NATIONAL HEALTH SERVICE: FUTURE STRUCTURE

HL Deb 10 March 1970 vol 308 cc699-794

3.0 p.m.

THE MINISTER OF STATE. DEPARTMENT OF HEALTH AND SOCIAL SECURITY (BARONESS SEROTA) rose to move, That this House takes note of the Green Paper on The Future Structure of the National Health Service. The noble Baroness said: My Lords, I beg to move that this House takes note of the Green Paper on The Future Structure of the National Health Service. Although this, therefore, will be a debate mainly on organisation, the House will be considering the future of a Service which directly affects the life of every citizen, and one in which we are all potential or indeed actual consumers, quite apart from any specific responsibilities, either professional or voluntary, that we hold within it. Its introduction some 25 years ago in its present tripartite form (which was so fiercely contested in certain circles), formed an integral part of that great range of social measures introduced in the immediate post-war period, and was designed to provide health ser-vices that were universally available and freely accessible to everybody in the country. It was, however, not wholly a new Service but one with roots already well established. The methods of organising it were closely related to history, and in 1946 its three parts gave formal, statutory and administrative recognition to already established divisions.

Criticisms of this tripartite structure have been steadily growing for at least a decade. One thinks here of the Porritt Report in 1962, a resolution from the T.U.C. in 1965, and indeed a resolution from the Royal College of Nursing in 1967 calling for the unification of our present tripartite health structure. This growing concern, indeed demand, was fully borne out in the overwhelming response to the publication of the first Green Paper presented by my right honourable friend the then Minister of Health. Comments received were almost overwhelmingly in support of this principle of unification, and it is interesting to note here that pressure has come in this direction not from the professional critics of the Service but from those people who are deeply committed to its principles and who are only concerned to make it work better.

The present structure, as I indicated a moment ago, reflects both the historical evolution of the services, and indeed the thinking of a generation or more ago, in which the hospital was the dominant concept and the community services ancillary to it. There are three streams of care—general practitioner services, the local authority domiciliary services and the hospital services—with their separate managements, which now really flow together; and a static structure which places artificial boundaries and artificial obstacles in the way of comprehensive care, and gives insufficient emphasis to treatment outside institutions, no longer, in our view, corresponds to medical and social realities. This Green Paper, there-fore, which my right honourable friend the Secretary of State for Social Services published four weeks ago, sets out proposals for a new structure that is designed to meet the changing needs of society and the progress of medicine—in which ill-health prevention and health promotion can be given a fresh and stronger emphasis in a community-based service centred on the family doctor team, the absolute grass roots of the Service.

The need for changes of this kind does not in any sense mean that the Service has failed; it means merely that the statutory apparatus of the 1940s has been outgrown as medicine has changed and developed in a society undergoing rapid social and technological change. Indeed, the very pressures on the Service to-day, of which we are all so conscious and on which some of your Lordships are often vocal, are to my mind the very measure of its success. The provision of all social services inevitably means that we shall reveal unmet needs, and I think the striking improvements that have taken place in the standards of the nation's health since the inception of the National Health Service are the true measure of its outstanding achievements.

One has only to think, as the Green Paper indicates, of the great advances in the control of infectious diseases, of the record low rates of infant mortality and the increased standards of dental health that were revealed to the public only last week, in the Government's Social Survey report on the epidemiological study carried out by the London Hospital team, to realise the striking achievements of the Service, which I believe all of us are on occasion inclined to take for granted. Perhaps the most important of all, and the best illustration I can give the House of the way success has generated its own demand, is in the increasing number of people in the community who live into old age and correspondingly re-quire care, support and help from the health and personal social services that we provide.

Not all these improvements are solely attributable to the development of the Service: I would be the first to admit that. But I do believe that if we had not had a National Health Service both the developments and the standards that we see to-day would have been much more variable. To lake only two general examples, a patient to-day, whatever his or her income, now has access to medical and nursing care, regardless of cost, regardless of where or when it is needed, from his family doctor, or as part of the local health authority services, or as part of a hospital service. Secondly, although there is still, unfortunately, far too much variation in the standards of hospital pro-vision between different parts of the country, the Regional Hospital Boards, through their great efforts over these last 20 years or more, have achieved a remarkable evening out of provision as regards availability of consultant and specialist medical staff. As many noble Lords in the House will be aware, in 1948 specialist medical practice outside large centres of population scarcely existed. To-day, albeit there are occasions when we have to wait for them, these specialist services are at last within everyone's reach.

There is no doubt, my Lords, as successive opinion polls have demonstrated, that the British public values its National Health Service, and appreciates the work done in it. I am sure that all noble Lords will wish to join with me to-day in paying tribute to the energy and devotion of all those people, at all levels throughout the Service—Regional Hospital Boards, hospital management committes, teaching hospitals, local authorities—who freely give their services in a voluntary capacity to the day-to-day management of the Service, and also to that great range of staff—professional staff of all kinds, administrative staff, and manual workers—without whom no struc- ture, however well devised, would have any meaning whatsoever.

Our objectives, when reviewing the existing administrative patterns of the Service, have been to try to ensure that management and staff in our hospitals, and in the community services, can continue to give the public—and to an ever-increasing standard—the kind of service it requires. Administrative structures must always be responsive to changing needs, and must be capable of making the best use of available resources. I think the House as a whole would agree that it has become increasingly clear over the years that the structure we now have falls short on both counts—largely because of the divisive and wasteful effect of services that are now split into three separate parts and splintered into a great multiplicity of authorities. In practice, as we all know from our experience, there is a great deal of co-operation and liaison between the three parts of the Service. But, useful though this is, such liaison services can only patch the existing structure; they cannot achieve what we believe it is neces-sary do achieve if we are to move forward —namely, the full integration of the three separate parts.

It is only by this local integration and by strong links with local government that we believe, for example, that the mentally ill, the mentally handicapped or the elderly, can be enabled to stay out of hospital when the special resources of hospitals are not needed; and that care in their own homes or in community homes can be made available as soon as they have ceased to need treatment in hospital. We must now move away from the out-dated concept of the hospital in isolation as the primary element in health care, and replace the three separate streams of care by comprehensive community-based services, with the hospital reserved for those very special and complex technological tasks which only it can perform.

The first Green Paper made proposals for drawing the Service together, principally into some 40 or 50 area health boards. The principle was supported, but we received very widespread and general criticism of the remoteness of the boards from the very people they were intended to serve. Certain circles also suggested that the boards proposed would be dominated by the hospitals. There were also criticisms of the lack of pro-vision for regional planning.

This Green Paper, which might more accurately be described as a Green Paper with white edges rather than an entirely tentative document such as its predecessor was, has been written as part of a major reappraisal by the Govern-ment—the first for some twenty-five years—of the whole range of the health and personal social services, in the light both of the main recommendations of the Royal Commission on Local Government, under the chairmanship of the noble Lord, Lord Redclifie-Maud, which the House has been debating at some length only recently, and of the Report of the Committee on Local Authority and Allied Personal Social Services, under the chairmanship of Sir Frederic Seebohm, which is now the subject of a Bill in another place.

The first Green Paper performed a most valuable function in analysing the organisational defects of the present structure and in working out several possible methods of curing them. But it did not claim more than an intention, in its own words, to focus the debate as the time for important and far-reaching decisions draws near. Nor, indeed, could it do much more than that, because it was written in advance of the recommendations of the Seebohm Committee—whose Report appeared on the same day as the Green Paper—and of the Redcliffe-Maud Report. The way in which reform of the National Health Service might fit in with these essentially related matters could not, therefore, have been known at that time.

The second Green Paper has accordingly taken account of the fundamental criticisms of the first, and has been written in the light of the main recom-mendations both of the Redcliffe-Maud Report and of the Seebohm Report. That is why we are anxious to consult widely, to consult further and to consult thoroughly, before setting out in detail an administrative pattern for the Health Services for what might be another generation—hence a second Green Paper, rather than a White Paper leading directly to legislation. I see this debate to-day as a most valuable part of the process of comment and consultation on which we are already engaged, as so many of your Lordships will be speaking to-day with direct knowledge of and experience in different parts of the Service, both professional and voluntary. I look forward to hearing your Lordships' reactions to and comments on the Green Paper— and, I have no doubt, certain criticisms, too.

This new Green Paper contains three firm decisions which the Government have taken, the effect of which is to secure integration locally of the separate parts of the National Health Service, while at the same time co-ordinating them horizontally or laterally with local government public health and social services and—I would stress this point—involving local communities in the running of the health services in their own districts.

The first of the decisions which the Government have taken, which has not been universally welcomed in all quarters, is that the reorganised National Health Service is not to be administered by local government. There are certain organisations, particularly local government bodies, which have already expressed their disappointment at this decision, and I, as one who served almost continuously for some twenty years in local government, can well understand their reaction. It has also been asked: why, if the running of the health services is to be brought nearer to the people and to be made a matter for close local participation, should not the proposed new unitary authorities be given the job. Who, one could reasonably ask, would be more appropriate to administer community-based services than the elected representatives of the communities themselves?

The Government accept, as the Report of the Royal Commission suggested, that there is a case for asking the proposed new local authorities to operate the National Health Service; but, having considered all the factors involved, we have concluded that the case against that course is stronger. The Green Paper refers—I hope in quite clear terms—to two factors which the Government had in mind in coming to this decision. The first is the unwillingness of the professions, based on their belief that the clinical freedom which they have preserved, in spite of the gloomy forecasts of the debates on this subject, would best be safeguarded under a Service run by special bodies on which they were represented and which were responsible to central Government. Secondly—and this was a very important part of the Government's consideration of this problem—there was the ever-growing financial scale of the health and care services, which is illustrated quite graphically by the fact that central Government spending on the National Health Service in England is about three-quarters of the present total of Government grants to local authorities.

Taken on the whole, we believe that the Health Service might prove an indigestible meal for local government, especially at a time when local government outside Greater London is itself about to endure the throes of one of its most fundamental reorganisations of the century; and I can now confess to the House that it was that point which was, with me, a very powerful factor in coming to the conclusion that we reached. As one who lived through the years of reorganisation of London government, and served both on a new local authority and on an old one, being responsible for services which we had to continue and at the same time break up—and knowing, as the noble Lord, Lord Fiske, pointed out in the debate on the Redcliffe-Maud Report, just what that means in terms of strains and stresses for the staffs of local authorities—I could not envisage a situation where we were reorganising and reforming local government on the scale proposed in the Government's White Paper, and at the same time integrating the three parts of our National Health Service and putting them into a reorganised local government.

There is one other point which weighed heavily with us in our considerations. A major achievement of the Service has been, as I have suggested, to bring all the areas of the country more nearly into line as regards the standards of service offered. This levelling-up of standards is perhaps something which only a centrally financed Service can achieve. It would certainly be difficult to ensure that local authorities, with their inevitably varying resources and priorities, were able to reach a similar degree of balanced provision.

But if the National Health Service is not to be organised directly within local government, we were most anxious to make sure that the interdependent ser- vices provided by these two sets of authorities could develop in harmony. Part of the answer to this problem lies in the two other firm decisions which are set out in the Green Paper. The area health authorities—some ninety of them —will be directly responsible to the Secretary ofState, but they are to be closely associated with the proposed new unitary authorities;. They will run parallel with each other; and outside Greater London we intend that they should have the identical geographical boundaries. Fur-thermore, we have settled the administrative frontiers between the National Health Service and those public health and social services which will continue to be run by local authorities. This was perhaps one of the most difficult issues of all to decide.

