scarlet fever), enteric fever, typhoid fever and diphtheria should be removed from the definition. To be added to the definition is one disease, plague, at present notifiable under regulations to which I now refer.
I should explain that the diseases listed in the revised definition are not the only infectious diseases about which information will be sent to medical officers of health by general practitioners and other doctors attending patients. The Minister of Health is empowered by Section 143 of the 1936 Act to make regulations with regard to epidemic, endemic and infectious diseases generally, and by any such regulations to apply, with or without modifications, to any disease to which the regulations relate whichever of the precautionary and preventive provisions of Part V of the Public Health Act seem to him, on medical advice, to be appropriate. It is under these regulations that information is already sent to medical officers of health about cases of a number of other diseases, including, for example, tuberculosis, poliomyelitis, measles and whooping cough. Of the diseases now to be removed from the definition of "notifiable disease", the Minister proposes that scarlet fever, typhoid fever and diphtheria shall be made subject to the notification procedures, and information of cases of those diseases will continue to come to medical officers of health.
567 The other public health clause that I want to mention is Clause 68. Section 172 of the 1936 Act provides for court orders for the removal to hospital of a patient suffering from respiratory tuberculosis, and empowers the court to direct the local authority to make a contribution to the maintenance of the patient's dependants. The provisions for these maintenance contributions have been criticised by local authorities, on the ground that the maintenance of the dependants of such a hospital patient is the responsibility of the Supplementary Benefits Commission, as is the case with the dependants of a patient suffering from tuberculosis who voluntarily enters hospital or of a patient suffering from any other notifiable diseases removed to and retained in hospital under Sections 169 and 170 of the Public Health Act 1936. For these reasons, the Government are proposing the repeal of Section 172. Subsequently, any legal action needed to secure the removal and retention in hospital of a patient suffering from respiratory tuberculosis can be taken under the provisions of Sections 169 and 170 of the 1936 Act, which will be applied to tuberculosis by regulations to be made under Section 143 of the 1936 Act.
My Lords, I have so far dealt with the provisions in the Bill which, broadly speaking, are concerned with one or other arm of the service, but before I sit down I should like to refer briefly to two clauses which do not fit readily under any of the heads I have so far used. The first, Clause 62, is concerned with training. When making training arrangements for persons working, or contemplating work, in the health and welfare services, Ministers have had to rely mainly upon a power inferred from a duty to provide services: for specific powers, such as those under Section 48 of the 1946 Act, which covers certain types of training for practitioners in the Part IV Services, are very limited. A few instances have arisen where doubts have been expressed about the legal basis of current practices, and further doubts arise in relation to some of the increased opportunities for training that are being planned for the future. It is essential that proper training be provided for those engaged in the health and welfare services, whether as direct employees or as contractors, and that the 568 continuation and development of those services be assured by the availability of an adequate number of suitably trained persons. Clause 62 seeks to clarify the position and, by empowering the Minister to provide training direct, and one health or welfare authority to undertake the training of persons providing or intending to provide a service for another such authority, ensures that training can be organised on a rational and economic pattern of mutual aid. For similar reasons the clause allows for the making of reciprocal arrangements with Scotland and Northern Ireland.
The final provision I wish to describe is Clause 33, which provides specific powers for the supply to severely disabled persons of the invalid carriages and the associated benefits that successive Ministers have made available since 1948 under general powers in the 1946 Act. The clause also provides new powers for the supply of motor cars instead of invalid carriages, thus enabling the Health Ministers to extend even further the excellent service that they already provide for the severely disabled. But it will not, of course, be possible to make full use of the new powers overnight. They will be there for Ministers to use to introduce improvements, stage by stage, as the resources available to the Health Service permit.
My Lords, what I have said this afternoon has, I am afraid, no doubt appeared rather disjointed and lacking any obvious common thread or argument. But this is probably inevitable when describing a miscellaneous Bill of this kind. But I hope that, by very reason of the wide-ranging nature of the provisions in the Bill, I shall at least have been able to find in it something to please everyone. There is indeed much in the Bill which will be helpful to the development of the health, welfare and public health services—services which we all, I know, on whatever side of the House we may sit, wish to see developed and strengthened and on whose efficiency we all at one time or another must rely. I am confident that noble Lords will wish to give a general welcome to the Bill. I beg to move.
§ Moved, That the Bill be now read 2a. —(Baroness Phillips.)569
§ 7.23 p.m.
§ LORD NEWTON
My Lords, I am sure we are all grateful to the noble Baroness for her very thorough exposition of this very long Bill. She said that it is a miscellaneous Bill. It is, my Lords, very miscellaneous indeed. I am going to be rather more selective in the choice of the clauses on which I am going to speak because I suspect that probably the greatest service I can do your Lordships at this time of night is to be as brief as I decently can. As well as being a miscellaneous Bill, this is very largely, of course, an enabling Bill. Some of the powers which it gives to the Minister are pretty sweeping, and so a great deal will turn on how the Bill is used when it becomes law. That is something on which we shall have to keep a fairly critical eye from time to time.
The noble Baroness said that the description of the Bill that she preferred was "a bran tub with something for everybody". That is a reasonably accurate description, but I think that a more accurate one would be to say that it is a stodgy pudding with a few plums. On the whole, however, the stodge is mostly palatable and wholesome; and, whatever may happen at later stages, I hope that the House will give the Bill a Second Reading this evening. I congratulate the Minister on succeeding in getting this Bill into this Session's legislative programme, because it strikes me that it is not really the sort of Bill that is likely to arouse a great deal of enthusiasm in the breasts of those Ministers whose duty it is to advise Her Majesty on the contents of the gracious Speech. I would go so far as to say that the promotion of this Bill confirms me in my belief that Mr. Robinson is the most successful departmental Minister in this Government—and the best. That is not, perhaps, much of a compliment; but it is a compliment.
My Lords, that is the only Party political comment I propose to make; because anyone who has served in the Ministry of Health knows how extremely difficult it is, with the best will in the world—or even with the worst will in the world—to inject Party politics into the activities and policies of that Department. I personally would not have it otherwise. Nevertheless, the opponents of pay beds in hospitals and of private 570 practice generally have from time to time, since the inception of the National Health Service sought to represent this as a significant Party political issue. Personally, I think it is an issue that should be treated absolutely pragmatically.
All Ministers of Health, from Aneurin Bevan onwards, have recognised that there is a demand, a fairly substantial demand, for amenities which can be purchased by payment over and above that which is automatically paid for in taxation. This being so it has always seemed to me—and seems to me still—that, precisely because the National Health Service is a national service and a monopoly, it ought to recognise the existence of this need and do its best to meet it, so long as it can do so economically and efficiently. The demand for pay beds in hospitals fluctuates from year to year. I rather think that it is going through a period of decline at the moment. I should not like to prophesy what the demand is likely to be in ten or twenty years' time, but there is no doubt that the number of people taking out insurance policies to cover private treatment is growing all the time. I believe that something like 4 per cent. of the population is now covered by insurance policies for private treatment purposes. That is something of which I should have thought any Minister of Health is bound to take notice, and to try to meet, whether he likes is or not.
My Lords, the important thing about the clauses in the Bill dealing with pay beds—and I was glad that the noble Baroness drew attention to the point—is that they do not alter in any substantial way the power of the Minister to increase or reduce the number of pay beds in National Health Service hospitals. This is a power that he has always had, and I am certain that it is a power that he must always have. But the important thing that these clauses do is to put an end to the designation of pay beds for particular purposes, for particular specialities. I am sure that that is a sensible reform; because designation has led to unnecessary under-occupancy of beds.
Clause 5 is the biggest plum in the pudding. It enables the Minister to create new teaching hospitals administered by the Regional Hospital Boards instead of by independent boards of governors. I welcome this power in the 571 Bill, but I am bound to say that I do not much like the name "university hospitals" which is proposed for these hospitals. It seems to me to be somewhat pretentious, and it suggests either that there will be something different in the role of these new teaching hospitals from the role of the existing teaching hospitals—which I am sure is not meant to be the intention—or, if it does not suggest that, that in some way or other these new teaching hospitals are going to be superior to the present teaching hospitals, but I do not believe that is the intention either. I should have preferred a more modest name, such as regional teaching hospital or district teaching hospital. However, I recognise that this is not really a substantial point.
My Lords, I know that some people connected with the great teaching hospitals are afraid that this clause may be a threat to their continued existence; that it may be the thin end of a rather large wedge. I sincerely hope that is not so, and I doubt whether it is. So far as I know, the Minister has always had the power to de-designate teaching hospitals without having to lay an Order before Parliament. If I am right about that—and I think I am—it seems to me that what is in Clause 5 does not add anything to the powers which the Minister always has had in this respect. I am not going to say any more about this matter now. I think that my noble friend Lord Cottesloe will be saying something about the position of teaching hospitals later on.
I welcome Clause 5 particularly for two reasons. The first is that I am all for variety and experiment in the National Health Service, and being a native of those parts I am particularly glad that Southampton is probably going to be one of the first towns where the experiment is to be conducted. I hope that the experiment will be tried there, because then the university hospital will be administered by the Wessex Regional Hospital Board, which I happen to think is an extremely efficient organisation. Certainly it attracts to its service consultants and specialists of all kinds whose calibre is second to none in the country.
The second reason why I welcome the clause is that for a long time I have felt that members of hospital management 572 committee and Regional Hospital Boards do not receive the recognition that they deserve. When I was at the Ministry I tried very hard—I admit without any success—to think up ways in which they could receive more recognition than they do. The fact that this clause is in the Bill will give the members of these bodies the knowledge that they are now deemed worthy to establish their own teaching hospitals, and that will be a good boost to morale. I do not share the anxieties of those people, and there are some, who doubt whether the Regional Hospital Boards will have the ability or perhaps even the inclination to rise to the occasion.
I think that on the whole the changes in the powers and duties of the local health authorities are sensible. I particularly welcome Clause 13, which imposes on the authorities the statutory duty to provide a home help service. As the noble Baroness said, all local health authorities in England and Wales provide a home help service, but I am fairly certain that there are parts of the country where this service has not been developed to the extent that it should have been. With the substitution of this duty for the former power—and I realise that it will not become effective just yet—there will be an added inducement to those local health authorities who have not done so to develop their service as they should.
My Lords, my noble friend Lord Sandford will comment on some of the clauses with which I do not propose to deal. I intend to comment on only two other clauses. The first is Clause 25, which brings the general medical and pharmaceutical services within the definition of "services of the Crown" for the purposes of Section 46 of the Patents Act 1949. I was interested to hear from the noble Baroness that although in another place the Government liked the drafting, they do not like it in your Lordships' House. We shall be most interested to see what Amendments are put down by the noble Baroness. She probably realises as well as I do that the pharmaceutical industry regard the clause, at any rate as it is now drafted, as a serious threat to their interests and to the development of and research into new drugs. They are also, I think, of the opinion that they ought to have been 573 properly consulted about this clause. It may be that my noble friend Lord Cawley will say something about this clause, and that other speakers will wish to do so either now or at some later stage in the discussions on the Bill. The astonishing thing about the clause is that nothing was heard of it until the Report stage in another place, when it was moved by a Private Member, not a Minister; whereupon the Minister of Health promptly advised the other place to accept the clause.