Drawing the line has not been easy, not least because the health needs and the social needs of individuals and families are by no means clear-cut and distinctive, bat overlap and shade into each other. The guiding principle, as noble Lords will see set out in the paragraphs of the White Paper, has been that the health authorities will control those ser-vices where the skills required are pre-dominantly those of the health professions, while local authorities will be responsible for those services where the primary skill required is social care and support. I saw with interest, reading the debates in another place, that on the Second Reading of the Bill arising from the Seebohm Report, which incorporates these proposals, there was general agreement on all sides that the dividing line had been reasonably drawn.

We have also attempted to solve a problem which several noble Lords have mentioned in debates in this House on the Health Service, and particularly in debates on mental health—a problem which has proved one of the most intransigent of all in our present structure, following the passing of the Mental Health Act 1959. Experience has shown us only too clearly how difficult it is for a hospital authority and a local authority, often comprising totally different geo-graphical areas, to work together to pro-vide the right balance and proper variety of residential care in the community and half-way house accommodation needed for the mentally ill and the mentally handicapped. It seemed to us here that the difficulties could be resolved only by enabling both authorities to provide such services according to the patients' needs and according to the main professional skills involved. This answers a question which the noble Lord, Lord Grenfell, I know, has often put in debates here, when he has pleaded with us to allow him to build half-way homes in the grounds of his hospital for the men-tally handicapped children for whom he is caring. This is a solution, as I have said, my Lords, which we have come to after long thought, and I hope that this division of responsibility between local authorities and health authorities will make it easier for them to work closely together and to co-operate together in order to meet the needs in the communities in which they serve.

These, then, are the three main decisions which set out the white framework of the Green Paper, and it is within this framework that we hope the reorganised Health Service can take shape. But these three decisions apart, I should like to make it quite clear that the proposals in the Green Paper are wide open for discussion. They are not only truly green, but there are, as I shall indicate in a moment, some areas which are even greener than others. However, they represent collectively, in the Government's view, a means of reaching the objectives which I think all noble Lords will agree are those for which our National Health Service should aim: unification; the establishment of close links between health services and social services; the maximum devolution of responsibility and the maximum involve-ment of local people in the running of their own health services; and, at the same time, ensuring that the central Department exercises proper control and supervision of public money which is spent in very great sums on the Service, so that the patients get full value for it.

My Lords, in view of the long list of speakers I will not attempt, in opening, to elaborate further on the proposals in the Green Paper. I had intended to try-to demonstrate the ways in which we saw the pattern working out, and also to indicate to the House the importance we attach to the role of the teaching hospitals in the development of our new Health Service. But I know that there are a number of noble Lords wishing to speak, including the chairmen of two great teaching hospitals, one an undergraduate and one a postgraduate hospital of great international repute, and therefore I feel that perhaps it would be wiser if I were to let the debate now take its course and to try to answer the various points as they are made in the debate.

I would conclude by saying simply this. I hope that as noble Lords speak on the structure and the organisation, they will not lose sight of what is our prime objective; namely, an integrated and comprehensive set of services. We believe that the proposals that we put forward to-day provide the required framework; and I thought that before I concluded noble Lords would wish to know that my right honourable friend the Secretary of State is intending to publish a White Paper this summer announcing the Government's conclusions on these major issues. This is why he and I welcome this early debate in your Lordships' House. We have already started the processes of consultation and discussion, and we are anxious that the timetable for the re-organisation of the National Health Ser-vice should keep in line with that for local government, which is set out in the White Paper. I look forward with interest to hearing the views of noble Lords on the Green Paper to-day.

LORD SALTER

Before the noble Baroness sits down, may I ask her to men-tion one thing which I think greatly adds to the general strength of her argument? Within living memory, I was myself an official in Whitehall when Bleriot crossed the seas for the first time. Since then, we have had to face an additional difficulty that no preceding generations concerned with health had; that is, that no longer had we any chance to see a dangerous disease develop before the people arriving on board a ship reached here from another country. As I say, that has added to our difficulties; and all the credit which is due, which has been explained by the noble Baroness, is, I think, to be greatly added to by the fact that in the present generation, since Bleriot, there has been that extra difficulty for everybody concerned with the health of the people of this country.

BARONESS SEROTA

My Lords, if with the leave of the House I may speak at the end of the debate, perhaps the noble Lord will allow me to answer that point then. I beg to move.

Moved, That this House takes note of the Green Paper on The Future Structure of the National Health Service.— (Baroness Serota.)

3.29 p.m.

BARONESS BROOKE OF YSTRAD-FELLTE

My Lords, many of us who try to master the contents of one important document after another, as they pour out from Ministries or emerge as the offspring of Committees, Working Parties or Royal Commissions, may be forgiven if we tend to become a little confused from time to time. Recently it was Maud, now it is Seebohm who is commanding our attention. Todd has remained in the background, but is due to take its bow some time next month. Bonham-Carter, Cogwheel and the Responsibilities of the Consultant Grade seem to have been left by Parliament to the experts in their fields so far; and Salmon is rising in all sorts of streams. To-day we concentrate upon the second Green Paper, the "Revised Version" so to speak, produced by the Department of Health; and it is of special significance that on this particular day the noble Baroness who introduced this Green Paper is herself garbed in a green and white chequered suit. Would that the author of the Latey Report had been commissioned to write the Green Paper! Our homework then might have been more lively.

It is a new attempt to suggest guide-lines for the future of the National Health Service and to invite discussion as to their viability. For the second Tuesday in succession noble Lords mainly interested in Scotland or Wales may feel a little frustrated in that your Lordships have been asked to examine a document which relates only to England. I am Welsh but I suppose that I can afford to be generous about English nationalism.

The noble Baroness has given us a clear picture of what the Secretary of State would like us to know. He has already taken decisions on three factors, so the Paper starts by assuming the appearance of a greensward covered with a light sprinkling of snow. This Paper appeared less than a month ago and has already given rise to dozens of columns of opinion in the Press, and a mass of briefs from interested parties. I want to examine some of the proposals made, and I do so in the light of the doubts that have been expressed in a number of informed quarters. Those of us who care—and some of us do care deeply—about the National Health Service and all that it can do, and could do, to alleviate physical distress and to cure mind and body must welcome the fresh thought which has been given to the subject. The Government are attempting to do some-thing for a Service which is unique in the world. It is up to us to see that the something will be an improvement and not a hindrance to future progress and good management. But it must never be forgotten that the Service is for the patient and not for the administrator.

The whole local authority world is naturally deeply disappointed that the medical world has won the battle of administration. It is not only the local authority world that has a monopoly of this disappointment. The Director of the Hospital Centre, Mr. Miles Hardie, writing in the British Hospital Journal and Social Service Review, says categorically: From the patients' point of view health and welfare needs should be most effectively met by unified health and social services operated by the new revitalised local authorities envisaged in the Maud Report. In the Green Paper political expediency and professional prejudice have combined to bar that solution. Now the patient will be offered unified health services under strong central control and unified Seebohm-type social ser-vices under decentralised local government direction. What is meant by "strong central control"? I think we must examine the structure. The first Green Paper, which was published nearly two years ago, was widely criticised for recommending area boards which looked like being too small for effective regional planning but too large for day-to-day control. The cry was for a two-tier system. Now we seem to be offered four. The Government have opted for about 90 area health boards, instead of the 40 to 50 suggested in Mr. Kenneth Robinson's original plan. These area health boards are to share the same geo-graphical boundaries with the local authorities running the social welfare ser-vices. This is welcomed by some, but care will have to be taken to see that there is complete understanding of the proposed distribution of functions between the two authorities in order to avoid overlap, or indeed omission. I cannot help feeling that at the back of the Secretary of State's mind is the hope that the medical opposition to putting the Health Service under the local authorities will gradually diminish, and his proposed plan would facilitate an eventual takeover or transfer. Perhaps after another decade such a transfer would be in the best interests of everyone, but in 1970 it is obviously not going to be "on".

Above the new area health boards there are to be regional health councils. It is here that the great weakness of the Green Paper appears. It provides only a second-class role for these new regional health councils. There will be 14 or more of these councils, covering areas six or seven times larger than those of the 90 area health authorities. They are to exist for the purpose of overall planning of the hospital and specialist services—including the rarer specialties (such as neurology, radiotherapy, neurosurgery, nephrology and specialised laboratory facilities; the organisation of facilities for post-graduate medical and dental education; the deployment of senior hospital medical, dental and scientific staff"— and in the middle of this quotation may I ask the noble Baroness to tell us how the staff are to be appointed? I can find no mention of this anywhere. The quotation goes on: the regional organisation of staff training; blood transfusion services; and the planning of ambulance services. I have been quoting from Chapter 7 of the Green Paper.

Now, my Lords, if regional health councils are to have any purpose they must not only have authority, they must command respect. Otherwise, it will be impossible to get people of quality to serve on them, and the officers they attract will not be of first-class calibre. They must be given some "teeth": their functions must be more than just advisory. Over the last 21 years Regional Hospital Boards have built up an experienced staff and a great loyalty from senior officials in the various hospital groups. It would be a thousand pities if the Regional Board staffs were ill-advisedly dispersed and these loyalties disappeared. And what-ever shortcomings they may have shown the country has every reason to be deeply grateful to the voluntary members of the existing Regional Hospital Boards and hospital management committees for the hours of unpaid work they have given to help establish a remarkable Service.

In paragraph 90 of the Green Paper there is a statement that there will be a need for strengthened regional offices. To many of us this statement has an ominous ring about it. What is to be the relation-ship between the regional offices of the Secretary of State's central Department and the regional health councils? Is it not rather ridiculous to have two regional organisations in the same town or city, each with some sort of staff and liable to duplicate one another's functions? The ominous point is that the regional office is to have power and the regional council none. Is this what the Secretary of State intends—so that he can exercise central control?

Let us look for a minute at the pro-posed regional councils. The Green Paper states that these councils are to plan the hospital and specialist services in the region. Planning is nowadays a very sophisticated matter. Are the councils to have access to statistical information and knowledge of current trends in building costs and revenue costs? Are they to have a staff of architects, statisticians and finance officers? How are the councils to deploy senior hospital, medical, dental and scientific staff unless they control them? Should not senior staff remain under contract with regional councils, rather than be transferred to the proposed area health authorities; and should not the present method of appointment of senior staff by Regional Hospital Boards be transferred to the proposed regional councils? It may be that this is the intention, but I find it difficult to discover in the Green Paper words to that effect.

To-day the medical services are really kept going by the expertise of Regional Boards, in moving consultants to fill temporary gaps in the service owing to illness, study leave and shortage in some specialties. It has been known for an entire hospital group to be without a radiologist and for the problem to have been solved by the Regional Board's persuading radiologists from other groups to provide cover. As for the organisation of postgraduate medical and dental education, this is likely to be a much bigger job in the future than it is at present, and it is bound to involve university and teaching hospitals. These bodies, I am sure, will want to deal with some-thing equivalent to a Regional Board. I cannot see them welcoming a council with only advisory functions.

Here I should like to draw the attention of the noble Baroness to two immediate causes for worry. In the interregnum between the implementation of Seebohm and the emergence of a new policy for the National Health Service there are bound to be uncertainties and consequent loss of morale among public health authority staff and some members of hospital staff. In some cases deputy medical officers of health are already resigning, for they see no future in their chosen career; and medical social workers who have been working in hospitals because they want to are not at all anxious to be transferred to the community health service as a result of recommendations in the Seebohm Report, though the terms of reference did not include reference to medical social workers in hospitals.

Secondly, with the implementation of Seebohm several responsibilities of local health authorities will be transferred to the new family welfare departments which will be a local authority function. At the same time it is now clear that health, other than public health, will cease to be a local authority responsibility when the new national health policy is implemented. Some local authorities are already considering spending no more on health and concentrating on welfare—and this at a time when the calls on local health resources are increasing, due to early discharge policies and to attachment schemes which, however good they are, lead to more work. Good local authorities will not take this line, but the danger is there, and I hope that the Government are aware of it.