The other clause about which I wish to make a few remarks is Clause 33, which clarifies the law on the position of single-seater invalid carriages and enables the Minister to provide cars instead of carriages for the severely disabled. I realise that this new power can be used only sparingly to begin with because of the cost, but I am delighted that the Minister has taken this power and I am sure that a very large number of people will be equally delighted.
My Lords, this Bill makes a large number of fairly minor alterations to the structure of the National Health Service. For good reasons, which she gave, the noble Baroness did not say anything about the structure, but I am not precluded because of that from doing so myself. I am an enthusiastic supporter of the National Health Service. It is a developing organism and its basic structure should not therefore be considered to be immutable; but I am sceptical about the extent to which its efficiency can be improved and its weaknesses eradicated by organisation. For instance, the principal weakness, or what I think is the principal weakness, is the sometimes inadequate co-operation between the component parts, which is very largely a question of individual personal relationships. I have never found that such relationships are much affected by changes in organisation. There is always a way if there is a will, but if the will is not there the way gets obscured.
I was sorry to learn that one of Mr. Richard Crossman's new responsibilities is to be to try to evolve a merger between the Ministry of Health and the Ministry concerned with pensions and National Insurance. I read that in the newspapers At one time this was the policy of my 574 own Party. I hope very much that they have lost it, but whether they have I do not know. The point is that unless you split up the National Health Service and regionalise it in some way, it is bound to be a very large, bureaucratic organisation. To my mind this makes it essential that the man at the top, the Minister, should have the time to be, and to be seen to be, a human being and not just an automaton.
My Lords, the Minister of Health is constantly involved in delicate negotiations with important bodies of all kinds, and not least with the most powerful "trade union" in this country, the medical profession. He has also to deal all the time with very complicated details, and it seems to me that to ask him or her, as the case may be, to be responsible as well for pensions and insurance is asking too much of one person, unless you want that one person to be no more than a figurehead. So I hope very much that Mr. Crossman will conclude that a merger is undesirable. I have no doubt whatever that it would not be in the interests of the National Health Service. I apologise for a scrappy speech but it is a scrappy Bill, though on the whole not too bad a one.
§ 7.40 p.m.
§ LORD OGMORE
My Lords, on this St. George's Day I think it is right to look back for a moment, as the noble Baroness, Lady Phillips, and the noble Lord, Lord Newton, have done, on the 20 years of the National Health Service. I was Member for Croydon in another place at that time, and as Member for a town like Croydon with so many excellent hospitals, I had to consider the Bill carefully. I discussed it on many occasions with Mr. Aneurin Bevan, the Minister, and with Mr. Herbert Morrison. Mr. Bevan wanted to have a centralised system with nominated representatives, while Mr. Morrison, being a great local government man, was keener on having a system under which, by and large, the hospitals would come under the local authorities. Mr. Bevan's system prevailed. I think we can say, with certain qualifications here and there, that we have a magnificent health service in this country. I do not know of any country of a comparable kind which has a better and very few with as good, so I feel that it calls for some congratulation to-day.
575 I am cognisant of the necessity expressed by the noble Lord, Lord Newton, for brevity, and though I could go through many of the clauses of the Bill and give my views on them I do not propose to do so. I am going to confine myself to one issue which I think of the highest importance and which has been touched on by both speakers before me. It has caused a great deal of anxiety in the pharmaceutical industry and I should not be doing the House justice if I did not refer to it. I must declare my interest. I am the director of a research-based pharmaceutical company. In Clause 25 of the Bill an important principle is at stake. It goes far beyond the Bill and even beyond the National Health Service and the pharmaceutical industry. It might apply to industry as a whole and to all products and manufactures which are made in this country. The history of the clause has been touched on by both speakers so I need not go into it at great length. Section 46 of the Patents Act 1949 was intended to enable the Government in a time of national emergency, such as war—and we must remember that that was the time of the Korean War, when there was a great deal of unrest in the world—to take over patents at short notice and then argue about the costs later. The idea was to use patents of a defence nature and not to take over pharmaceutical products. It was the great apostle of private enterprise, Mr. Enoch Powell, who extended that principle to pharmaceutical products. In 1961 he misused Clause 46 by awarding contracts to firms who had not been licensed by the four patentees concerned, on the basis that the contractors would import the drugs in question from manufacturers abroad. Similar contracts were relet in 1962 and 1964.
When the Pfizer Corporation case against the Ministry of Health came before this House in its appellate capacity, some caustic comments were made by noble and learned Lords, particularly by the noble and learned Lord, Lord Wilberforce, who said, referring to this procedure of the Crown:Such a definition of the powers of the Crown to use or authorise the use of patented inventions, seems to me to be alarmingly wide and to make a formidable incision into the supposedly valuable monopoly rights which the Crown has granted to the patentee.576 That was in 1965. This Government terminated the use of Section 46 for the products for which it was in operation. The Minister said, on Report:As a result, I probably got a better bargain for the National Health Service."—[OFFICIAL REPORT, Commons, col. 100; 1/4/68.]If that was so, it seems odd that the Government now want to take extended powers to do what Mr. Enoch Powell had started to do in a more limited way.
The Banks Committee is now undertaking a general review of the patent system and of Patent Law. This Bill did not originally include this clause at all. A Labour Back Bencher in another place moved it on Report stage; therefore it was not discussed in another place on Second Reading and Committee, and it was passed after a Division. I was much interested to hear from the noble Baroness that the Government are not satisfied with this clause and propose to amend it in Committee, and I shall be interested to know what the Amendments will be, because I am not satisfied either.
May I suggest a few considerations which the Minister might bear in mind before the Amendment is put down? First of all, the voluntary price regulation scheme which is now in operation is an agreement between the Health Departments and the Association of the British Pharmaceutical Industry to maintain an agreed basis for determining satisfactory prices for medical speciality products supplied under the National Health Service. On the whole it works well. My own company, among others, go before this Committee. There is keen argument and discussion and eventually a price is arrived at. Recently, Sir Derrick Dunlop, Chairman of the Committee on Safety of Drugs, said:The pharmaceutical industry has made enormous contributions to our society. Professor Chain, of penicillin fame, recently reviewed the 66 most valuable compounds introduced to medicine since aspirin in 1899. His analysis showed that only nine of these came from universities and research institutes.The rest came from scientists in the pharmaceutical industry. Of course, the universities, the Medical Research Council, the research institutes and the pharmaceutical industry work very closely together.
The Ministry and the industry are at this moment in a discussion on the future of costs in the Service. It seems to the 577 industry that this is an odd time in which to introduce this clause, which is a sort of bludgeon, into the discussions which are taking place. I do not know what the industry thinks about it. Here I am speaking for myself. But I think that there is a great danger here which goes far beyond the pharmaceutical industry. What is a patent? It virtually originates from the Statute of Monopolies of 1623, which gave a monopoly to the true and first inventor, the purpose being to reward him for his knowledge, his skill and patience, for his imagination above all, and for his expenditure of time and money. If this clause in its present form remains—or substantially remains, bcause I appreciate that it may be altered—then the power may discourage the companies from the vast expenditure on research, development and production: because there is a vast expenditure. It has been thought that for every one successful product on the market in the pharmaceutical industry 99 have been commenced, discussed, considered and had money spent on them. Eventually only about one out of every hundred gets into the hands of the medical profession.
On top of that there is the great cost of production, and the cost, once it is produced, of attaining and keeping the standard, cleanliness and quality of the particular pharmaceutical product. The pharmaceutical industry considers that it does not deserve this treatment. It feels that there has been some breach of faith, or will be if this clause as it stands is allowed to remain, because the Minister gave an assurance that the recommendations of the Sainsbury Report would be discussed with the industry before a decision was taken, and no detailed discussion has taken place. It was also believed by the industry that a Bill would not be introduced to deal with patents of pharmaceutical products until the Banks Committee had made its Report.
The Sainsbury Report said in paragraph 13:In many ways the industry has admirably served the public interest.I have quoted the view of Sir Derrick Dunlop. It is a vast export earner on a rising scale. Last year the export value of the products was £80 million. Of home sales and exports the figures were (and one must remember that we are 578 dealing only with a segment of the industry when we are dealing with Clause 25) that 39 per cent. of the product goes to the National Health Service, 27 per cent. to export, 17 per cent. to household medicines, and 17 per cent. to other places, parties or persons, mainly veterinary. So we are now dealing with 39 per cent. of the output of the industry.
The cost of the research and production I have mentioned. My own company spends 10.6 of its annual turnover on research alone, and it is estimated that British industry this year will spend some £14 million on research. In the last 25 years, as the Sainsbury Report pointed out, there has been a vast expansion in the relief of serious diseases which in my young days, and in the young days of many of your Lordships, were killers—illnesses like tuberculosis and diphtheria. One can remember how many children—one's own playmates—died of those killer diseases. The other day one of my grandchildren had chicken pox, and thinking back to my own days I took a serious view of it. But to-day it is a comparatively minor matter, and he was running about in no time. Not only have these formerly killer diseases been relieved, but in many instances, as we know, the demands on the hospital services have been enormously reduced through the use of drugs. If we take mental illness, for example, we find that in the last few years there has come into operation treatment through drugs which was quite unheard of a few years ago. A patient can be treated and cured, or at least maintained in comparatively normal health in his own home, in a way which would have been quite impossible ten years ago or perhaps even five years ago.
I do not at this moment intend to delay your Lordships any longer, except to leave this one thought with you. Anybody who is connected, in however humble a capacity, as I am, with the industry cannot help but realise that the industry is on the threshold of a vast expansion in contributions to human and animal health. The scope is enormous. Take, for instance, foot-and mouth disease, which caused a terrible lot of animal suffering, hundreds of thousands of animals to be slaughtered, and brought vast losses to the farming community and to the taxpayer. It is to the curing of that sort of disease that one may hope 579 that the pharmaceutical industry, combined with the veterinary research institutes and the university institutes, will in the next 25 years be able to make a contribution.
One must not think only of human health; one must think also of animal health. I am interested in this latter subject for family reasons, and I constantly have this question of animal health in mind. We are, as I say, only on the threshold. In other words, in the next 25 years there may well be the opportunity, for an even greater advance in human and animal health than in the past 25 years. I ask the Minister, through the noble Baroness, to consider whether it is wise to risk the great contributions that the industry could make in this field for the purpose of a clause such as Clause 25.
§ 7.57 p.m.
§ LORD PLATT
My Lords, I think that, in general terms, noble Lords in all parts of the House seem to be welcoming the introduction of this Bill. It is not revolutionary, but it does seek to extend in various ways the scope of the health services of this country, and I think almost entirely in beneficial ways. As the noble Baroness, Lady Phillips, has said in her introduction, it is a miscellaneous Bill; and I am glad that she said it is to some extent an interim measure, as the administrative structure of the Health Service, to which I shall refer shortly again, is under review at the present time.
I think there are several passages in the Bill which will need to be looked at rather carefully, but this I feel will be more usefully done when the Bill comes under scrutiny at the Committee stage. I am surprised that not more has been made of Clause 15, which may be said to remove another potential cause of racial tension, in that the Scots now, as well as the English, are to have the benefit of advice on family planning. I hesitate to think, as Vice-President of the Family Planning Association, of the dire consequences of unbridled reproductive activity in Scotland while the English are still reducing their families.
I find myself largely in agreement with the noble Lord, Lord Newton, in the wise and non-Party reflections which he had on the question of pay beds, and the perfectly reasonable desire of certain 580 people to pay for the kind of amenities in hospitals which they have in their own homes. And I endorse his view that many of the consultants in Wessex are of a very high standard indeed. I also strongly agree with what he said about the inadequacy of communication between different branches of our service being very largely a personal matter. As one who has worked as a consultant in hospitals for many years, both before and after the introduction of the National Health Service, I know that if my relations with the general practitioners outside, who were sending me cases, were not free and easy, or right and proper, as they should be, it was either my fault or their fault: it was nothing to do with the fact that we happened to be paid out of a different section of the national purse. I agree with him, too, in having very considerable fears about any merging operation between the Ministry of Health and the Ministry of Social Security; and, unless I am convinced by a great many further arguments, I hope that this will not happen.
If the noble Lord, Lord Ogmore, has read my Harveian Oration to the Royal College of Physicians, he will know that I support his claim that a very large number of advances in therapeutics which have come in our lifetime have come not through the medical profession but through the pharmaceutical industry.
There are many improvements which could still be made to the Health Service, but many of them can be done without further Acts of Parliament. Although some of the rather modest reforms in this Bill are of considerable urgency—and therefore, of course, I strongly support this Bill—it is nevertheless a little regrettable that it has been introduced at the present time, in view of the recent Report of the Royal Commission on Medical Education, of which I was a member and whose very able Chairman was my master and friend, the noble Lord, Lord Todd. This applies particularly to Clause 5 of this Bill, on the whole question of the designation of teaching hospitals and this new category of university hospital. If this is regarded as a temporary expedient, while further thought is being given to the whole government of teaching and non-teaching hospitals, then I support it as an interim measure. But I hope that it will not 581 be regarded as any kind of excuse, or partial excuse, for not giving the recommendations of the Royal Commission on Medical Education the fullest consideration, which I hope Her Majesty's Government will do at the earliest possible opportunity.
Many of your Lordships, of course, will already know that the Royal Commission have recommended that the boards of governors of teaching hospitals be discontinued altogether, and that Regional Hospital Boards, possibly reorganised and rearranged (and this reorganisation may particularly need to take place in London), must have an overall responsibility for the medical services in their region, and within them the teaching hospitals—or shall we say, to avoid any particular terminology, the hospitals used for teaching—should be governed by a special governing body with heavy university representation: something like the scheme which is at present planned for Nottingham and, I think, is being planned for Southampton. This, if the recommendations are accepted and acceptable, will render out of date a good deal of Clause 5, so I will not go any further into it at the present time except to reiterate that I hope that our recommendations will be very seriously considered.
In another area the Royal Commission, though primarily concerned with medical education, do of course have very important repercussions on the reorganisation of the Health Service in its recommendations for post-graduate education in which we go into the whole question of the staffing structure and the career prospects of young men in the Health Service. So I regard this Bill as very much an interim measure, and I hope that if we pass it, further consideration will be given to these matters.
The only other thing which I might have said is that in the Royal Commission we refer to the recruitment and importance of women doctors; but as this is a subject to which I understand the noble Baroness, Lady Summerskill, may be referring in her speech very shortly, and since she will no doubt do it more eloquently than I can, I will say no more on it, other than perhaps to give an endorsement in anticipation of most of what I think she is going to say.
§ 8.5 p.m.
§ LADY RUTHVEN OF FREELAND
My Lords, in rising to address your Lordships' House for the first time, I must ask for your indulgence. I hope I shall not make any mistakes in the observance of the customs of this House. If I do, I hope I shall be forgiven.
I speak to-day on this Bill because I have been closely connected with the Health Service for over 16 years. I think this new Health Services and Public Health Bill is in many ways a very good Bill: it constitutes a definite improvement on the existing Act of 1946, for it ties up many loose ends, it introduces improvements in administrative procedures, and also gives the Minister further powers which I hope will be of value to the patients.
Having recommended this Bill to your Lordships, I should like to make a few criticisms of one or two clauses. The first clause to which I should like to refer is Clause 1. I know that the noble Baroness has spoken about this clause, but I should like to say that I know the situation in hospitals very well. The present position is that private patients can be admitted only to certain beds—either those specifically designated under Section 5 of the National Health Service Act 1946, or to beds in general wards where designation has been obtained from the Ministry for the admission of a particular patient. Presumably under this new Bill the Minister's intention is to allocate a number of private patients' beds to each hospital or group of hospitals so that patients can be accommodated in any bed, provided the number approved by the Minister is not exceeded.
This new system has many advantages. It will ensure patients being admitted to beds where they can be best treated from the medical point of view. I know it is not always possible to give proper special nursing to patients in private wards who have had E.N.T. or ophthalmic operations. I think it may be possible to treat these patients in the same way as the patients who are now given treatment for thoracic and neuro-surgery operations, nursing them for the first 24 or 36 hours in an intensive care unit before they are moved to their private ward; but I see the advantage of getting the patient into the right nursing care immediately after 583 the operation. We must assume that the patient who wants to be a private patient probably wants to be treated privately for reasons such as choice of doctor, a wish for privacy, additional amenities such as extra visiting, television, and so on, and it seems unfair to expect such patients to pay for what they are not getting if they are put into a general ward.
I should like to remind your Lordships that privacy in hospitals is highly prized by patients. In our old hospitals more and more wards are being curtained, and in plans for new hospitals and when old hospitals are upgraded the old Florence Nightingale ward plan is discarded, and wards are broken down into small units of four or six beds, all curtained. It is curious that before this Bill was introduced the Minister made a survey of private beds in all hospitals and drastically cut the numbers of private beds on the grounds that these beds were not fully occupied.
On this point I should like to say that in most hospitals these private beds are not kept empty but are filled by patients who, through the nature of their illness, need privacy. So I make a plea for the patient who is prepared to pay for selectivity and privacy, for in our older hospitals there are very few single rooms attached to general wards, and as to amenities such as W.C.'s and bathrooms which we have on general wards, these can be used by all other patients. This disadvantage will not exist in the new hospitals, where there will be a large number of single rooms attached to general wards. I hope that in the regulations to be made by the Minister the arrangements in existing hospitals will be left so that boards of governors and management committees decide how Section 5 patients be accommodated, as so much will depend on local circumstances.
Also, I very much hope that consideration will be given to payments, which are not the same over the country for a private ward or for a bed designated in a ward. With regard to the charges for private patients, I think there is a great deal to be said for the Ministry's fixing national charges in certain classes of hospitals. At the moment there are great differences, as the noble Baroness said, in what a private patient pays, 584 depending on the type of hospital and where the hospital is situated. The actual hospital charges for private patients are not published, but are directly related to the cost per in-patient per week at the various hospitals. The following figures indicate the sort of differences which exist. I expect your Lordships know them, but I will give them because they illustrate the differences. In London teaching hospitals the cost is about £61 16s. 5d. per week; in provincial teaching hospitals, £54 16s. 7d.; non-teaching hospitals, £43 11s. 5d. These figures are the average cost per in-patient per week in acute hospitals of over 100 beds, and are taken from the Ministry of Health costing returns for the year ending March 31, 1967.
The next clause I would refer to is Clause 5. Some time ago I believe that the Ministry discussed with representatives of teaching hospitals a clause on these lines in a future Bill. I understand that the primary reason for seeking these powers was, as the noble Baroness said, because of the new medical schools at Nottingham and Southampton. Of course, it was rather difficult at Nottingham, because Nottingham is in the Sheffield Regional Board area which already has the board of governors of Sheffield Teaching Hospital run on traditional lines. I believe that in discussions with teaching hospitals the Minister's view was that new powers were required to try out new administrative arrangements on an experimental basis. An attempt was made to persuade the Ministry that these powers should be limited to Nottingham. Understandably, I think, the Minister has taken the view that if he has to seek an alteration of an Act of Parliament he must do so in such a way as to be able to use the extended powers where he thinks they will be appropriate in the future, rather than to have a restrictive amendment limited to the present position in two hospitals and two medical schools.
I feel that, while the Minister is seeking these wide enabling powers, I should like to ask the noble Baroness who is to reply for the Government for an undertaking that the Minister intends to use them initially for experimenting with the constitutional arrangements for the newly-established medical schools and teaching 585 hospitals which are to be called university hospitals, and that before he extends his powers 10 existing teaching hospitals he should not only consult the university concerned but also the board of governors of the existing teaching hospitals; also that the result of the experiments in these new university hospitals should be properly and independently evaluated, and, finally, that the unique position in London should be given special consideration, particularly in view of the Report of the Royal Commission on Medical Education, which, as the noble Lord said just now, has just been published and where many drastic recommendations on teaching hospitals, and London teaching hospitals in particular, are suggested.
I should like to say that I am a little disappointed that there is no mention of the ambulance services, which I hoped were going to be transferred from the local health authorities to the hospital authorities, which I am sure would make for more efficient running. But I hope that this is only a delay. I should like to end by saying that I am extremely glad to hear from the noble Baroness that the Minister is to have further powers to pay fares for journeys by road as well as by rail of visitors to special hospitals. I know something about special hospitals, and I know how important visitors are to the patients in those hospitals, and it will make a tremendous difference if the visitors can go by road as well as by rail.
§ 8.15 p.m.
§ BARONESS SUMMERSKILL
My Lords, I am very pleased to have the opportunity of congratulating the noble Lady on her maiden speech. She has acquitted herself excellently, if I may say so without appearing to be patronising, and I am sure that the House was very impressed by the fact that she had studied the Bill well and was able to approach it with specialised knowledge—indeed not only with specialised knowledge but, obviously, with practical knowledge of hospitals in which, I presume, she has worked. I am quite sure that I am voicing the opinion of noble Lords on all sides in telling her that we look forward to her next contribution to a debate of this kind.