My Lords, the proposed responsibilities of the regional councils seems to be delightfully vague. They are to advise the central Department and the area authorities on the planning of services. But who is to control the capital building programme and capital expenditure? The central Government are proposing to be advised by the area health authorities, by the regional health councils, by the Central Advisory Council and the Hospital Advisory Service—four sources of advice. Human nature being what it is, it is unlikely that there will be complete unanimity, and any Secretary of State under this pressure would be less than human if he did not impose the central Government's final decision on priorities and the allocation of resources. Everywhere one is conscious of a deep suspicion that the dominant factor of the future will be strong central control.

At grass roots level there will be the district committees, some 200 or so, and they are to be serviced by the staffs of the area authorities. They are to have no money and no statutory powers. The Green Paper says that their functions require study. I bet they do, my Lords! If worthwhile people are prepared to serve, I can see some of them becoming an embarrassing goad to their area authority, as the really good house committees often were to their hospital management committees in the past. The noble Baroness and I share memories of that sort of experience—and very effective it can be. I believe that the viability and vitality of district commit-tees are mainsprings from which enthusiasm, pride and skill in the Health Service may emanate. Without strong district committees capable of purposeful action the National Health Service will be in danger of becoming an impersonal bureaucracy.

I believe that the preservation of personal voluntary service by the public, even if not in the identical form of boards of governors and hospital management committees, should be a cardinal feature of any new planning. Voluntary organisations are given a welcome. I am sure that their contribution will continue to be as valuable in the future as it has been in the past. With the cost of the Service going up all the time, unless some of the work can be undertaken by trained volunteers there will be large gaps which, because of shortage of money, cannot be filled by salaried employees.

Hospital care is far more expensive than community care, but there are now thousands of people who are having to be looked after in the acute hospitals simply and solely because the facilities for community care are not yet adequate, or are not yet being properly used. We do not need more beds in acute hospitals; we need more community facilities avail-able, both in the home and in purpose-built accommodation, with supporting services of a domiciliary nature. Every-one interested in the Health Service wants more money for it, but I am sure that there is also considerable scope for saving by closer co-ordination and unified decisions on priorities.

My Lords, there are many noble Lords who wish to speak in this debate and who are far more knowledgeable and experienced than I am. Knowing this, and not wishing to weary your Lordships by too long a speech at the beginning of the afternoon, I have said nothing about the family practitioner service; the community physician, teaching hospitals and their trust funds; peripheral hospitals; complaints and a Health Com-missioner, or the arrangements for London. This is not because I do not consider these matters to be important, but because I do not want to speak for too long, and I am sure they will be taken care of by other speakers during the course of our debate.

I should like to end, however, on a modest note of advice to the noble Baroness. If she can get her right honourable friend the Secretary of State to read the Report of our debate, and then to study all the sensible recommendations which I am sure he will find in it—

BARONESS SEROTA

My Lords, if I may interrupt the noble Baroness for a moment, I would say that my right honourable friend the Secretary of State is listening to our debate.

BARONESS BROOKE OF YSTRAD-FELLTE

My Lords, I entirely and absolutely accept that intervention, but I suggest that the right honourable gentleman will be a strong man if he remains to the end of our debate, which I reckon will not be over until 9 o'clock to-night. So, if he will study all the sensible recommendations which I am sure he will find in the speeches to which he has already listened, this debate will have served a most useful purpose in complying with his invitation for comments and suggestions on the proposals made in his Green Paper; and possibly a better White Paper may be the result.

3.48 p.m.

LORD AMULREE

My Lords, I find the Green Paper we are discussing to-day a very interesting document. There are far more things in it with which I agree than there were in the one which came out two years ago. I do not propose to follow the noble Baroness, Lady Brooke of Ystradfellte, by going into a great analysis of what the Paper says, but I should like to comment on one or two points which are of particular interest to me and which I think are worthy of having something said about them.

I am sure we are all pleased to see that the Service is to be united from its present tripartite structure into one Service, but I am bound to say that I do not think that the patients, and doctors, like my-self, who are practising in the Service, suffered a great deal from its tripartite nature. Much of our success depended on the fact that there were involved on all sides reasonable people who were interested in the welfare of the patients. And, after all, as the noble Baroness said, it is the patients for whom the National Health Service is really intended. I am quite prepared to believe that in the tri-partite system there was a good deal of overlapping administratively and it was probably rather more expensive to run than if it had been united; but I think that it went wrong, from the practical working point of view, because there was not always good will and friendship among the various parties involved.

Supposing that is true, and I think that it is, I do not believe you are going to change that state of affairs by making it a unitary service rather than a tripartite thing. You have to change the spirit of the people working in it. I am sure that it will change in time, but in the past there have been difficult areas where things have not worked very well. One thing might be improved by closer collaboration. I am pleased to see that there are going to be members of local authorities upon the local health administration in the areas, and I trust that the same thing will apply to local authorities: that members of the local area health boards will be co-opted on to the local authority committees. A good deal of time and money is wasted by keeping people in hospital who do not need to be there, because the domiciliary services and residential accommodation are not available for them.

Obviously a great deal has been done about the domiciliary services. There is the Home Help Service and the Meals on Wheels service, which is the particular interest of the noble Baroness, Lady Swanborough, with her Women's Royal Voluntary Service. But it wants a great deal of expansion. If it is to be a service to take care of elderly people who have been in hospital, they have to be able to get meals five or six days a week and not merely on one or two days. One of the problems we may come up against there is whether there will be a sufficient number of people to staff these extra services. I think that this matter should be gone into carefully before we assume or promise more than we can do.

In the debate on the Seebohm Bill in another place it was denied that there were occupying expensive beds in teaching hospitals elderly patients who do not need to be there. I am afraid it certainly was so during my day, but I retired from hospital work in 1966. Things may have improved since then, but I do not think they have, and I am certain that we shall find elderly folk being kept in teaching hospitals and costing the State £70 to £80 a week, because there is no room for them in local authority accommodation and they are not quite fit enough to go home. I do not want to labour this point, because I have said this on more than one occasion, but I think it is worth while remembering that this problem has not been solved. Things have been improved but it has not been solved.

This seems to me to be one of the matters in which we may get greater improvement when we have the area health authorities and the local authorities both dealing with coterminous areas. I know that among some sources there is a fear that in due course this may lead to a merger between the two under the local authority. That is a thing I am not particularly worried about. I have never been so worried as some of my colleagues about the local authorities; and if that were to come in time it would possibly be a good thing rather than a bad thing.

There is one point in regard to which we have to be careful to see that nothing goes wrong. Two excellent statements are made by the Government in the Green Paper. The first is in paragraph 1 (ii), which says: The service should be national in the sense that the same high quality of service, but not a standardised service, should be pro-vided in every part of the country. Then paragraph 94 says: Every hospital has something it can teach others; every hospital has something it can learn from others. Those are impeccable sentiments that no-body would deny at all. One just wonders whether they will not sometimes be forgotten. If there is a really strong, centralised authority, one wonders whether they may not want to make things rather more standardised, not realising that one hospital can teach another and learn from another. It makes one rather think of little Red Riding Hood coming up to that strangely metamorphosed grandmother and almost hearing those teeth coming together, as little people get bitten and chopped off.

However, I think it is here that we must be careful. When I think of the Regional Board system, I should like to join those noble Ladies who have spoken in saying what a first-class job the Regional Boards and boards of governors have done, especially in encouraging experiments in the patterns of medical care. I do not mean this in any wrong or evil kind of way, but people could try out their ideas in different kinds of way and that has been one of the great features of the Health Service. It was not all standardised. People could try things. If they were wrong or bad they could be put right and if they were good they could be adopted by other people. We have to be careful that this sort of thing does not vanish in the future under some system of central control and standardisation. I have no particular reason to sup-pose that it will, but it is a point for which we have to be constantly looking out.

To come back to more detail, I think we have to see that there is a close link between the social work departments of the local authorities and the hospitals. I am sure that people (if they are to be called medical and social workers in the new world I would not know, but what-ever they are called) have to be seconded to hospitals not merely for a day or two but for a long period of time so that they really become part of a hospital team taking care of patients. That particularly applies to elderly patients, the only ones of whom I have had experience. I see that paragraph 46 of the Green Paper says: Social workers would be made available by the local authority to serve the hospitals …". Should not that be "should" rather than "would"? Surely "should" is a far more mandatory word than "would", which is a permissive word. It has always seemed to me that one of the troubles in legislation, particularly when dealing with local authorities, is that if it is too per-missive, then the bad authorities do not play and the good authorities have already done it, so we do not get anywhere. Therefore, I should like to see this paragraph changed.

There is another point in paragraph 46, where it says that general practitioners will be able to call in specialist help. This is particularly important in dealing with elderly people when they are first taken ill. I think that this should be made stronger. I believe that specialist help should be almost compulsorily available, because if one is dealing with social problems, particularly those affecting elderly people, there is an enormous amount of medical background which should be looked into. I do not want to talk non-sense about going back to the bad old days; but this was the cause of trouble in the past. People were put into these bad institutions and not seen by a proper doctor, and they were neglected in that way. Because one has seen that happen in the past one does not want to see any-thing like that happen again, merely because it was not thought about and nothing done to prevent it occurring.

These are the only criticisms I have to make of the Green Paper. They are not severe ones and I trust that they will be dealt with. There are two questions that I should like to ask. Paragraph 103 reads: Rates of pay and conditions of service in the new administrative structure will continue to be settled through national machinery. Does that mean that the Whitley Council is to go on its way plunging through professional people in a way which was never intended? If that is going to happen, will you not get a continuation of the absurd anomaly whereby the medical social worker under the local authority is paid more than the medical social worker under the National Health Service, and someone who is teaching chiropody under the local education authority is paid more than if he is teaching chiropody in one of the foot hospitals under the National Health Service? Surely the time has come when professional workers should be given a new body, such as my profession man-aged to secure for itself some time ago. I do not think it has been a frightfully ex-pensive body, and it has certainly kept people comfortably happy.

In paragraphs 57 and 80 reference is made to money being available from various trust funds for voluntary bodies working in the appropriate area. Does this refer to the endowment funds of the leaching hospitals; does it refer to the "friends of hospital" funds which have been set up, or what funds are they going to be? That is only a minor point.

I agree with what the noble Baroness, Lady Brooke, said about the regional councils and the district councils. It seems that the regional council has no well-defined functions, but paragraph 85 says that in view of their membership, their recommendations will carry great weight". I have been a civil servant working in the Ministry of Health for ten years or more, and that just does not go down. You do not fall down when great names are mentioned if they have no power behind them. I do not think that will get one very far. I do not propose to follow what the noble Baroness, Lady Brooke, said about the district councils, as time is running on.

I said that I had two questions, but I am afraid I have four. I should like to come to the position of the medical officer of health. I see that one of the medical officers of health is to become the chief administrative medical officer of the area health authority. Does that mean that the others are going to be disposed of? The Green Paper is a little vague about what kind of work they will do. These men and women have done extremely valuable work in the past, and will continue to do so, and I do not think we should forget the importance of environmental hygiene at the present time.

I see in Appendix II that there is to be a close link between the area local authority and the employment medical advisory service. I am pleased to see this, but as in a way they are all part of a health service, I wonder why they should not all be tied up with the National Health Service. The same point applies to the prison medical services, which is a tiny thing that one would have thought could come under the National Health Service. That is all I want to say about the Green Paper. It is an interesting Paper, and I am sure that what has been said to-day will contribute towards making the forthcoming White Paper a better document than it would otherwise be.

4.5 p.m.

THE LORD BISHOP OF LICHFIELD

My Lords, it has been a great privilege to me to be allowed to serve either on a board of governors or on a Regional Hospital Board practically without break since the appointed day. That experience has left me a most convinced sup-porter of the great merits that have been conferred on this nation by the National Health Service. We sometimes hear about the brain-drain, and about those who say they feel they must go abroad because there they will have greater financial resources for their work, and so on. And one can understand that altitude. On the other hand, it should also be remembered that the patients in the hospitals which they leave may have to pay an appalling price if they are ill. In our own country I think it has been a great benefit to the whole community to know that if any member of the family is taken ill he or she will get excellent treatment free; and the result has been to remove great anxiety from the lives of many people.

In the interesting Green Paper which we are discussing to-day another look is being taken at the structure of the National Health Service: and the aim, of course, is that it should be more efficient in order that it may give still better treatment to the patients. The main proposal is that there should be a unification of the present tripartite system. There are many of us who would support this idea in general. I am sure that the time has come for a greater unification. We may have certain criticisms (and I want to refer to one or two) about the way in which it is proposed that this should be done, but, unification of the system is clearly right, because the patient is an individual, one person, and cannot be treated in compartments. He is the same person whether he is at home or in hospital. We must see to it that his treatment is such that everything is geared together. The general public, I feel, do not always realise the way in which the parts of the system interlock at the pre-sent time. For instance, in the region in which I serve—Birmingham—we have at the moment no fewer than 609 general practitioners who hold appointments in our hospitals, either in cottage hospitals or as clinical assistants in the larger hospitals. They are equal to 132.5 full-time appointed doctors, which is a con-siderable number.

But I come back to the point that undoubtedly treating the person as a whole person is right. That is what the Church in its sphere has always sought to do; namely, to work for the wholeness of the person, and I hope that the work of our chaplains in our hospitals will con-tribute towards making men whole. It would be a pity if the wholeness for which we are working were to be in any way weakened by the structure of the National Health Service itself. But in all these matters of structure we must remember that what is vital is that there should be the spirit of humanity in every-thing we do. The patient is an individual, a person, with all his hopes and fears, and not just a case.

So I hope that in all the reorganisation which is coming upon us we shall not lose altogether the relationship between the doctor and the patient, which I think has been a great blessing to many of us. And I also hope that in our hospitals we shall always remember to treat the patients as people, remembering that they have these anxieties as they enter hospital. Here I should like to pay great tribute to what is done. I always recall the fact that in one hospital it was said that the hospital porter did a great deal for the patients as they arrived, simply by his demeanour and by the way in which he helped to give them confidence.

In this matter of humanity and humaneness I should like to say how glad I am that the Green Paper refers to the need for voluntary work in our hospitals, and that it makes arrangements for that to be still further strengthened. A great deal of this is going on. It has been my duty lately to visit some of the long-stay hospitals for the mentally sub-normal, and other patients of that description. I have been very heartened to see the way in which various local organisations were doing things, in a most un-selfish spirit, for the benefit of the patients. That is something we ought to encourage still further, and I believe it is true to say that at the present time there is more voluntary work going on for the hospitals than ever there has been before. Let us encourage that by all possible means.

There is one other matter in which I hope this humanity will not be forgotten, and that is in regard to what the Church used to call "moral welfare work", which in its present form is bound to come to an end if the proposals of this Green Paper go through. And that may be right, because in these days one cannot help these changes. But in the association between our moral welfare associations for the unmarried mother and her child, the welfare worker has in the past worked very closely with the medical officer of health; and if the office of medical officer of health is to be phased out, I hope that in one way or another the Government will see that grants are given to our moral welfare associations to carry on the work of caring for these mothers and their children, in association with the local authorities, as happens at the present time.

In the National Health Service, and particularly, of course, in hospitals, the nurses play a vital role, and clearly much attention must be given to this matter. I noted that the Secretary of State was speaking about this on the television a few nights ago; and he said, if I remember correctly, that recruitment of nurses would be encouraged, first, if the chores could be taken off them, and, secondly, if they were given greater participation in the running of the Service. I am sure that the Royal College of Nursing would welcome that greater participation in all decisions which affect the nurses and their profession. We owe a great debt to the nurses for what they have done for us over the years. If they can be encouraged in their work by this still greater participation, that is some thing which will help them much, and thus help the Service much.

If I may speak from the point of view of Regional Boards (and I should like to make it quite clear that I speak in my personal capacity, and in no way represent my Board in what I am now saying), I think that most of us who serve in that way agree entirely with the central theme of the Green Paper. We also agree with the second and third of the three decisions which have already been taken; namely, that there must be an administrative boundary set between the National Health Service itself and the local authorities. We must also agree that the boundaries of the area health authorities should be the same as those of the local authorities. It is with regard to the first of the decisions that our doubts would arise; that is to say, that there should be a direct association between the Department and the area health authorities, with a phasing out of that tier of administration at present occupied by the Regional Hospital Boards.

My Lords, I think that we ought to reconsider the role that is played by the Regional Boards, and I would ask whether the part they play is not really essential for the planning of the hospital system of the future. It is recognised in the Green Paper, in paragraph 90, that for this planning to be adequately carried out there would have to be strengthened regional officers of the Department. I am afraid that this might lead to increased bureaucratic control. I was interested to see that in a leading article in The Times on February 12 that point seemed to be made very clearly.

I should like also to underline the remarks of the noble Baroness, Lady Brooke, with regard to the loyalties which have been built up between the Regional Boards and the hospital management committees. That loyalty is outstanding and very moving. My own region is a very big one, covering five counties. It might be thought that, because of its size, there would not be that close relationship between the Region and the management committees. But, on the contrary, when the meetings of the various chairmen of the hospital management committees are held, or other meetings of that description, one can feel a real sense of fellowship. That loyalty has been built up, and it must not be dissipated, because it is of the utmost value to the whole Service.

Further, the Regional Boards have been able to provide in various ways specialist and expert services for the hospital management committees. Will the area health authorities be able to do this in the same way? Will they be able to recruit specialist staff of the same high quality? The Green Paper recognises this difficulty, and, in paragraph 89, it suggests the setting up of consortia. So, in place of the Regional Board system we shall have the enlarged regional offices of the Department, consortia, and also the regional health councils. I should like to say how grateful I am that the Green Paper introduces an element of flexibility into its remarks about the regional health councils. We are not confronted with cut-and-dried decisions. That means that here is a sphere in which we can make our suggestions.

The point is made in the Green Paper that the regional health council will be there in an advisory capacity: it will advise the Department and the area health authorities. But, it is said, because of the nature of its membership, its advice will carry very great weight. So, doubt-less, the Department will consult the regional health councils; and so will the area health authorities. My Lords, I have had a certain amount of experience in administration in the Church. The word "consult" is one that can lead to endless difficulties. It can mean any-thing or nothing: you may consult people, but there may be absolutely no obligation on you to take their advice in the end. I do not believe that a body which is purely consultative will, in the end, have any real future. As the noble Baroness, Lady Brooke, said, I do not think it will be able to build up the loyalties in the way that the Regional Boards have done. Nor will it possess any sanctions. To be effective I am sure that the regional health councils must have power; and that means money. They must have finance at their disposal.

The Green Paper says that the regional health council will deploy the senior medical, dental and scientific staff. I would urge that it should not merely deploy them but should also employ them, and that it should have executive power and finance in the planning of the hospital programme. To come back to the words of the leading article in The Times, I am sure that if the regional health council is going to be effective it must be a link in the chain of command. At the moment, it stands outside.

There is one other point that troubles me, and that is that the area health authorities will have a tremendous amount to do. Will it be possible to find people who are able to give enough time to this work? Reference has been made to the fact that members of the Regional Boards and hospital management committees give up a good deal of time voluntarily to this work. And that is true. I give up as much time as I can to it, but I am afraid that sometimes I feel a divided loyalty between my own work and the work that I try to do in this capacity. The members of these area health authorities, in my view, are going to have their work cut out to do the job as I am sure they would wish. I notice that the chairman is to be paid on a part-time basis. But if we are to get people of the ability to serve, we want people who are not getting on too much in regard to their years in life: we want people in the prime of life; people right "on the ball"; people who are full of interest and initiative and are forward-looking. Yet sometimes these are the very people who, by the nature of their own work, simply cannot find the time to serve on that kind of authority. I believe that this is a difficulty that will have to be faced.

In conclusion, I would make one other point. I have mentioned one or two criticisms, and I am very grateful to the noble Baroness, Lady Serota, for the generous way in which she said in her opening speech that criticisms were to be put forward and would be listened to. That is something which I greatly appreciate. But I would say, at the end, that I fully suport the idea of trying to link the Health Service with the local community. Here I believe that the Church ought to play its part. I am sure that it is the duty of the Church to do all we can to interest the local community in the work of healing of the sick, so that we may encourage people to serve, whether full-time or in a voluntary capacity. So the linking of this work with the community is wholly desirable. Therefore, my Lords, although, as I have said, I have certain criticisms, and would most earnestly plead that this matter of the regional health council should be seriously looked at, I give the basis of the Green Paper my support; and I am very grateful to the noble Baroness for bringing this matter to our attention this afternoon.

4.22 p.m.

LORD SOPER

My Lords, may I offer an apology to my noble friend for the fact that 1 shall have to leave this House for a professional engagement associated with the spiritual health service, but I will return if I can. The House will be grateful to the noble Baroness for repeating what is in the prelude to this particular document: that it is mainly for discussion and for comment. We shall also be grateful to her for the way in which she set out the kind of work and the area in which she hoped we might apply ourselves to that task. In general terms, I shall have something to say about those services which are alike social and health services, and therefore I shall say nothing about the various matters raised by the previous speaker, although in principle it seems to me that there are many factors to which he gave attention which are of great importance.

As a preliminary, it seems to me that there is ample evidence for the contention that this Service should be unified —168 various bodies, and those of us concerned in some practical way with health and welfare sometimes have felt that we were compelled to address our-selves to most of them. Unification of service is required from a simple and practical level. Was it not Sarah Bernhardt who, when confronted with the Ten Commandments, said that she agreed with them in general but thought there were too many of them? Is it not a fact that where there is a multiplicity of orders and of organisations there is a lack of a sense of direction and purpose? Therefore, in principle, I have nothing but commendation for the general outlook of the Green Paper in this regard.

Then again, to equate practically the Health Service with the Maud proposals is of course to reverse Maud and the garden. We are being invited by Maud to enter the garden and generally to consider the lay-out which Maud has pro-vided. I for one do not subscribe to those who feel that we are being led up any garden path; it seems to me reason-able and proper that where this new allocation of geographical local authori- ties has been decided and will be carried into effect, as I suppose it will, it would be highly improper, in fact it would be factitious, to attempt to run any health service without taking due regard of this prepared ground. Further, I have on the whole a sense of agreement with the contention that the local authorities them-selves should not be made ultimately responsible for the carrying out of the Health Service.

The noble Baroness on the other side has said that we must take account of human nature. I am sure we must. When the clinical freedom of the medical profession is at risk it might be, I suppose, ideally desirable to get all of them converted to the fact that there is no risk. But, meantime, there might be many people in need of care who would not receive it because of a failure on the part of the medical profession to believe that they had that necessary clinical freedom to do their work. That weighs pretty heavily with me, and I would think there-fore that it is desirable that the basis of the Health Service should be in the area authority rather than purely and solely within the framework of local administration.

A fourth matter on which there will be debate, but I can find nothing in principle to cavil at, is the distinction between the area for which the responsibility would lie with the area authority and the area of the social services of the local authority. The distinction between these areas should be a matter not of primary user but of primary skill. This is a matter of judgment, and I have no doubt that those who are responsible for this judgment have considered the matter with great care. I agree with them. I should like to advance one or two of the areas of health which have not been specifically stated in the Green Paper, as an illustration (if you like) of the complexity of this task and the need for the greatest of care in the collaboration between that kind of work which the area authority will do in primary skill and that kind of responsibility which will be taken by the social services of the local authority.