We have had this Bill described in all kinds of ways, but I think we should remember that, for some reason, it is the policy of Government Departments to 586 accumulate reports on anomalies and grievances over the years; that these reports are collected together and, are dealt with in what is called an amending Bill. We have this curious Bill before us today. I feel very strongly that if as a result of some omission in an Act an obvious injustice becomes apparent, this injustice should be remedied forthwith. In this case 17 years have elapsed since the last amending Act. It is an absolutely remarkable feat of a Government Department. I should have thought that this long time lag must have been responsible for causing pain and distress to untold numbers of people who might have benefited by many of the recommendations which are embodied in the clauses of this Bill. Nevertheless, I must say, having been in at the debate upon the inception of the National Health Service, that the magnificent contribution of that Service remains outstanding, despite the attempts on the part of some people to introduce prescription charges.
I, like others, of course, muss pursue a kind of obstacle race and leave out reference to certain clauses while emphasising others, and as usual I am tempted to digress. The noble Lord, Lord Ogmore, tempted me once more. The noble Lord, Lord Ferrier, told me the other day that never more was he going to take part in a pharmaceutical debate; he had retired from that area. Whenever I raise this question he gets up and says. "This is the noble Lady's ritual dance". The noble Lady has now performed the "ritual dance" for many years in both Houses, and, of course, when I have this invitation to the dance from the Front Bench of the Liberal Party to-day I must intervene.
The noble Lord, Lord Ogmore, said something that has been repeated over and over again in both places year after year since the introduction of the National Health Service. He told us how important the contribution of the pharmaceutical industry has been to the National Health Service. No one denies that the pharmaceutical industry has some brilliant young men working for it, but what we object to intensely time after time—and this is why Clause 25, which I welcome, has been embodied in the Bill—is that the pharmaceutical industry makes colossal profits, out of all proportion to the contribution it makes. 587 As I went to my front door this morning, I saw 18 glossy advertisements which had been put through the door with my letters. I agree that there are two doctors in our house, but the cost of sales promotion is absolutely disproportionate. And do not think that I am, as the noble Lord says, performing my "ritual dance": I am echoing what the Estimates Committee said. The Estimates Committee sits in another place to examine the estimates of Government Departments and to examine the estimates of the National Health Service. It has proved time after time that the pharmaceautical industry over the years has used the National Health Service as a milch cow. That is what we object to. Having said that once more, I must return to my main comments. But the reason I get so annoyed is because I know that all this money that is wasted could be used in other ways. We have heard to-night from the noble Baroness who introduced the Bill that some of these clauses which embody important recommendations cannot be brought into force yet, for economic reasons. That is why some of us feel that some of this money which is spent on drugs that are entirely unnecessary could be diverted into other channels.
Having taken up time in saying that, I want now to say that I welcome—and I am sure the noble Lord, Lord Cottesloe, will "smack me down" after I have said this—Clause 5, which at long last transfers the administration of some hospitals concerned with teaching from the arbitrary direction of the boards of governors to the less hidebound Regional Hospital Boards.
The noble Lord, Lord Platt, said he would leave it to me to say something about women medical students. The noble Lord, Lord Cottesloe, may criticise this provision in Clause 5, but may I say that the case I can put to him, to support what I have just said, is the record of the treatment of women medical students by the medical schools over the last hundred years. I hope that now there is this little light at the end of the tunnel we shall take the power from some of the governors and transfer it to a body which, in my opinion, is more democratic and more generous in its treatment of women medical students. I hope that perhaps he also will change his mind.
588 The noble Lord knows as well as I do—and again I must digress, despite the lateness of the hour—that here in this country we have doctors from Pakistan and from India, countries which are desperately in need of doctors themselves, yet in the medical schools of London only a small percentage of women medical students are allowed.
In another place a discussion is going on at the moment in regard to race discrimination, when the most disgraceful sex discrimination exists in this country, particularly in the teaching hospitals of London. If the women of this country, the able girls from our schools, had been permitted, to go into the medical schools, we should have had so many first-class doctors that we should have been able to leave the Pakistanis and the Indians to their own countries. I welcome Clause 5, because at long last we are going to take the power from the governors of the hospitals and give it to the Regional Hospital Boards.
I also welcome the change in policy effected in Clause 10, which is in the interests of the midwifery service. Those things are quite revolutionary in the field of medicine, because the domiciliary midwives are to be allowed to work in our hospitals and thus, with the general practitioners, they will be more closely related to the hospital service. I am also glad to think that this will help to remove any lingering prejudice concerning hospital confinements.
We come back to the question of home-helps. Your Lordships will recall that the noble Lord, Lord Byers, put down a Motion on welfare just before the Recess, and many of us raised these matters on that occasion. Many of the points we raised then are embodied in this Bill. The provision which makes it a statutory duty of local authorities to provide home-help services and laundry facilities is long overdue. For years speakers in health debates, in both Houses, have emphasised the need for a comprehensive domiciliary service, and the nub of a domiciliary service is the assistance given by an efficient home-help, particularly where the patient is old and infirm.
Again, I am exceedingly sorry to learn from my noble friend that this service may have to be deferred. She said, "This is what we want to do, but it 589 may have to be deferred because we have not enough money". The home-help is the key worker in a home in which both the man and the wife are getting on and need some help, yet we have been told to-day that not enough money is available for that key worker.
Then, although we make the provision of home-helps a statutory duty, that will not necessarily increase the number of women who are prepared to do domestic work. Perhaps my noble friend will recall that on the occasion of the Motion moved by the noble Lord, Lord Byers, I asked whether a method could be introduced which would be cheap and effective. I suggested that in roads where there were old and sick people women should be invited to give their services on an hourly or two-hourly basis, instead of the old people having to have the home-help service, which is often full-time and does not enable many women to help the sick. I suggested that there might be a kind of warden service, such as we had during the war, so that in an emergency a woman could still run her home, and be there for her husband's dinner, and could also give a hand along the road. That would be a practical approach to the problem, and it would be much cheaper. I did not have an answer to that suggestion, but maybe the Ministry could say that although they are unable to introduce the more expensive service they could introduce something along the lines that I have suggested.
Clause 45 deals with the promotion, by local authorities, of the welfare of old people. Again, the only question is: where are all the people who will be needed, with their various qualifications, to be found? I would point out—and the noble Baroness has mentioned it—that this clause deals not only with personal services for the old people but also with providing accommodation, converting houses and doing all kinds of things for them in the home, apart from domestic work.
I am surprised that the Minister has not put any date to this provision. He has given the power, but he has not said to the local authorities, "We expect you to do something within a certain period". If we are to be guided by experience, this will mean that those authorities which in the past have been 590 slow to implement welfare provisions will again be dilatory. My noble friend knows that throughout the country there are efficient local authorities who have a well-developed social conscience, and who use their powers. But there are others who are slow; and now, of course, if the Minister fails to put a date to any of these provisions, those who have failed to make proper provision previously will continue in that way.
I now come to Clause 59, which makes amendments to the Nurseries and Child-Minders Regulation Act 1948. This clause may not appear to be related to the provisions concerned with the welfare of the aged, but it seems to me that there is a close connection, for it is agreed that the welfare of old people depends so much on the availability of a number of women, many of whom have had some special kind of training. The trained woman to-day is growing accustomed to taking marriage in her stride and to resuming the work for which she has been trained as soon as she can secure adequate care for her small children. This has resulted in a widespread demand for day accommodation for the pre-school child. I have only to remind your Lordships of the calls one hears on the radio for women to go into education and into the social services—the pressure put on married women to use their skills. And the women are quite prepared to come forward.
It has been estimated that in England and Wales nineteen times more children are now being looked after in day nurseries or by minders than in 1929. But owing to the failure of the local authorities to provide adequate facilities, women have been compelled to find childminders some of whom undoubtedly do not achieve the highest standard>. This Bill provides for more supervision in those cases where a person is paid for caring for a child. This seems highly desirable, but of course it will result in reducing the available accommodation. Therefore I say that it should be accompanied by provisions whereby the local authorities will make amends for their serious omission to provide nurseries.
Of course many of the child minders are short of the ideal. We have only to recall some of the stories of the 19th century when the children in the factories in the North were all looked after by 591 child-minders and all developed rickets. But it ill-behoves the Ministry to wave the big stick at the culprits and threaten all kinds of dire penalties. Under this Bill, if a woman who takes in children has not been registered, and so on, her offence will cost her £100 and she may go to prison for three months. The real culprits are the central and local government departments, which includes the education departments, who fail to provide adequate accommodation. Private minders can thrive only if the alternative arrangements are not there. There are more than 4 million children under the age of 5, and a little under half that number are in the 2 to 4 age groups. During the war, when the Government felt it was absolutely necessary to get the services of every woman, as indeed they do to-day, they provided 1,599 nurseries in England and Wales. Now there are only 448 and the number is being steadily reduced.
I hope that the men who read my speech will forgive my saying this, but I feel very deeply about it. It seems to me that there exists a conflict between the emotional and the intellectual approach of many men in places of authority to-day. On the one hand, they recognise that the trained woman is in great demand and they are the first to describe her training as wasted if she does not use her skill. The noble Lord, Lord Cottesloe, has heard that word before in medicine. On the other hand, they turn a deaf ear to her appeals for help in finding accommodation for her pre-school child without which she cannot offer her services. Successive Governments have exploited the loyalty of women, but this is more reprehensible in a Labour Government whose members have been parties to the pledges made to women over the years of more nursery schools and all the provisions calculated to lighten the load of the working woman and housewife. That has been said time after time, yet no action has been taken.
Now we have got to the stage of having to introduce a clause in this Bill which threatens those women who dare to care for the children of women whose services are desperately needed, unless they have fulfilled certain obligations. So often we have to repeat appeals here time after time. There are matters in this Bill which should have been considered long, long 592 ago; but at last they have come before this House and another place. I ask the noble Baroness, who understands the points I have raised, to use her power in the right places to bring pressure to bear, because my voice has been ineffectual for many years.
THE EARL OF ARRAN
My Lords, may I say one thing to the noble Baroness? She made certain strictures upon hospitals for their unwillingness to accept female persons into the medical schools. Would she not agree that in certain London teaching hospitals, notably the Middlesex Hospital at least, there is a high proportion of women nowadays?
§ BARONESS SUMMERSKILL
My Lords, I am glad the noble Earl has raised this point. In the old days there was a very tiny proportion—something like 5 per cent. I was educated at the Charing Cross Hospital after the First World War when they were very short of men. It only needed the men to come back for the Charing Cross Hospital to close its doors and not admit one woman. The reason why things have changed is because the University Grants Committee wagged a big stick at the governors and said, "If you do not admit women, no more money". We got in not because there was a moral change but only because it was financially advantageous to admit us.
§ 8.35 p.m.
§ LORD AMULREE
My Lords, I should not like the noble Baroness to get away with being the only person to congratulate Lady Ruthven of Freeland on her maiden speech. I think it should come from a male Member of your Lordships' House as well as from one of our most distinguished women Members. I am sure we all enjoyed her speech very much and hope to hear her again on many occasions on this subject.
This Bill is indeed a sort of rag-bag, but you cannot expect it to be otherwise because it is the first amending Bill for 17 years, and if you wait 17 years you are bound to have a rag-bag. There are only one or two points I want to bring up; I cannot possibly deal with the whole Bill at this time. One of the things I was pleased to see was in Clause 5, where at last we are going to get Nottingham and Southampton recognised as medical schools. I was very interested in the remarks of the noble Lord, Lord Platt, 593 about what may be the future of boards of governors and Regional Boards, but there was one point that occurred to me concerning Nottingham and Southampton. At the present time one of the great advantages of the boards of governors of the teaching schools is that they have, I believe, direct access to the Minister. Will that be the same for the short period until the Report on medical education is presented and something is finally settled? Will those two university hospitals have the same privilege?
Suppose they have not, it may come, because things take some time to develop, and it may take some time for the Report of the Royal Commission to be implemented. There may be a first-class and a second-class grade of teaching hospital, which would be a most unfortunate thing, because I think the plan which has come out for Nottingham and Southampton is one which should be very much in our minds when we are planning in the future. I should like to say one kind word about boards of governors. I worked under a board for a very long time, though I do not any more. Even supposing they were to encourage more women to become medical students, the point is that a school cannot take more than a certain number of people. If you get a larger proportion of women you will not get so many men, and as so many of the women get married, because they are most charming and attractive people, and go away from the profession, the final result will be that there will not be so many doctors as there were.
§ LORD PLATT
My Lords, there is a balance a little bit on the other side, in that the men emigrate more than the women do.
§ LORD AMULREE
My Lords, I thank the noble Lord for that comment. I should like to touch on Clause 13. I am very pleased indeed that the home help service has become statutory. I do not think this will mean that there will be many more home helps, because so far as I know there are no areas where there is not a good local authority home help scheme operating at the present time. The real drawback to increasing the number of home helps is not the fact that local authorities cannot afford to pay them, but that they cannot get suitable women or men—there have been one or 594 two quite good men home helps—to take on the job. Although one wants to see the practice expanded as much as possible, the fact that it becomes statutory does not necesarily mean that people will become home helps. What I think is sad, and where money may play a part, is that the laundry service is not a statutory but a permissive service. I talk from considerable experience with regard to the elderly. I think this is a service of enormous value in keeping people in their homes.
As the noble Baroness I think said, one wants to make a complete domiciliary service, and therefore one wants considerably more meals-on-wheels available. The Women's Royal Voluntary Service, the Red Cross and local authorities do a great deal in regard to these meals, but quite frequently one sees a scheme operating where the meals are available on only two or three days a week, whereas to be really effective they ought to be available on days a week at a minimum. If it could be made seven days a week, that would be marvellous, but that is not something which I think is simple to bring about.
One trouble about planning domiciliary services is that one does not really know accurately what number of people require the services. One wonders whether that information could not be obtained from a certain type of patient, certainly those who have been in hospital. When the patient is discharged from hospital, perhaps some kind of social note as well as a medical summary could be put on his notes. This could be sent to the appropriate authority, who would then know of the number of people who are coming out and would or would no: need some kind of service. At present I do not think that this is done at all, and it makes things just a little difficult.
The other clause which I should like to touch on is Clause 33, which enables the Minister to give vehicles to cli5abled persons. I think that is something which could be expanded a good deal. There are complicated and good typewriters called "Possums" which are used particularly at the spinal injury centre at Stoke Mandeville, where people who are completely paralysed, apart from their faces and heads—they may have had a fracture of their neck rather high up 595 —can learn to type. If they cannot type, at least they can be left by themselves, because they can work their Possum machines with their tongues, and they can do an enormous number of things which are necessary if someone is to be left by himself. I admit that these machines are expensive, but they are nowhere near as expensive as the cost of keeping someone in a hospital of that sort. I think it was the noble Baroness who quoted the cost of keeping people in hospital. A Possum machine costs, I think, about £700 or £800, but that is not a great deal compared with keeping a person in an expensive hospital for the rest of his life. So I hope that that matter will be taken care of when this Bill becomes an Act.
One point which was made by the noble Baroness I did not quite understand—perhaps I did not hear her aright. I refer to Clause 68. I did not quite follow what is to take the place of nursing a patient with respiratory tuberculosis in a general ward. I know that one has all sorts of treatment for open tuberculosis. But I somehow feel that a person in a general ward who has open tuberculosis should be taken to some other ward. I wonder whether the noble Baroness can tell me at some time what is going to take the place of that service.
There are two other things that I should like to mention. First of all, I am pleased to see that arrangements are being made for local authorities to assist voluntary organisations. I am quite sure that that will do much to quieten some of the fears of the voluntary bodies, who are rather afraid that their work might be taken from them by the local authorities. I am sure that the need for voluntary service in the future will go on just as much as now, if not to a greater extent. I am pleased to see that it is now going to be possible to house people in nursing homes run for profit, provided they are registered by the local authority. If that sort of accommodation is available and it is properly inspected it seems to me that there is no harm in paying for people to be taken into such places.
Finally, I should like to say how sorry I am that no attempt is being made in this Bill to bring industrial health into the National Health Service. No attempt is 596 being made to modify the school medical service, an extremely valuable and necessary service when it came into being. One wonders whether it now ought to be made more a part of the family doctor service. One thing has always worried me. The budgeting for hospital is done on an annual basis. The money which has not been spent by the end of March has to go back to the Treasury. Nothing can be saved in order to put into operation a project in five years' time. I think that is a point which a Bill like this, or some amending Bill, should take care of, because I am sure that a great deal of money is spent unnecessarily.
I must apologise, as I have already done to the noble Baroness, that because of a prior engagement I shall not be able to stay. I promised that I would ask her a number of questions, but as this Bill has come on rather late tonight I should be most grateful if the noble Baroness could reply to my points so that I may read them in the OFFICIAL REPORT, or possibly she may answer by post.
§ 8.48 p.m.
§ LORD COTTESLOE
My Lords, I too should like to say what a great pleasure it has been to hear my noble friend Lady Ruthven of Freeland make her maiden speech in this House, and to congratulate her on what I hope is the first of many speeches that we shall hear from her. It is of course entirely right and proper that some twenty years after the passing of the Act of 1946 which brought into being the National Health Services Parliament should review, in the light of experience, the working of that Act, and other associated Acts, and should amend them to enable them to function more smoothly and effectively.
In general, in my view, this Bill will have that effect; and although it does not, and perhaps could not, attempt to solve some of the more intractable major difficulties inherent in the Health Service, some of them of great importance—such as the difficulties that are inherent in the tripartite administration of the Service as between the executive councils, the local authorities, the Regional Hospital Boards and boards of governors; and although this Bill can only scratch the surface and deal with some of the difficulties and anomalies, it is a Bill which, in general, we must all wish to welcome. 597 It has the advantage of having been brought to Parliament by a Minister who for many years has devoted himself wholeheartedly to the Health Service and to its problems, as I myself have seen when for seven years Mr. Kenneth Robinson and I served as members of the same Regional Hospital Board. We may all feel fortunate, whatever our political attachments may be, that we have him in charge of the Health Service at present.
Having said that, I want only to raise one particular point on the Bill, but it is a point of such importance that I make no apology for raising it in this Second Reading debate, rather than waiting for the Committee stage of the Bill. It is in fact a point to which reference has been made by a number of other speakers. Clause 5 of the Bill is an enabling clause by which the Minister takes power to designate a hospital or a group of hospitals as a "university hospital"—a new kind of animal—to be administered under the Regional Hospital Board. It is well understood that the purpose of this provision is to enable the Minister to introduce experimentally a new form of administration for the new university teaching hospital at Nottingham, and perhaps also for a similar experiment at Southampton. No-one takes exception to a limited experiment of that kind—or, at any rate, if there are those who take exception, I am not one of them; I am entirely in favour of it.
But this enabling clause goes a great deal further than that. It would enable the Minister, if he so wished, at any time and without reference to Parliament, to make a fundamental and far-reaching change in the whole administrative structure of the hospital service. He could at any time designate any or all of the teaching hospitals which are at present administered by their own boards of governors directly responsible to the Minister, so as to put them under the Regional Hospital Boards. It has been suggested that he already has this power, but I doubt this. If indeed he already has the power, then I do not know why the clause is in the Bill at all.
I do not believe that the present Minister has in fact any intention of doing anything of the sort—indeed, he 598 has said so in another place. But it seems to me to be absolutely wrong that, in order that he may conduct a limited experiment at Nottingham and Southampton, he should take not only the limited powers necessary for that purpose but these very sweeping general enabling powers. The fact that he proposes to do so has caused widespread concern among the Metropolitan teaching hospitals, 12 undergraduate teaching hospitals and 15 post-graduate teaching hospitals. This concern is, in my view, fully justified. Not only would such a change (and, as we have heard, is is not without its advocates) be contrary to the considered advice of both the Guillebaud and the Porritt Committees (I will come later to the Royal Commission under the noble Lord, Lord Todd), but would almost certainly, in the Metropolitan area, be detrimental to the exemplary standard of the service given to the public by those hospitals and to the training given in their medical schools.
I do not speak without some knowledge, as a layman, of both sides of this matter. I was for seven years the Chairman of a Regional Hospital Board responsible for 150 hospitals; and I am presently Chairman of a great teaching hospital, Hammersmith Hospital. I can assure the noble Baroness, Lady Summer-skill, that the board of governors of that hospital, is no more hidebound than was the Regional Hospital Board, and the Regional Hospital Board was no more democratic than is the board of governors; and I am closely in touch through their teaching institutes with more than half the other teaching hospitals in London.
In another place, during the debates on this Bill, the Minister gave the following assurance:It is not my present intention to use the clause to effect sweeping changes in the administration of teaching hospitals already controlled by boards of governors."—[OFFICIAL REPORT, Commons, 7/12/67; col. 1686.]And in the Committee stage he repeated that assurance in these words:… and I assure the Committee that there is nothing in my mind at present concerning the possibility of using this power.Then subsequently he said:I hope that I have said enough … to set at rest any fears that exist in teaching hospitals about the passage of the Bill and the clause into law or about these provisions presaging 599 great and sweeping changes in their functions and responsibilities."—[OFFICIAL REPORT, Standing Committee D, 30/1/68; col. 107.]Since those assurances were given in another place the Report of the Royal Commission on Medical Education, Lord Todd's Commission, has been published, and the noble Lord, Lord Platt, has referred to that Report. I do not propose to follow Lord Platt into any discussion of the Report, except on the one relevant point. We shall no doubt have an opportunity at some other time of wide-ranging discussion on the sweeping and drastic recommendations of the Royal Commission. On the particular point with which we are dealing at this moment, the Commission recommend arrangements for the teaching hospitals generally on the pattern of those proposed for the Nottingham experiment. They thus, as it seems to me, prejudge the issue of that experiment.