Let me speak about alcoholism because here, although it is not specifically mentioned, is an area of human need which demands a great deal more care than has been given to it up till now. I remember that when in your Lordships' House some years ago I said that there were probably 400,000 or 500,000 alcoholic men in this country, and Heaven knows how many alcoholic women, it was regarded as an extravagant gesture and perfectly in line with the kind of emotional attitude which the Church often takes in these matters; but as a matter of fact 400,000 is by no means beside the mark, and the Carter Foundation would in fact insist that the figure is nearer 500,000. Here is a matter for which, obviously, a number of services are required.

I would agree that the primary skill for an alcoholic is not moral redemption by a process of exhortation, or even some kind of domiciliary advance to a dry state and then to a permanent convalescence. It seems to me that the first requirement is the prescription by the doctor who can himself understand and diagnose the condition—because the condition of alcoholism is by no means easy to describe or to diagnose. It is not the same kind of thing as a condition of drunken-ness, and of course it is not the same condition as that of the drunkards' poor relation, the spirit drinker. But first of all it is necessary that there should be a prescription in terms of skill. There-after the rehabilitation process must begin in some kind of domiciliary place—and I know something about one or two of them. After that stage of rehabilitation or "drying out" there is a third stage of the utmost importance and that is the stage of supported housing for those who, provided that the strain is not too great, are likely to keep sober, but if the strain exceeds a certain point will relapse.

It is obvious from what I have said that in this field the overlapping of the two services is inevitable. I wonder whether the noble Baroness will agree that, as many alcoholics are nomadic, if not migratory; and as at the moment there is a proliferation of emotionally promoted and sometimes quite inefficient attempts to deal with alcoholism; and further, in view of the fact that the National Council for Alcoholism is seek-ing to unify its own programme and to bring it into line with a more general discipline, the whole problem of alcoholism should come within the frame-work of the area authority in the first place. I think it should.

It is completely the other way round when the problem of drug addiction is considered. I know a little about the Day Centre for addicts, not very far from here. If any of your Lordships are of a queasy disposition, I would warn you against any contact with this most terrible condition. But here is a need which is not first of all to be met by primary skill; it is a need which can only be met when there is some domestication of the addict, who can obviously find if he so desires—and he does so desire—some kind of medication or some kind of drug prescription from his chemist. Here is an indication where it is obvious that the first requirement does not lie within the precise skill of the medical profession; it lies within the social services of the local authority. I mention these facts because, in general principle, this Green Paper, I think, meets the very proper need; but it will fail unless there is a far more rigorous attempt to unite and bring together the two ends of this process. In this regard, may I refer to the meagre references made in the Green Paper to the solution of this problem: that in fact there should be members of the local authority upon the area authority, and vice versa. I should like to see this particular link much more strengthened than it appears to be in the document; and I have no doubt that it can be.

There is one other matter. As I see it, there is need for unification within the framework of the social services. I should like to refer to one area in which great progress can be made, and the indications of such progress are already evident. There is need for the domiciliary care of unmarried mothers and their babies. But the need is often in inverse proportion to the kind of assistance that can be given, precisely because the mother is tied to her baby during the very hours when she, more or less un-supported, requires to earn her own living. I should like to see a vast extension of the scheme for hostels for un-married mothers, in which there is, as an integral part of that hostel, a properly instituted nursery for the care of the children during the day. This is part of the unification within the framework of the social services, but it is one of those instances where a little more experience and a great deal more care can provide much more advantageous conditions for many of those for whom I have profound sympathy, and of whose condition I know a little.

There is another matter I should like to mention. I heartily agree with the right reverend Prelate as to the need for voluntary help and for the invitation and stimulation of voluntary help which can be found, I am sure, within the district committees and can be rendered by voluntary associations which, in their turn, can, we are encouraged to think by the Green Paper, look to the authority for some public funds which have not been forthcoming up to now.

There is another, wider, problem. If the National Health Service, of which we are justly proud, does not end its ministrations at the point at which the critical stage of need has been passed—and, as has been evident from the discussions to-day, the purpose of the Health Service is to treat the whole man and to help him under such conditions that sooner or later he will go out as a whole man— then, to take the illustration of the tertiary stage of the alcoholic in his redemptive process, there is great need for the friendship, sympathy and support which voluntary people can give in their spare time: the kind of friendship they can offer, the kind of comradeship they can offer, and the kind of solicitude they can show. Beyond the medicaments, the antabuse and the various processes of drying out of the alcoholic, beyond all the various psychological processes, beyond all the spiritual ministrations, the need for sheer, simple human kindness, where it is allied to efficiency, is one of those things to which the Green Paper looks. I pray God's blessing on it, for it looks to the efforts of all people in recognising their public duty to those who are in need.

4.35 p.m.

LORD COTTESLOE

My Lords, we must all be grateful to the noble Baroness for putting down this Motion and for the helpful and generous way in which she introduced it. On the day upon which the Green Paper was published I had myself put down a Motion in somewhat similar terms, but if I had had to wait until my Motion came for-ward for discussion we should have been getting near the Summer Recess, whereas on her Government Motion we are able to discuss the Green Paper without any long delay. It certainly ought to be discussed without any undue delay, for the Green Paper envisages a major and far-reaching reorganisation, not perhaps quite as great as that which brought the National Health Service into existence twenty-one years ago, but of the same order. It will do away with every existing hospital board and every existing hospital management committee; it will do away with the executive councils that administer the general practitioner ser-vice and it will remove from the local authorities the personal and domiciliary health services that they now look after. In fact, the whole system of the administration of the Health Services set up under the 1948 Act will be swept away and re-placed by an entirely new structure.

It may well be right to do this—it probably is—but we should have our eyes opened to the scale of the upheaval involved, which will affect everyone engaged in the administration of the Health Service, at every level, and to the fact that the new structure now envisaged will necessarily suffer from severe growing pains for some considerable time be-fore it settles down to smooth and efficient operation. In looking at the proposals, we should judge them against the background of the present system, of its successes and of its weaknesses, as they have emerged during the last twenty-one years.

If we do this, my Lords, we must acknowledge that these two decades of the National Health Service have produced a remarkable advance in the standards of the service given to the public generally, and I was glad that the right reverend Prelate laid stress on this. In the Hospital Service that advance has been outstanding. The standards of the great teaching hospitals, always high, are certainly as high as ever they were, and they are in the forefront of the ever-changing battle against disease that is constantly being fought throughout the world. The generality of the hospitals, the great majority of which were the old Poor Law hospitals taken over in 1931 by the local authorities, have improved out of all knowledge. No one would claim that they are perfect, but for the most part they are very good indeed. That is due to a number of factors, of which higher standards of medical staffing and more money are perhaps the most important. But the centralised administration under the Department of Health, with all its faults, has certainly been a major factor, too. The existing structure is far from perfect, but we ought to be very certain before we sweep it away that the new structure is such that it will give better service than the one which has been the basis of such a striking advance.

Of course the hospitals are not the whole story, although they form the major part of the National Health Service. As the noble Baroness said in introducing the Green Paper, certainly not enough emphasis has been put on preventive medicine, on keeping people out of hos-pital in the first instance. The general practitioner service as at present admini-stered by the executive councils has sub-stantial weaknesses in a world of increas-ing specialisation, weaknesses that might have been less if the original concepts of health centres and group practices had been more vigorously pursued. And the domiciliary services and the personal ser-vices in the hands of the local authorities, though they have made great strides, are in many places a weakness too. But, my Lords, taking it by and large the National Health Service has worked, falsifying the predictions of many prophets, and it has worked well. It has worked well, not by any inherent virtue of the set-up, but because the men and women concerned in it have determined to make it work; and I think we must all be very grateful to them.

The obvious weakness—we all know it and it has already been said—has been the tripartite administration. This weakness has been in most places mitigated by informal contacts and co-operation between those operating the three branches of the Service at every level. But it is still a weakness in practice, although less in practice than in theory, and it is the integration of this tripartite administration at all levels that is the prime purpose of the system the Green Paper advocates—a comprehensive district health service administered by area health authorities. This is a concept that is logical and one that we can all unreservedly welcome in principle.

I hope we can all welcome, too— though there are probably some of us who are not willing to—the decision of the Government not to return the Health Service to the local authorities. No one who has seen, as I have, for I was on the hospital committee of a county council at that time, the remark-able development of the hospital services since they were taken over by the Depart-ment from the local authorities in 1948, could conceivably wish for that change to be reversed, and I must confess that I am perfectly astonished that a body of such weight and responsibility as the County Councils Association, or an in-dividual of such judgment as my friend Mr. Hardie, quoted by the noble Baroness, Lady Brooke, can seriously advocate it.

The severest problem set by the new proposals—and there are of course many problems—is how, within the frame-work of the comprehensive district ser-vice, the teaching hospitals can take their place and play their full part with-out detriment to their teaching functions. And here I suppose I must declare an interest, though not a financial one, as chairman of the board of governors of a teaching hospital, as chairman of the postgraduate section of the Teaching Hospitals Association and of the School of the University of London which is called the British Postgraduate Medical Federation—that comprises the teaching schools and institutes of the specialist postgraduate teaching hospitals. And as I was also for seven years the chair-man of a Regional Hospital Board administering 150 hospitals of all shapes and sizes, I have indeed been privileged to familiarise myself with hospitals of every kind and with the problems of their administration.

What is to be the place of the teaching hospitals in the new pattern of administration of area health authorities? At the present time they are administered, 36 of them I think, by separate boards of governors appointed by the Secretary of State, with nominations from the universities and the Regional Hospital Boards concerned, and these boards of governors form a single tier of administration direct under the Department. That arrangement is no doubt in some ways inconvenient to the Department, and I know that the noble Baroness, Lady Summerskill. disapproves of boards of governors. But in fact it is an arrangement that has enabled the teaching hospitals to satisfy their dual role with a great measure of success.

It is not an easy role. Like all hospitals, they have as their prime responsibility the service of the patients in their care. But they have also, and equally, a responsibility for training the doctors, without whom the Health Service could not continue to function at all. If the teaching hospitals are to do these two things effectively, they have to give a district service. That is something that they need to do, and are most anxious to continue, not only for the service of the public but also to enable them to satisfy their teaching functions. There can be no question whatever of their wanting to contract out of this district service in any way. But they must also be free to draw on patients from outside their immediate locality; and they must have a higher level of medical staffing. They must also have special facilities and equipment for research, if they are to discharge their teaching functions at all adequately; and, of course, the way in which they discharge those functions determines the quality of the medical services the public receive.

The danger inherent in the new structure, the Green Paper structure, is this— and it is so serious that it cannot by overstated. If the hospital service is to be administered by area health authorities whose prime function is the provision of a comprehensive area health service in a specified area, those authorities will never have funds enough to do everything they wish. They will be pre-occupied, and quite rightly preoccupied, with providing the comprehensive service in their own area as the first priority. They will not have enough funds, as they believe, to do that adequately, and the extra requirements for teaching and re-search that the teaching hospitals need to discharge their wider functions will take second place; they will be squeezed out.

That is the danger. How can it be overcome? My Lords, it seems to me that there are some half a dozen essential requirements that must be met if the teaching functions of these hospitals are not to be prejudiced or stultified. In the first place, the composition of the area health authority must be strong, and it must be able to take a broad and not just a narrow local view. There must be a strong university representation. Then these hospitals must be free to use at their own discretion a proportion of their beds (and in some cases of the special hospitals it may need to be a substantial proportion) for patients from outside their own area or district. There must be no rigidity about the boundaries of their catchment areas in practice, even though as a matter of convenience they are coterminous on the map with local authority boundaries: no such nonsense as, "You cannot have this patient because he lives on the other side of the street", or indeed "on the other side of the county".