It reminds me a little of a specification I once saw for a War Office trial, which started with the words, "The object of this trial is to establish the fact that …" I have far too much respect for the Minister to think that he will wish to prejudge this issue. It may indeed be that the Nottingham pattern (which derives from a somewhat similar arrangement in Scotland, not altogether free from criticism in practice, though I am advised that it works pretty well) might be suitable for a hospital region in the English provinces with only one or, perhaps, two teaching hospitals in the region. It might at the same time be utterly unsuitable for the Metropolitan area with no fewer than 27 teaching hospitals. The circumstances of the two are quite different.
In my view, this clause ought to be amended so as to limit its effect to the particular experiment which the Minister wishes to carry out. If he has no intention of making sweeping changes there is no need for sweeping powers. I hope that the noble Baroness, Lady Phillips, when she comes to reply, may be able to hold out some hope that the Government will in Committee bring forward a suitable Amendment to this clause. However, I am a realist, and I suppose it is not very probable that she will feel able to do so. But, in any event, I ask her to repeat categorically what I understood 600 her to say in her opening speech, that the assurances that were given by the Minister in another place still stand.
§ 9.1 p.m.
§ LORD CAWLEY
My Lords, I intend to follow the noble Lords, Lord Newton and Lord Ogmore, in talking about Clause 25 of this Bill, which is a very important one and is based on recommendation 11 of the Sainsbury Committee. I must remind the House that two things have happened since that recommendation was made. The first is that the Banks Committee has been appointed by the President of the Board of Trade to 'consider the question of the law on patents generally. Clause 25 as it stands deals with a series of sections of the Patents Act. It may be that recommendations will be made to recast entirely all or some of the sections, and possibly even the words "the services of the Crown" may not appear. So we can expect that Clause 25 will be a fairly short time in operation. The second thing that has happened is that there was a disastrous error on the part of Mr. Enoch Powell in the use of Section 46 of the Patents Act. I think that both of those facts modify the effect of the Sainsbury Committee's recommendation.
I need only say that there appears to be no immediate need for this provision, because the Minister has already said that it is intended to put it into effect only as a last resort. Another defect is that the clause as drafted covers only Part IV of the National Health Service Acts; it does not cover the hospital services. Noble Lords may say, "Well, that was decided in Pfizer v. Minister of Health." So it was, but it was a three to two decision, and now that the decisions of this House are held not to be binding on a future appellate committee it might be somewhat rash to say that the House will find the same way in the future. The effect if this clause became law would be that Section 46 of the Patents Act would apply to the general practitioners, but not to the hospital services. I think that the clause ought, at any rate, to be amended to make it clear that it applies to all services under the National Health Act.
I think I must say something about the result which has followed the stretching of the scope of Section 46, which was commenced by Mr. Enoch Powell and 601 was continued by the present Government. That result has been rather disastrous, because it appears that there has been a great temptation to save money at the risk of patients. It is a fact that under Section 41 of the Act a bona fide seller of drugs can obtain a licence to sell a patented drug to anyone, although it is true that the Sainsbury Committee said that this was a difficult process. One can only hope that the Banks Committee may suggest some easier method than the elaborate hearings which have taken place. I must say that the elaborate hearings which have taken place under Section 41 have been occasioned largely by the fact that the opponents have challenged the bona fides of the intending licensee. But if a really reputable firm came forward I feel that the time taken in hearings under Section 41 would be very much shorter than in the past.
The noble Baroness, Lady Summerskill, who is not in her place, was, I believe, wrong in suggesting that the big drug companies made enormous profits, rather implying in the alternative that those people who were authorised to supply under Section 46 did not make enormous profits. That is exactly the opposite from the truth. Those small importers who are employed by the Minister make enormous profits. They may supply the drugs to the Ministry more cheaply than do the big firms, but they have no overheads whatsoever—no advertising, no research, nothing else, and they can make a colossal profit on their goods. It really is a case of bringing in other suppliers who are going to make a very good thing out of it. I think that Clause 25 as it stands is an invitation to extend the dangers of Section 46 of the Patents Act to the field of general practice, and I cannot help thinking that those dangers are very considerable.
§ 9.7 p.m.
§ LORD AUCKLAND
My Lords, this is a very late hour indeed at which to be discussing a major Bill. I certainly do not want to be critical of those in charge of our Parliamentary programme, but, after all, this is a far-reaching measure and it is a great pity that at this late hour these vital deliberations should be taking place. This is one of two major medical Bills in the present Session of Parliament. This par- 602 ticular Bill has many provisions. It had a long discussion in the other place, which included twelve full sittings in Standing Committee and quite a large number of Divisions. As a result, the Bill has been very fully discussed. Although I think it is an overloaded Bill, an indigestible Bill in that it has so much content in it, there is much in it which can be fully commended.
Like the noble Baroness, Lady Phillips, I should like to commend most particularly Clause 65 of the Bill. I sit on the house committee of a mental hospital, although it is not in fact one of the special hospitals to which this Bill chiefly refers, and I have read the Report of the Select Committee on Special Hospitals. It is an excellent Report and a very moving Report. I am sun!, that the provisions contained in this Bill to make available more transport facilities will improve the morale, not only of the patients, and particularly those patients who are sufficiently in possession of a sound mind to understand at least a little of what goes on around them, but also of their parents, relations and friends. At a time when something like one in every nine people in this country undergoes treatment for some kind of mental condition, possibly a very minor mental condition, at some time in their lives, this is a significant pointer. These hospitals, or some of them at any rate, are situated a very long way from public transport, and therefore it is not a ways possible for those who have not got cars of their own, or even for those who have cars, to visit their relations or friends as often as they would like.
Clauses 1 and 2 of this Bill are particularly important, especially the provisions relating to pay beds. Like, I think, all my noble friends—and, indeed, all noble Lords in this House—I have the greatest admiration for the National Health Service. My family and I use it ourselves. But there is no doubt that various schemes, such as that provided by the British United Provident Association and others, at least help to off load some of the enormous burdens put on the National Health Service. I noticed that in the proceedings in another place the Minister seemed, if not to pour scorn on B.U.P.A., to have certain reservations about it. Since I do not use the scheme myself I will not pursue that point 603 further, but there are times when people like to avail themselves of private treatment, and I hope that the present Minister, for whom I have a great deal of respect, even if I do not always respect his politics, will not entirely close his mind to being more flexible on this particular clause.
The clauses relating to the welfare services are very important, but I shall not pursue them at this hour of the evening. The Bill itself is obviously one for thorough discussion on the Committee stage. Reference has been made to the new Clause 5, particularly by my noble friend Lord Cawley, who has given a full explanation of its legal contents. I must add my own, albeit mild, protest at the fact that it has been slipped into this Bill under the auspices of a private Member in another place, and not put in what I should have thought was its rightful place, in the Medicines Bill, when there had been more opportunity to allow the profession and the pharmaceutical industry as a whole to have a proper discussion of the Sainsbury Report.
I dare say the pharmaceutical industry make mistakes, and I dare say that some companies make bigger profits than is perhaps decent in these days of stringency. But it is also true to say—and I have seen this with my own eyes among pharmaceutical companies which I have visited and where I have asked close questions—that much is put into genuine research and that the outcome of that research is that many people have a shorter stay in hospital than they previously would have had. What worries me about this amendment to Section 46 is this. Who bears the blame when something goes wrong? As the Sunday Telegraph recently reminded us, we have had the harrowing story of the thalidomide tragedy. This is not the hour and I am not a qualified person to re-live this scene; but I fear that if this clause goes through in its present form and if something like this happens again, if the Ministry take the powers they have done, we shall have enormous difficulties when it comes to litigation. We all pray that this will not happen again. I think the general care which is taken by the pharmaceutical industry to-day will ensure that it will not.
604 This Bill will need a great deal of looking into in the Committee and its further stages; but, taken as a whole, although I think it is an overweighted Bill, it will be another landmark in the history of our health service; and this St. George's Day is a suitable day, even though at a late hour, for giving the initial discussion in your Lordships' House to this measure.
§ 9.16 p.m.
§ LORD FERRIER
My Lords, I should like to begin my speech by supporting the noble Lord who has just sat down in what he has said about the hour at which this very important Bill is being discussed in this House. This is not the first time recently that words such as these have passed my lips in this House; but I feel that it is quite wrong that the somewhat cumbrous proceedings like those of the Committee and Report stages of the Social Work (Scotland) Bill should have occupied so much time. Including the Amendments to the Schedules on Committee and the 97 Amendments at the Report stage, there were 345 Amendments to a Bill of 98 clauses. Can nothing be done to see that a major Bill of this important nature is discussed in a full House at a proper time of day? I apologise for taking up your Lordships' time on this, but I feel that it is a matter of great importance.
My Lords, I now turn to the pleasure it has given us all to hear the maiden speech of the noble Lady, Lady Ruthven of Freeland, and to express the hope that we shall hear from her again. I was struck by and interested in her pointing to the fact that the Bill contains no reference to the ambulance services. I would in passing mention that these services are of very great importance in Scotland. The farther away you get from the centres, the longer the distance to hospital, the more important become the ambulance services, their cost, their frequency, the conditions of the vehicles, the heating and so on, in their contribution to the national health.
I welcome the clauses which apply to Scotland, and particularly Clause 15, which is a provision for advice et cetera on family planning. The noble Lord, Lord Platt, made some reference to that clause. I presume that this will mean that the district nurses services in Scotland will be used in connection with 605 family planning advice in a way that they have not been able to be used before. I should like also to know how collaboration with the Family Planning Association, to which the noble Lord, Lord Platt, referred, is going to work out in Scotland. If it is not possible at this time to give an answer, as it were, across the table, perhaps the noble Baroness could write to me.
Speaking as a Scotsman, I also welcome Clause 19, which refers to the ophthalmic services, and to Clause 37, which provides for the payment of allowances and remuneration to members of certain advisory bodies, committees and the like in Scotland. This is reasonable and welcome if only because of the long distances which these people have to travel and the great sacrifices which they have to make. The greater the distance, the greater the cost of transport and the amount of time which an individual puts at the disposal of the State. The levels at which these people will be compensated will be moderate, and so they should be; though it is as well to remember that one of the troubles of the active professional man, or the highly paid commercial executive, or the busy tradesman who undertakes public work is that at these levels he will not be compensated for loss of earnings.
My Lords, as might be expected after the speech of the noble Baroness, Lady Summerskill, to whom I sent a message that I proposed to refer to her speech, I intend to refer to Clause 25. I assure your Lordships that I have very little interest to declare in the pharmaceutical industry compared with that which I used to have. I am a small shareholder but now I am "on the shelf". I hold no directorships and no executive position, but after the dozen or so years during which I enjoyed an active and fascinating connection with the industry, I feel that I have a contribution to make, and knowledge and experience which that connection gave to me which I can place at the disposal of your Lordships. No longer having an active interest in the pharmaceutical industry, I am enabled, while stepping a measure with the noble Lady in her ritual dance, to feel rather like a boy out of school. But joking apart, I have something important to say, and not only with regard to patents as they refer to the pharmaceutical 606 industry. I must declare an interest as a patentee, as I have a patent of my own, but that has nothing to do with pharmaceuticals.