Thirdly, they must have the scale of medical staffing that is necessary for their teaching and research. I have been told that at Hammersmith Hospital we have a scale of medical staffing twice as high per bed as that of the London under-graduate teaching hospitals—though, even so, it is lower than in Scotland. I have been told that as though it were evidence of extravagance. Of course it is nothing of the sort. It is simply a measure of the intensity and depth of the teaching and research that is carried on at Hammersmith.

Fourthly, the university, the medical school, must have a determining voice in the selection of the medical staff, especially the senior medical staff of the hospital. Fifthly, they must be assured of allocations of funds adequate to enable them to satisfy the special requirements of a teaching hospital, by positive directives to the area health authority; and perhaps also some system of earmarked grants, on the analogy of the University Grants Committee, may be necessary. Incidentally, they must have control of their own endowments, which have in many cases been given for specific pur-poses. It would be a breach of trust if they were thrown into a general area pool. Finally, they must preserve their own name and identity, which in nearly every case carry with them a national and international prestige of which we ought to be proud. They must not just be sunk without trace in an area denomination.

If those points can be safeguarded effectively, then I think the teaching hospitals will be able to take their full share in a comprehensive area health service without prejudice to their essential teaching work. I feel sure that means can be found of safeguarding them. In London, indeed, rather smaller areas—some sub-division particularly of Areas B and C in Appendix I of the Green Paper— might go far towards solving the problem.

Finally, my Lords, I must speak of the most difficult of all the teaching hospitals to fit into the pattern of a comprehensive health area service—the London specialist postgraduate hospitals. This handful of metropolitan specialist hospitals, a dozen of them, together with Hammersmith Hospital (which is a general hospital organised in a large number of highly specialised departments), have an importance and a value, national and inter-national, out of all proportion to their number and size. The postgraduate training that they give is something entirely different from the further training of general practitioners in district hospitals all over the country, on which Todd (the Report of the Royal Commission on Medical Education) quite rightly lays so much stress—the training that I take the Green Paper to mean when in paragraphs 83 and 88 it speaks of "postgraduate education".

The postgraduate training given in the London specialist postgraduate hospitals which is virtually ignored by Todd, is something entirely different in intensity and in depth, something that is not given anywhere else in this country and some-thing that is vital to the wellbeing of the medical services, both in this country and overseas. These hospitals largely train the teachers in the undergraduate medical schools, and the specialist training they give has a profound influence that pervades the whole fabric of medical practice. They train the consultants, and the scale of the work done by this handful of hospitals, none of them very large, is shown by the fact that, as I am advised, more doctors come to them each year from overseas alone for training as con-sultants than the whole of the output of new doctors of all the medical schools in the United Kingdom. More doctors from overseas alone—and there are many more, of course, from this country in addition—go to these hospitals for training as consultants than the total output of new doctors of all the medical schools in this country.

If your Lordships will ponder that fact, I think you will understand how highly regarded is the work of these few London specialist postgraduate hospitals throughout the world, how valuable their prestige is to this country, and how essential it is that the specialist training they give should go on uninhibited by their incorporation into the new district ser-vice. It is not only a matter of training. Their postgraduate teaching is accompanied by a broad river of research of the most distinguished kind that constantly flows out from them. I know of no means of measuring the volume of research. If it could be measured, I do not doubt that it would be found that the output of medical research from these few London specialist postgraduate hospitals was greater than that from all the other hospitals in the country.

These hospitals, with their teaching schools and institutes, serve as a focus on which specialist resources can be concentrated in a way that could not otherwise be possible. To take one example, it is inconceivable that the dramatic advances in opthalmology that have taken place in this country in the last two decades and which have brought British opthalmology to a position recognised as equal to, or better than, anything in America, and certainly better than anything in Europe (I have the most august professional auth-ority for that assumption) could have been achieved had there not been a concentration of the resources of research and development in a single high-powered institute, the Institute of Opthalmology, working in conjunction with a specialist hospital, Moorfields Eye Hospital.

This just could not have happened if those resources had been dissipated in the ophthalmic departments of a number of undergraduate teaching hospitals. It was the concentration in the teaching institute of an independent specialist hospital that made it possible at all. So it is in other specialties—in the Maudsley, with its incomparable Institute of Psychiatry; in the Institute of Child Health at Great Ormond Street, and in the specialist departments of the Royal Postgraduate Medical School at Hammersmith, and in others, too.

Your Lordships will therefore appreciate the essential importance of preserving the separate identity of these postgraduate hospitals and of the new set-up enabling them to continue uninhibited their teaching and research. They all give, and they all must give for their own wellbeing, an important local service in their own specialties. They all give, and they must all be free to give, an important national and international service.

Tucked away in a paragraph at the end of Appendix I, at page 81 of the Green Paper, there is, I am happy to observe, a note that no final decision on the administration of these London post-graduate hospitals will be made until their affairs have been more fully discussed. I can think of various possible solutions of their difficult problems, all, in one way or another, open to objection. I am quite sure that the best solution would be the administration of each of these special hospitals, at any rate the larger of them, by a special board analogous to their present board of governors although under the Department, with close and firm operational linkages with the area health boards in whose district they lie. This is a form of organisation, with lateral linkages, that operates successfully in many other fields, in business and so on. They would indeed be administrative freaks; and of course administrators do not like freaks, they like tidy and uniform administrative patterns. But the hospitals are in any case operational freaks in a district ser-vice. They would not be many, and the advantage to the Service as a whole would greatly outweigh the inconveniences. I hope that the noble Baroness and her colleagues will ponder this possibility with sympathy and with a regard to the very real loss—a loss not merely to these hospitals themselves but to the Service as a whole—that any other arrangement would inevitably entail.

5.1 p.m.

LORD PLATT

My Lords, I should like to add my thanks to the noble Baroness, Lady Serota, for giving us this early opportunity of debating points in the Green Paper. A friend of mine has pointed out to me an extraordinary similarity between some of its principles and those enumerated by the Dawson Report on the Future Provision of Medical and Allied Services which, of course, dates from 1920. But this is not to be looked upon as a criticism of the old-fashioned nature of the Green Paper, but rather in praise of the far-seeing people who were on Lord Dawson's Committee at that time. I suppose it also points to the fact that although the pattern of medicine, and indeed of disease, changes over the generations, nevertheless the principles of medical care do not perhaps alter so very much.

On the whole, I should like to support most of the aims of the Green Paper as they are set out, including the unification of services—both those at present under the local authority and general practitioner service and the Hospital Ser-vice. I support strongly the idea that these should be administered by special area authorities and not by local authorities. The enormous changes for the better in the Hospital Service since it ceased to be administered by the local authorities and was taken over by the Health Service have been pointed out. Of course this is not quite fair to the local authorities, who probably could never have raised anything like the amount of money which central finance can provide. I should also like to say that I support this change for another reason, which has only indirectly been expressed so far; that is, that as a medical man I would rather work under an authority whose members have been nominated and appointed than one whose members have been elected for largely other purposes.

I think that the bringing together of general practice and the Hospital Ser-vice in particular should be very good for both. I can see that it would help the general practitioner part of the Service to keep itself up to date; would stimulate it with new ideas and principles, and I can see the educative value for the hospital staffs—many of whom never go outside a hospital at all, and never see a patient except in a hospital bed or out-patient department—of working together with general practitioners and under an authority which has to provide the best in general practice as well as in the hospitals. I can see that there will be some snags: the hospital people will complain that far too much money is going into general practice, and the general practitioners will complain that they are being starved of money because of the hospitals. I think it has also a very important educative function in that we hope—and I speak now partly for the Royal Commission on Medical Education, whose Report I hope will be debated at any early date—that in future the training of general practitioners will be very much better and more rigorous than it has been in the past; and such a system as is proposed here should facilitate this very much and should lead to the improved status of the general practitioner, for which we all hope. One can see that in the planning of the general practitioner services within hospital precincts as an experimental pattern.

I am glad to see, as President of the Family Planning Association, that family planning has been mentioned. I am glad again that the proposal is to put family planning under the area health authority which is dealing with other medical ser-vices, and to make it a proper part of the medical services which this country provides. I am sure that the noble Baroness realises that the Family Planning Association has plans to offer where-by its structure, its expertise, its staffs and so on could be utilised to the best in such a unified service.

I think the main criticism—and this has been voiced by so many noble Lords that I will not stress it very much—is on the question of what the regional health councils will in fact do. It does not look as though the advisory functions pro-posed for them will attract very high-powered people; and unless these coun-cils do attract important, valuable and useful people with ideas, their advice will not be very important advice and will probably be neglected. I should have thought—and many of the people I have spoken to agree strongly with this—that these regional councils should have some executive powers and should have money to spend, even if their powers were limited to quite definite areas of the Health Service such as the capital projects for the Hospital Service, or some-thing of that kind. If they were it would probably save money in the long run, be-cause I think the regional councils have done an extremely good job of work in this field. They know how to do it, and are perhaps able to do it at more economic rates than the central department. If this were done, there would not seem to be very much need for the proposed extension of the central department into regional offices.

The remainder of my remarks will largely apply to the teaching hospitals on whose behalf the noble Lord, Lord Cottesloe, has just been speaking with such great effect. I should like to read his six points again in Hansard, but I think I could give almost unqualified support to them. Historically, the National Health Service in England was based on its 13 regions—that is without Wales and before Wessex came on the scene—and each region was to be centred on a teaching hospital. These teaching hospitals were to be preserved for the function of teaching and research, in addition to the function of looking after the sick. They were to be centres of excellence, it being accepted that you could not put all your money into every hospital in the country at the level at which you hoped to staff and equip certain teaching hospitals.

Since that time there has been a general feeling that a great deal of the teaching of undergraduates is very properly done in hospitals which have not been desig-nated as teaching hospitals, and that the distinction between the two types of hos-pitals—the teaching hospitals and the regional hospitals—has been too strict, and, in many respects, should be blurred. The Royal Commission on Medical Education put a great deal of thought into this, and came down on the side of abolishing the boards of governors of the undergraduate teaching hospitals as they at present exist, and putting the new hospitals at Nottingham and Southampton under the existing regional boards. But they were to have special management committees, specially chosen with high university representation, and there was to be a realisation that hospitals which were in a major degree concerned with teaching and research were bound to cost more than other regional hospitals. We thought that those experiments at Nottingham and Southampton would probably point the way, and that all the undergraduate hospitals would in time come to be managed in that way.

I should like to ask the noble Baroness, when she winds up this debate, to be more specific on the use of the endowment funds of the teaching hospitals, to which the noble Lord, Lord Cottesloe, referred. It is very important to have some money which does not have to be spent purely on the provision of a service for treatment and diagnosis. I should also like her to say more about the representation of the universities at the regional level. Finally, I should like to endorse what the noble Lord, Lord Cottesloe, has been saying on the post-graduate teaching hospitals of this country, because they are something quite unique, something which we must not lose to British medicine, something on which the medical reputation of this country abroad very largely depends.

5.13 p.m.

LORD STONHAM

My Lords, I should like to add to what other noble Lords have said in thanking my noble friend Lady Serota for giving us this early opportunity of discussing the Green Paper, and also, in effect, for emphasising its tentative nature and the fact that discussion and suggestions will be welcomed and carefully considered. Most of my contribution will be critical, although I trust that it will be constructive criticism, and I would therefore say at once that it is my firm conviction that the establishment of our National Health Service—the best in the world, as I think this debate has demonstrated— will always rank among the finest achievements of the British people.