I should like to support what was said by the noble Lord, Lord Ogmore, and I would ask the noble Baroness, Lady Phillips, to give most careful consideration to the figures which he quoted, and which I have no doubt are thoroughly reliable. I was interested to hear her say that it is the intention of the Government to amend Clause 25 during the Committee stage. Like many other noble Lords, I look forward to seeing what Amendments will be proposed. I assure your Lordships that unless the Amendments alter the whole structure of the clause, I am one who will oppose it tooth and nail.
I wish to refer to the cost of drugs—I will refer to profits later—and the fact that costs are increasing. Right from the beginning of the attack on the pharmaceutical industry (which dates from the occasion when Mr. Enoch Powell invoked Section 46 of the Patents Act; perhaps it would be wrong at this juncture to refer to him as "the nigger in the woodpile") people have overlooked the fact that in return for the increased cost of drugs, which arises from the drugs themselves being infinitely more complex and more costly to manufacture, the State and the people have obtained a reward as a "contra" entry in terms of hours of work saved, lives saved and fewer bed-days in hospital which is out of all proportion to the increase in the cost of drugs, which I think I am right in saying is less than the cost of the laundry. The costs may be high, but when people talk about the value of patents, they must remember that something like 99 out of 100 prove failures. There is another element, that of risk, to which I would draw your Lordships' attention. I know of an instance where some £100,000 was spent on a pilot plant to develop a new invention of an excellent drug, and not one single ounce came from that plant because before it was complete a better drug had been discovered. This is the sort of outlay that falls upon an industry of this nature, in which research has to be followed by the running of risks. Is the noble Baroness, Lady Summerskill, so sure that the profits are vast?
607 The noble Lord, Lord Cawley, has referred to the profits on the turnover of small importers. When we look at the dividends paid by the main manufacturing groups, we find that there are other products besides drugs, and besides those drugs which are sold to the National Health Service. There are bulk products, health drinks, invalid foods and the like. There is one very profitable line, which is hair cream. I am told that there is one drug on which the research costs were so great that although it is now beginning to sell well, some £8 million of profit will have to be made before the research costs are recouped. I beg your Lordships to take the stories of vast profits with a good grain of salt. In saying this, I do not omit the Sainsbury Report, as this is not altogether wide enough in its range on this subject.
I am sorry that the noble Baroness is not here, because she referred to the promotional expenditure undertaken by the pharmaceutical industry and to the loads of "glossies" which arrived in her letterbox. If I may say so, the noble Baroness is excessively fussy to-day. How many of your Lordships read more than a fraction of the "glossies" that come through the letterbox of a simple Peer every day? I have a son-in-law who is an architect, and he says that his letterbox is infinitely fuller of glossy brochures than any doctor's. We must face the fact that we are living in the 20th century and that this promotion, though quite unethical in regard to medicinal products in this country, is the usual way in which such products are sold, greatly to the benefit of the people in other parts of the world, particularly in backward nations.
I think it is proper to refer to another factor in promotional expenditure. The pharmaceutical representative is sometimes pictured as a sort of bagman. This is most unfair. The pharmaceutical representative of to-day is a highly skilled individual, qualified not only by experience in his trade, but almost certainly by training as well. The point I particularly want to make to your Lordships is that the representative not only goes to the doctor—and he is a very welcome caller on many doctors—with information of the latest developments in these complex drugs, but also provides 608 a link in the reverse direction between the doctor and the manufacturer. The manufacturer uses the representative as a way of keeping in touch with what the doctor needs; and what the doctor needs is what the patient needs. The noble Lord, Lord Platt, made reference to the enormous contribution to curative medicine which the pharmaceutical industry has made.
I would conclude with a further reference to the main principle of Clause 25. If this sort of attitude is the attitude of the Government to reward ingenuity or inventiveness, then no wonder there is a brain-drain. This sort of attitude to patents or copyrights is a chip on the shoulder. It is total disregard of the Tenth Commandment. As soon as an invention is profitable, surely the State benefits from taxation. I should like to congratulate the noble Lord, Lord Auckland, on his point about the dangers that lie ahead if the State is going to try to take a share in the profits on patents. I would go further and remind your Lordships that Clause 25 does not refer alone to medicines. It is a widely spread clause, and a much more tricky matter than appears on the surface. I am sure all noble Lords will join with me in congratulating the noble Baroness, Lady Phillips, when she said that Clause 25 is to be considerably amended in Committee. If patents or copyrights are to be disregarded like this, it will, as the noble Lord, Lord Ogmore, said, drive research and ingenuity out of this country; and it will lead to the brain-drain to which I have referred.
§ LORD OGMORE
If I may intervene, is there not another matter which arises here? I overlooked this point, but had intended to mention it. Many countries who copy us will adopt this procedure, not only for pharmaceutical products, but for all sorts of manufactures, and that will be an enormous loss to our export trade. That is one of the points that I think should be made.
§ LORD FERRIER
The noble Lord is absolutely right, and I agree with every word that he says. In the light of what the noble Lord has said, I think it is fair to advert to the fact that one of the biggest troubles (I speak from memory) is the import of complex medicaments from Italy where no patent law exists. 609 It is this fact which has brought about the profits of certain importers to which the noble Lord, Lord Cawley, referred. I am sure I am right in saying that Italy is finding that this is not worth the candle, and that they will have to change their attitude. In other words, what the noble Lord has said reinforces the point I am trying to make; namely, that this clause is the thin end of an important and valuable wedge to anybody who wishes to strike at the profitability of British industries. It would contribute to long-term loss in balance of payments, and it would make us more and more dependent in the future on the import of foreign drugs, which of course would affect the whole economic situation. But the State should not have power, I believe, to override patent rights except in grave national emergency—and, my Lords, surely it is possible that a middle course would be that independent arbitration could be adopted, or something like that. But with other of your Lordships I await with interest the Amendments which the noble Baroness has promised us at the Committee stage.
§ 9.41 p.m.
§ LORD SANDFORD
My Lords, this is certainly a Bill which can be welcomed wholeheartedly for its intentions, the present intentions of the present Minister who, I think it would be true to say, is admired by all Members of your Lordships' House, on both sides but I do not think it is surprising that it has nevertheless aroused a number of fears and suspicions about its possible future intentions under future Ministers. If, as the Minister has explained in another place, he does not want to make sweeping changes, then, as my noble friend Lord Cottesloe has already said, he ought not to be given sweeping powers by Parliament. It is a good maxim, which was first enunciated by, I think, John Stuart Mill, that any powers the Government are given ought to be treated as though sooner or later they were going to be abused. I think this is something we may have to bear in mind, however much we may admire the present Minister, when it comes to looking at these clauses in Committee.
There were a number of matters I was prepared to talk about on the earlier clauses of this Bill, but as these have all been fully covered by other Members of 610 your Lordships' House I will not touch on any of them, except perhaps to say how welcome, no matter how much overdue, is the news that the Minister is going to publish his proposed plans for an overall change of the whole administrative structure of the National Health Service. I think this is very much to he welcomed.
I should now like to come to a number of clauses which, through no fault of the noble Baroness or of the Minister himself, now amount to little mole than "window-dressing". There is this excellent Clause 13 about the home-help service—in this clause it is called the domestic-help service, but I think that home-help service is better. Then Clause 45 contains provisions for the welfare of the elderly, and Clause 64 deals with local authority grants to voluntary bodies. All these, especially when taken together, would open up tremendous prospects for a person such as the elderly, perhaps bed-ridden, widow, who so far, of all the people who might have been helped by the National Health Service, has probably been helped least.
These are all provisions to which she could look forward with considerable expectation. They provide services in a sector where they have been badly needed for a long time. But, unfortunately, even before this Bill had reached the Committee stage, we had the Prime Minister's Statement in another place on January 16 about the economic state of this country—something for which our noble Lords and Ladies opposite are responsible—and a circular from the Ministry of Housing and Local Government, making it quite clear that none of the rate support grant, on which all these three clauses hinge, could be expected before 1969–70. So here is the window full of attractive-looking goods, but all unfortunately labelled, "Not for sale"—a sad commentary on our affairs. Nevertheless, there it is.
I should like now to turn for a moment to one clause on which, surprisingly, I find myself almost in entire agreement with the noble Baroness, Lady Summer-skill, Clause 59—the clause about child-minders and nurseries. Here I believe we have a situation where the Government are in error in trying to legislate their way out of difficulties which have very little to do with legislation. As 611 the noble Baroness pointed out, we have a situation in which there is tremendous pressure and inducement of married women to go out to work but extraordinarily little provision for their children under 5, who must be put in somebody else's care if their mothers are to go out working.
Many of the arrangements, I should be the first to admit, made to fill this gap are unsatisfactory. The main remedy, as the noble Lady pointed out so forcibly, lies in better provision. I feel that it is a great mistake to try to put so much of this matter right by legislation. The result will be that much greater and unwarranted restrictions will be put on our freedom as individuals. There will he further intrusion into our homes; further heavy burdens will be laid on the police and officials of the town hall; and I do not believe that, at the end of it, the children now suffering and being abused will be any better off. I think that this is a matter to which we shall have to return at the Committee stage, to see whether we are not able to put it right by adjustment of the clauses as they stand at the moment.
I had intended to turn to the group of clauses, including Clause 25, which give the Minister power to manufacture, sell, supply, and so on, this range of goods over the whole National Health Service. I will not go any more into this now, as it has been so fully covered, except to say that it is not surprising that there is now fear and suspicion about the Minister's intentions. The Sainsbury Report has been called in aid, particularly of Clause 25, but the Sainsbury Report contained these words, under the heading, "Powers of Minister":If, after Ministers have settled the details of the future system and have completed discussions with the industry upon it, it appears that the existing powers are insufficient, then the Minister should take the necessary further powers".And more particularly, under the section headed, "Patents", Article 265, it said:Nevertheless, we make no proposals in this respect for we recognise the complexity of the subject and we know that a Committee"—the Banks Committee—has been set up to consider the patent law and recently appointed".612 In those circumstances, it really is not surprising, if a clause is slipped in at the Report stage, with no mention of it on Second Reading or throughout Committee, that people in the pharmaceutical industry and elsewhere are somewhat bothered. I have no interest whatever in the pharmaceutical industry and I am not here to defend it; but I do not think it ought to surprise the noble Lady and the Minister if people are a little suspicious and fearful if that procedure is the one that has been followed.
I have nearly finished. The only other thing I would say, before turning to my final remarks, is a word about the general practitioner. There is no clause anywhere in this Bill dealing with the general practitioner, but I think it would be absurd to have a debate on the National Health Service and not to say something about him, because he, after all, is the linchpin of the whole Service. The Minister made a number of claims about the general practitioner situation in his introduction of the Bill on Second Reading, and used that sanguine phrase, of which we have heard a good deal in the last three and a half years, about having turned the corner. I hope that we have. But the facts, as we have them, in contrast to the hopes of the Minister are as follows—and I take them from the Minister's last Annual Report (Cmnd. 3326) and the recent Report of the Royal Commission, under the noble Lord, Lord Todd (Cmnd. 3569).