I would also say that the Government's aim set out in the Green Paper, to ensure that the total health needs of every individual are met by one integrated Health Service, would, if achieved, mean a further tremendous advance. It is a magnificent concept, and one that deserves our full support. Unfortunately, in my view it cannot be achieved by the methods proposed. They seem calculated to disintegrate rather than to integrate the Service. My noble friend Lady Serota has said that the Paper is not only green, but contains some parts that are greener than others. After reading it several times, and studying it very carefully, I think there is more pure wool in this little Paper than you would find on the back of a healthy sheep. I have some knowledge of how these Papers are constructed, and it seems to me that whenever the Department has come up against objections from the medical or nursing professions, or from local authorities, it has met them by offering to form another committee. That may soothe the professionals, but it does not help integration; rather will it manufacture delays and create uncertainty.

I think the biggest criticism that I have—and it is one which was touched on by the noble Baroness, Lady Brooke— is that nowhere in the book is there any sign of who is to provide the driving force needed to make and implement badly needed changes in policy. As for making the Health Service less remote from the people it serves, the new machine will, I think, be more remote than the present one and will cost more, both in money and in manpower. No one grudges money for the Health Ser-vice, but the fact that it is now costing the taxpayer directly some £1,500 million a year is a serious barrier to further enlargement and improvement of the Service. The Green Paper must there-fore be judged from the standpoint of cost-effectiveness, and it is here that I think it is likely to fail.

Contrary to the view taken by some noble Lords, I feel that the proposed increase in the number of health authori-ties is right, because of their greatly enlarged responsibilities and the need for them to be roughly coterminous with the new local authorities. But the pro-posed district committees will inevitably be more remote from the individual patient than the present hospital management committees, because under existing arrangements hospital groups are allowed to set up house committees for individual hospitals. When I had the honour to serve as chairman of a London group of five hospitals I found that these house committees, properly encouraged, were of the greatest value. They made it possible in a real sense to keep contact with the individual patient, and to satisfy his needs. Those five hospitals are so close together—all within about a mile of each other—that they must come within one of the new district committees; and one or two other hospitals will be added to them. Thus, with the other responsibilities, in addition to hospitals, which are going to be put on district committees, the tasks of that district committee will be very great indeed. I do not see that it is remotely possible for them to get to know the individual patients; that can be achieved only if individual hospital committees are maintained. I hope my noble friend will say that that is the intention; and, if so, I hope that she will also say that it will be made mandatory—which it is not at present, because there are hospital groups which do not in fact set up house committees at all.

My right honourable friend the Secretary of State said, in his introduction to the Paper, that many fear that the boards will be dominated by the Hospital Ser-vice. In the sense that hospitals in most areas are focal points and main centres, that is surely inevitable and right. They have the highest skills and the most up-to-date equipment, and they are the places to which the family doctor service must always, in my view, however we arrange matters, look for co-operation and help. It would be tragic if, because of the ill-founded misgivings of some interests, we were to allow the Service to be hamstrung from the start or, worse still, were to set up a duplicate organisation.

I urge, therefore, that in most areas we consider basing the district organisation on the hospital house committees and expand their powers so that they become district committees. It would be much easier and less costly to build them up, rather than to start elsewhere de novo and finish up with two organisations in conflict, neither of them supplying a whole service and neither in close contact with the individual patient. I hope that this will be considered.

I hope also that my noble friend will be able to say by what means policy changes in the hospitals will be engendered and insisted on. The noble Baroness, Lady Brooke, put it another way when she asked: "Who is to control capital expenditure?" Let me give an example. In one London hospital it costs, on average, £80 a week to keep a patient. This cost, I am sure, is justified, because the service is superlative; but everyone at that hospital knows that there is a colossal waste of money and manpower which could be avoided if they could make certain changes.

A recent survey in that hospital disclosed that no less than 15 per cent. of the patients being looked after in the beds were not in need of any medical treatment at all; they were kept in hospital only for social reasons, or because their home conditions were unsatisfactory. I support the hospital in keeping them there for those reasons, but not at £80 a week. Another part of the same survey indicated that an additional 33 per cent. of patients needed only periodic treatment—perhaps once a week—and their continuance as bed patients was unnecessary; but difficulty in travelling meant that those patients could not be sent home. If the hospital could provide a residential hostel nearby for such patients, they could make a large saving in costs. Who would have the authority to make these changes; and how does the Green Paper ensure that they would be carried out? I have been unable to detect it, and I should be very glad if my noble friend could provide the answer.

My Lords, it is not only a question of getting value for money: it is a question of making the proper use of staff—an aspect that was touched on by the right reverend Prelate, the Bishop of Lichfield. We are constantly hearing of under-manned hospitals, of closed wards and of overworked nurses. Obviously, this will always be the case if they are busy serving patients half of whom would not need to be in hospital at all if we acted sensibly, especially when a great part of the day is spent by nurses acting as waitresses and domestics. I was very pleased when my right honourable friend the Secretary of State said that this matter was going to be dealt with, because I think that we should have enough nurses if we used them properly on work appropriate to their skills.

My Lords, facts like these apply in greater or lesser degree to almost all acute hospitals. The good hospital groups keep a very close eye on turn-round and usage of beds. This saves a great deal of money and cuts down the waiting lists. But in my experience such matters were never raised by the Regional Hospital Boards; nor do I think that the area health authorities would attend to them. If that is so, when the groups go a lot of good hospital management will go by default except where there are outstanding salaried staff.

I turn next to the relationship between the general practitioners and hospitals. The Green Paper asserts that there has been a rapid growth of group practice. It may have been rapid, but it is still a small development, and quite unrelated to the need. Our hospitals are over-loaded with tens of thousands of patients suffering from comparatively minor com-plaints: patients with whom the doctors, working alone, are too busy or insufficiently equipped to deal. Group practices are much better equipped and organised, and are thus able to deal with a much wider range of illness. This benefits the patients, the doctors, the hospitals and the nation. The Green Paper quite rightly stresses the need for more group practices, and for increased co-operation to prevent the unnecessary use of hospitals, but it does not foreshadow, so far as I can see, a single constructive action or incentive to bring this about. Indeed, in successive paragraphs it virtually states that no one will have the power to do so. Paragraph 67 declares: The closer linking of general practitioners and hospitals depends on this overall responsibility of the area health authority. Paragraph 68, just a few lines further on, flatly adds that: … the family practitioners … will not be under the direct control of the area health authority. My Lords, how, without authority, can they bring about the necessary closer linking? Some doctors have set up group practices so that they can be better doctors and provide a better service. All honour to them. But we shall not get the group practices we need unless there are strong inducements and powerful pressure. Exhortation in this matter is virtually useless, and the Health Service cannot be powered by platitude.

I remember a morning 22 years ago when I was coming from Standing Committee A in another place after a Committee session on the original Health Bill. At that time the Press was full of stories that only 3,000 doctors would come into the Service and that 20,000 had said they would stay out. The noble Lord, Lord Cottesloe, referred to some of the controversies we had at that time. It is just as well we should be reminded of them, because it is so easy to forget how many people prophesied disaster and how comparatively few people to-day are willing to proclaim the enormous success. But 20,000 had said they would stay out. I asked my right honourable friend the late, great Aneurin Bevan what he pro-posed to do if they did not come in. He replied immediately, "They'll come in, my boy—I've gorged them with gold." My Lords, the doctors did come in and, to their credit, have done a wonderful job. I do not know if their participation was for the reason which Mr. Bevan suggested, but at least he consciously set down the conditions, and they worked. What I wish to know is whether the Government will amend their proposals so as to ensure the setting up of enough group practices and the medical co-operation, without which, in my view, an integrated Service is an idle dream.

Finally, my Lords, I would comment on two true and important statements on page 1 of this Paper. The first is: There have been striking improvements in standards of health during the twenty-one years since the National Health Service was established. The second is: There are … unjustifiable differences between the average standards of care pro-vided for long stay hospital patients— … the mentally ill and handicapped—and the standards of care provided for short stay hospital patients. Both those statements are true. The tragedy is that a third statement is also true: that so far as the mentally ill and the handicapped are concerned there has been no improvement. Conditions, relatively, are no better than they were twenty years ago. The cruel disparity in the standards of provision is exactly the same as it was twenty years ago.

In the 1950s I was privileged to serve as chairman of the Mental Health Committee for the six South-Western counties, with responsibility for 17,000 patients in 100 hospitals. In those days the money allowed to us to keep a subnormal patient —food, clothing, housing, nursing, medical care and everything—was £4 5s. a week. At the same time, in the same area, the weekly cost per patient in acute hospitals was £30 a week—seven times as much. To-day we spend £11 per patient per week in hospitals for the subnormal against the £80 per week that I mentioned in a top-grade acute hospital. Again seven times as much. No change!

It is the same with capital expenditure. My Lords, we are all guilty, Parliament, Governments, the medical and nursing professions, the Press, the general public. For all those years nobody has wanted to know, and nobody wants to know now, unless there is a scandal in some benighted, under-equipped, under-staffed, overcrowded, Victorian ex-work-house. The Director of the Office of Health Economics said recently that existing subnormality hospitals could be replaced at a cost of £100 million. Will the Government ensure that this is done? I feel that a lot of influential people have to get angry and stay angry if this scandal is to be ended. We need more than a line in the Green Paper. Just substituting area health authorities for Regional Boards will not do it. The Regional Boards have failed to tackle it in over twenty years, and the majority of their members know little more about conditions in their own hospitals for the subnormal than do the general public.

This is ground into my very soul. In 1950 I found that my 17,000 beds constituted 52 per cent.—more than half—of all the beds in the region. My share of the capital expenditure was 13 per cent. —one-eighth. So I got angry. Fortunately I was blessed with wonderful colleagues on the board, including some very senior medical men. They abandoned or postponed cherished and necessary projects in favour of mental health projects seen to be far more urgent. They also authorised the production of a memorandum on conditions in mental hospitals which was submitted to the Government and resulted in an extra £2 million being provided for extensions in these hospitals. That sum of £2 million does not sound very much these days, but then it was a life-saver. But it was a short-lived spurt. We are back to where we were, and now there is even more to be put right. We have to overcome the prejudices which still exist within the medical and nursing professions against mental health and wipe out the handicaps in the Service. I think that we should do our utmost to see that work with the mentally ill and the handicapped is included in the training syllabus of every medical and nursing student.

We cannot rely on the area health boards to rectify the grave disparity in standards of care. Rectification can come only from decisive acts of policy stem-ming from the Minister and firmly applied. There are only 50,000 mentally subnormal patients in hospitals out of perhaps 500,000 in the community, and we are not even doing all that we could to develop the small talents possessed by the 1 in 10 cared for in hospital. So they become chronic adults who cannot go out into the community, and our gravely in-adequate accommodation gets choked up. I know that my noble friend Lady Serota and our right honourable friend the Secre- tary of State are fully aware and deeply concerned about this state of affairs and also that they are doing something about it. I felt impelled to raise the matter again because to-day we are discussing fundamental changes in the whole Service and it is imperative that we do not allow the setting up of an organisation which might permit these old scandals to be hidden away again. The Green Paper proves the case for unification. The concept of an integrated Health Service is magnificent. But we must see that the framework ensures the co-operation of the various elements, even if it means standing up to powerful vested interests. I hope that either to-night or later my noble friend will be able to reply to these matters and to convince us that the final set-up will have teeth, and will have teeth in the right places. If that can be done, then we shall get the Health Ser-vice that we all want to see.

5.35 p.m.