We have doctors coming into the Service, having cost £10,000 each to train. Three hundred out of the 2,000 a year coming into the Service then emigrate—15 per cent. of them—and no doubt some of the ladies among them marry, in spite of what the noble Baroness, Lady Summerskill has said.
§ BARONESS SUMMERSKILL
My Lords, they go on working, provided that accommodation is made available for their children.
§ LORD SANDFORD
But, my Lords, the situation is that the numbers in general practice are actually falling, and not even keeping pace with the population: and we have the general practitioners' lists at 2,453—higher than they have been for sixteen or seventeen years. When we recall, as the Royal Commission under Lord Todd recalled, that 613 90 per cent. of all the illness is treated by the general practitioners, one is bound to feel concerned; and much as I welcome the provisions of this Bill I think this situation should cause us grave concern.
§ LORD PLATT
My Lords, may I intervene to say that a great deal of what needs to be done in general practice can be done without Acts of Parliament? I think this is a point which should be borne in mind.
§ LORD SANDFORD
My Lords, I am grateful for that intervention. That was very much in my mind. I was not complaining that the general practitioner was not mentioned in the Bill. I was saying that I thought he deserved a mention while we were discussing the National Health Service as a whole.
§ LORD FERRIER
My Lords, may I interrupt, before the noble Lord sits down? On the question of women doctors, is it not the case that the taxation problem, in which the income of husband and wife are combined for income tax and surtax purposes, is a contributory factor to the drop-out in the number of women doctors practising to-day?
§ LORD SANDFORD
My Lords, I am sure that is not for me to answer. Indeed, perhaps it was a mistake on my part to mention general practitioners at all. I said it only as an aside.
§ LORD SANDFORD
My Lords, I hope that I have not taken too long at this late hour. In common with all who have spoken in this debate I have an interest, as we all have, in trying to do what we can to get a better Health Service. I do not think many of us are inclined, as I felt that perhaps the noble Lord, Lord Ogmore, was, to bask in the popular polls of opinion about the National Health Service. The poll conducted recently by New Society indicated a fair degree of satisfaction with the National Health Service, but I am quite sure that it could be made a great deal better.
§ LORD OGMORE
My Lords, I did not mention opinion polls at all. I said that, so far as I was concerned, with certain qualifications, we had a very good Health Service.
§ LORD SANDFORD
Yes, my Lords; but I should prefer to say that it is a good Health Service which could be made a great deal better. Other countries spend in proportion a great deal more of their national income on their health services. For instance, Sweden spends 5.6 per cent., the United States of America spend 6.8 per cent., and Canada spends 7.3 per cent., compared with our figure of 4.9 per cent. I am quite sure that a good many people in this country would be prepared to spend more on our Health Service in order to get it better, but I believe that that could be done only under two conditions. The first is that they had a much bigger and a more direct say in how it was to be run, and a chance to pay for the kind of service that they, particularly and their families, and their professional colleagues, and, their workmates, warned to have for themselves. The second condition is that we should all have a much greater assurance that the very large amounts of money that are being paid into the Health Service are producing real value. With those few words I should like to confirm our welcome to the Bill and our wish to give it a Second Reading.
§ 9.50 p.m.
§ BARONESS PHILLIPS
My Lords, I should first of all like to thank all noble Lords who have given a generous welcome to the Bill. I would also thank noble Lords who have paid tribute to the Minister—perhaps that is unique when it is linked with a Bill—and I am sure that my right honourable friend will be happy to read the words of commendation which noble Lords have given this evening. I should also like at once to express my appreciation and admiration for the maiden speech of the noble Lady, Lady Ruthven of Freeland. As al Nays, she has upheld the reputation of the female Members of this House by being concise, brief, and putting a great deal of "meat" into her speech. I am delighted to welcome her, and I hope we shall hear her again very often. The information she gave was particularly valuable.
615 Although it is late, I feel it would be wrong not to attempt at any rate to answer some of the major questions that have been raised, though I am certain we shall have long debates on certain of the clauses on Committee stage. The noble Lord, Lord Newton, I think in the first instance mentioned Clause 25, and this was subsequently mentioned by several other noble Lords. It is important to emphasise that the Government naturally have an interest in the maintenance of a strong pharmaceutical industry and would accordingly be strongly inhibited from using this clause in any way to destroy that industry. I felt there was some element of suggestion that that might be the case. It is the intention that the power in this clause will he used only as a fall-back where price negotiations break down. If agreement cannot be reached on compensation in lieu of royalties the amount would be determined by the courts; so the Minister does not have an arbitrary power in this respect.
The noble Lord, Lord Ogmore, dwelt at great length on Clause 25, and, referring to the fact that I said the clause would be amended, I think he will be interested to know that the major change it is intended to make will be to limit its application solely to pharmaceutical products and appliances. There may be some other drafting Amendments, as the Minister indicated, but the main purpose of the clause, as I described it in my opening speech, will remain the same after the Amendments. I think it is rather important to mention that, in case noble Lords felt the substance was to be changed in any way.
§ LORD OGMORE
My Lords, will the noble Baroness explain that a little further? Does she mean it does not apply to any other goods at all except pharmaceutical goods and appliances—no other goods whatever of any kind?
§ BARONESS PHILLIPS
My Lords, that is as I understand it, but I will check it for the noble Lord before Committee stage.
The other point on which I feel the noble Lord, Lord Ogmore, would like to have a reply is this. He referred to lack of consultation with the industry in connection with this clause, and I 616 would tell him that the Minister has written to the Association of British Pharmaceutical Industries explaining why he found it right to accept the clause at Report stage in another place. The implications of the clause, along with the recommendations of the Sainsbury Committee, are at present subject to discussion with the industry. I hope the noble Lord will accept that the Minister is well aware of any complications which may arise.
The noble Lord, Lord Platt, referred to Clause 5, as did several other noble Lords. Lord Platt particularly asked about the Royal Commission on Medical Education, on which he served with such distinction. I hope he will agree with me that the provisions of Clause 5 are not inconsistent with the recommendations of the Royal Commission. Those recommendations are going to be very fully considered by the Government, but the particular recommendations to which the noble Lord referred are very far-reaching, and it would be of course wrong for me at this point of time to prejudge Government decisions in this connection.
In reply to her first question as to whether the local hospital authorities would be able to decide where the pay beds will be, I would say to the noble Lady, Lady Ruthven of Freeland, that the reply is, Yes. The other point which she raised about basic charges in connection with pay beds in a single ward or in an open ward and so on, I would answer by saying that there will be a basic charge for each of the five different groups of hospitals for whom the Minister intends to fix national charges. The Minister intends to have flexibility in order to allow for variation in charges, where, for example, accommodation is in single rooms or in an open ward, or where extra amenity is provided. In this connection the Minister wishes to have flexibility.
My noble friend Lady Summerskill, as it were, passed the torch to me, and I hope that I shall justify her faith. At least she knows that she has a friend at court who not only has followed with great admiration everything she has done for many years but almost always concurs with her views. I would certainly not say that she is an ineffectual 617 voice, but I will do my best to follow the point she has raised.
On the question of the child minders, she suggested that the Minister should perhaps not attempt to control their activities quite so rigidly. But the reports from local health authorities about the operation of the Nurses and Child Minders Act have indicated that powers needed to be strengthened to safeguard the health and welfare of children. I would merely add my own personal note, that when I as a magistrate have asked for information about the conditions of some of the child minders I have found it distinctly alarming. The point on which I should wholeheartedly agree with my noble friend is that this is only one part of the question. But the two things do not run contrary. I would say also in reply to the noble Lord, Lord Sandford, that we certainly need more facilities for caring for the pre-school child, but it would be wrong to leave undesirable conditions if legislation could put this right.
The noble Lord, Lord Amulree, asked about the question of the supply of Possum typewriters. I must say that this is a new name to me, and one which I found extraordinarily fascinating. I think the noble Lord will be pleased to know that one form of this equipment on the market is already available to Health Service patients who need it, although they have to pay for the attachments—for example, a radio tape recorder. The noble Lord, Lord Amulree, also asked about Clause 68. Since in that connection he gave me the opportunity to write to him, I will do so.
The noble Lord, Lord Cottesloe, referred to Clause 5, as did several other noble Lords. I noticed that the noble Lord said that the Minister could designate university hospitals without reference to Parliament. That is not correct. It is necessary for the Minister to make an Order designating a hospital as a university hospital, and the Order would, of course, be subject to discussion and could be annulled in either House. The noble Lord, Lord Cottesloe, also referred to the remark of the noble Lord, Lord Newton, that he did not see why the power was necessary. Basically, it is necessary because, without the power, the Minister at present has power to dedesignate—what an awful expression!— 618 a teaching hospital, without Parliamentary control, but he has not the existing power to create a new entity of hospital such as a university hospital.
I think we shall have more discussions on Clause 5, but I should like to reiterate what the Minister, to whom so many Lords have paid tribute, has quite categorically stated that he has no intention of using this clause to make sweeping changes. I feel that all noble Lords—
§ LORD NEWTON
My Lords, I think that he has said all the time "no present intention". It is the use of the word "present" which has caused a certain amount of alarm and despondency.
§ BARONESS PHILLIPS
My Lords, the noble Lord, Lord Newton, to whom we pay great tribute for his own work in this sphere, would be the first to agree that no Minister would be unwise enough to say that he would never take action of any kind. I think that the word "present" is probably customary use. Since such great tributes have been paid to his integrity as a Minister, I think that we may base ourselves on that.
§ LORD NEWTON
My Lords, I think the point is that it is perfectly reasonable for any Minister to say "It is not my intention to do this" and then, if he changes his mind in due course, to say so.
§ LORD NEWTON
I am glad that the noble Baroness agrees with me. To say "It is not my present intention" might suggest "It is not my intention to-day, but it may be my intention to-morrow." It is the use of that word "present" which raises a doubt.
§ BARONESS PHILLIPS
My Lords, I take the point of the noble Lord, Lord Newton. I am sure that we shall return to this matter during the passage of this Bill through the House. I feel that I could go on talking for a long time oil this lengthy Bill. I am grateful to the many noble Lords who have spoken as I myself have felt singularly unhealthy this evening since I was the victim of a rather unpleasant car accident on Sunday, and the prospect of replying to points on the whole of the 74 Clauses of the Bill seemed somewhat formidable. As we move 619 through the Committee stage, and later on during proceedings on the Bill, I feel certain that we shall again debate these various clauses very fully; but I should like to thank all noble Lords for bringing their experience and wealth of knowledge to bear on this subject. I commend the Bill to your Lordships for a Second Reading.
§ On Question, Bill read 2a, and committed to a Committee of the Whole House.