LORD COBBOLD

My Lords, I, too, am grateful to the noble Baroness for the helpful way in which she has introduced this debate. I find myself in general agreement with the main objectives of the Green Paper: closer integration of the various parts of the Health Service and more local participation in the Service. I am speaking this after-noon in the capacity of chairman of the board of governors of a London under-graduate teaching hospital and of their associated medical school council. This is my only experience of the Health Ser-vice and it is from this angle that I should like to put a few thoughts before your Lordships. As we are both chair-men of teaching hospitals, I shall be developing some of the points of the noble Lord, Lord Cottesloe, but I shall be taking them rather more particularly from the angle of the undergraduate teaching hospital and associated medical council, my experience being less wide in this field than his.

May I first get out of the way the question of endowment funds, which are of much less fundamental importance than other points but which nevertheless loom large in the eyes of those of us who try to maintain standards and amenities on a tight budget? The Green Paper is a little vague on this subject and promises consultation. I should like to echo what was said by the noble Lord, Lord Platt. If the noble Baroness is able to give an assurance that funds given or bequeathed to a particular hospital will continue, whatever the administrative arrangements, to be used for the benefit of that hospital, she will relieve anxiety in the minds of the governors who are trustees for those monies.

My other points are more fundamental. It is true that the Green Paper makes several references to teaching and research and also to the special problems of the London area. I believe that both those points need a great deal more emphasis than they have received. The teaching of doctors and medical research are vital to the future of any health service. Unless standards are maintained and improved, it will be a waste of time trying to create a more efficient service to the country as a whole. The London area with its concentration of teaching hospitals, its complex overlapping of hospital districts with borough boundaries and the problem of providing sufficient "catchment areas" for the teaching requirements of individual hospitals, is in a totally different position from the rest of the country. We should not forget that something like half the under-graduate teaching hospitals in the country are located in London and that London medical schools train something like half the country's doctors. These are the two main issues, the vital importance of teaching and research for the future of medicine and the special and distinct problems of the London area, which I hope this debate may serve to emphasise.

Then there is the question of management. Many of your Lordships, I am sure, have had experience of management of a teaching hospital. It is rather a curious animal, with four legs not always finding it easy to function harmoniously without a good deal of co-ordination at the nerve centre—the two medical legs of care of patients and of teaching and research, the administrative leg and the nursing leg. It is further complicated by the fact that the hospital has one master, the Department of Health and Social Security, and the medical school another master, the university and thence the Department of Education. It is essential that at the management level there should be a body with authority in close touch with all these aspects where they can all be brought together and where decisions can be taken.

I do not claim that teaching hospital management is perfect. In the past, there has, I think, been too much "keeping up with the Joneses." Particularly in these days of expensive equipment it is silly for every teaching hospital to try to specialise in everything. There has also been too little contact with other services and authorities in the localities where the hospitals are situated. But one can claim that the present set-up of boards of governors has effectively combined internal administration with maintenance of close contact with the Department on the one hand and with the medical schools on the other. Boards and their committees perform an extremely useful function and attract devoted service from laymen who become an integral part of the hospital, to the great advantage of the medical, administrative and nursing staff.

I can speak only for the hospital I know, but I believe it is generally true that, despite their different Departmental masters, teaching hospitals and their associated medical schools function in practice almost as a single unit. There is interlocking membership of hospital board and school council and continuous involvement in each other's problems at all levels. This is as it should be, and any disturbance of this unity would do a great disservice to medical education.

The area with which I am concerned, the North-West Region and, in particu-lar, the City of Westminster, is probably the most difficult in London. In the pro-posals put forward for discussion the Green Paper suggests a health area board comprising the City of Westminster and the boroughs of Kensington, Chelsea and Hammersmith. This area includes four undergraduate and a number of post-graduate teaching hospitals. A single authority, even if it were advised by district committees, could not conceivably administer all these and the other services in the area without being far too distant to manage the individual hospitals efficiently and without leaving far too great a burden on the officers. It would seem to me wiser, at least for the time being and in the London area, to leave the boards of individual teaching hospitals, perhaps with their composition modified and with increasing emphasis on their district responsibilities and increasing local participation, but retaining their present powers of appointment of staff and their present relationship with the Department and with their medical school.

It is, I believe, conceivable, when the pairing of medical schools now in progress has become a reality, that the boards of the two teaching hospitals concerned might be merged and integrated with other services. This seems to be an objective towards which the boards concerned might well be encouraged to work. I suggest, my Lords, that boards of governors, with some such modification of composition and of function, might in the course of lime come to form the nucleus of the area boards proposed in the Green Paper. I would re-emphasise that I am speaking particularly of the London area and not so much of the country as a whole.

My purpose in intervening to-day is to welcome the objectives of the Green Paper, but also to express the hope that in considering the difficult problems of London full importance will be attached to maintaining the existing efficient inter-locking of teaching hospitals and medical schools, and to the overriding importance nationally, and indeed internationally, of medical training and research. As the noble Lord, Lord Cottesloe, has suggested, it is a good general administrative rule not to destroy something which works fairly well without being sure that you have something better to put in its place. A lot of new developments are in progress. With the assumption of district responsibility by teaching hospitals; with the establishment of joint consultative committee and the joint working group; with the moves towards pairing medical schools and with the Salmon Report on Nursing, to mention only some of the recent changes, professional and administrative staffs already have a lot to digest. I welcome the Secretary of State's fore-word to the Green Paper in which he invites comment and discussion. I suggest that the next steps should include a further period of experimentation on these lines and of intensive study of the very special problems of the London area.

5.45 p.m.

LORD AUCKLAND

My Lords, I join with those who have thanked the noble Baroness, Lady Serota, for having given us an opportunity to discuss this very important Green Paper. My only qualification to speak is that I am a member of the house committee of one of the seven mental hospitals in the Epsom area, and we have several hundred patients to look after.

I think the one word which must be threaded through this whole debate is the word "communication"; and it seems to me that the test of the success, or otherwise, of this Green Paper will be in whether communication throughout the whole Health Service can be improved by its existence. I am bound to say that in at least some respects I have reservations on this. Since 1948, the National Health Service has probably undergone more surgery, through inquiries of various kinds, than many of those whom it seeks to treat and who are waiting in need of even more important surgery. Here we have a major piece of surgery for the Service. There are those who criticise the National Health Ser-vice. They say that it is expensive, that it is not working properly, that waiting lists are too long, and so on. But I believe that all fair-minded and responsible people will agree that those who operate the National Health Service, whether in the nursing profession, as doctors or in the professions ancillary to medicine, or indeed as administrators themselves, have a devotion to their task.

Yesterday afternoon I spent three or four hours, as a member of the house committee of St. Ebba's at Epsom, on a comprehensive tour of the wards and other buildings in the hospital. Each month at least two members of the house committee go round with the chairman of the committee, the chief nursing officer and the hospital secretary. I should like to express particular concern at the proposals, as I understand them, in paragraphs 24 and 25 of the Green Paper, which seem to me to suggest that house committees are to be, if not disbanded, at any rate replaced by something else. The Green Paper suggests that the new health authorities must be more clearly representative of their areas. This is a laudable outlook, but I suggest that, certainly in an area such as Epsom, the house committees and the hospital management committees are representative of these areas. The amount of work which is put in is enormous. Moreover, the advantage of the house committee system in an area such as Epsom, where there is this concentration of mental hospitals (not all these hospitals have a house committee), is that complaints can be channelled through much more quickly than could happen, as I see it, with area boards.

Then I notice that the Government propose to elect, through the Secretary of State, one-third of the members, the other two-thirds to be elected from other sources. But all the members of the house committee in the hospital with which I am concerned live locally. What is more, many of them know many of the patients by name. They can talk to these people and though, understand-ably, some of the patients are not in a condition to reply orally, they still know in their own way that they are being spoken to. I think that this is important. Whether we are dealing with patients in general hospitals, in geriatric hospitals or in mental hospitals, in the last analysis we have to realise that they are human beings.

These interim visits that are made by the voluntary members of house committees, who work in co-operation with the leagues of friends, are able to keep a close and objective eye on what is going on. Some may raise the objection that these volunteers only "snoop around", but I do not think this is the view of the hospital authorities. I believe that it would be a tragic mistake if in this phase of the Health Service, when we hear all too much about what happens at places like Flax Bourton, we were to stop this work of visiting. It is right that cases of ill-treatment of patients should be brought up, but it is equally right that all the work by devoted male and female nurses and doctors of the Health Service in looking after thousands of patients should be made public to the full. It is largely through the voluntary committees that this can be done. It is a tremendous encouragement to hospital staffs that these committees take an interest not only in the patients but also, more vitally, in those who are looking after the patients. It is particularly vital to-day in our mental hospitals, where a large proportion of the nurses come from the Commonwealth and foreign countries, that they should receive this attention and praise.

I should like to know how much discussion of this kind will be possible with this new system. What is always disturbing about paid personnel running services of this kind is that complaints and suggestions do not always channel through quickly enough, whereas if voluntary people are running the services the process is speeded up. I do not say that the volunteers are as good—or perhaps as bad—as those who are paid. I am certainly not suggesting that the paid personnel in the National Health Service do not care—far from it. But I am sure that these voluntary committees help to bring to light complaints and suggestions before they fester or become magnified fifty-fold or a hundred-fold and cause a lowering of morale in the Health Service. That is the only point that I wanted to raise on the Green Paper. I wish the proposals in the Paper well, but I hope that the noble Baroness, Lady Serota, will be able to confirm that the voluntary services in our hospitals, particularly in our mental hospitals, still have a vital part to play.

5.53 p.m.

LORD STAMP

My Lords, in intervening briefly in this debate to-day, I should like to touch on one or two proposals contained in the Green Paper that have given rise to considerable concern in medical academic circles, even though this means to some extent emphasising what has already been said by other noble Lords, in particular by the noble Lords, Lord Cottesloe and Lord Cobbold.

First, I wish to consider the proposals as they are likely to influence philanthropy in relation to the medical causes, with which I personally have been very much concerned. The suggestion—and I hope that it is only a suggestion—contained in paragraphs 80 and 81, that trusts and endowments owned by many hospitals, particularly some of our older teaching hospitals, are to be transferred to area health authorities and may be diverted and used for purposes other than those for which they were intended, seems to me to be quite indefensible. Putting the worst interpretation on it, it would amount to a breach of faith, what-ever legal loopholes may be found to make this possible, and a complete disregard of the wishes of those who in the past contributed to these endowments.

Taking a more charitable view, it would indicate a complete lack of under-standing of the motives that lie behind giving to a medical cause. That this may be so is brought out in paragraph 80, where the hope is expressed that the public in each locality will continue to give generous support to their local health service. The idea of trying to obtain support for a local health service as such would make any fund-raiser shudder. In fact, one of the major problems that those of us who have been concerned with raising funds for medical causes have had to overcome since the introduction of the Health Service—and in this I can speak from personal experience—has been the widespread feeling, often very forcibly expressed, that the Government should now be paying for it all, particularly with company and private taxation at its present exorbitant level. Well, we all know that the Government cannot, especially with the ever-increasing cost of the Health Service, as a result of increasing complexity of medical treament and the growing number of the aged in the population. Apart from this, there is the vastly increased expenditure on other social services, such as education, that will be necessary in the next ten years with the enormous expansion envisaged for higher education, including medicine. In my view, there-fore, it has never been more necessary to encourage private benefaction in the field of medicine. As well as benefiting medical causes, this must help to promote that personal concern for the less fortunate that is at the foundation of a healthy society, even in a Welfare State.

Giving to medical charities is, of course, stimulated if there is a clear-cut objective, particularly if it has personal associations. Traditionally, the hospitals have been the main beneficiaries, among them in particular our famous London teaching hospitals. Now that they have been taken over by the Health Service, this is no longer the case, except to a minor extent, such as through the activities of associations of Friends of various hospitals—and I would not want to minimise for one moment the help that these give.

The medical schools, also the recipients of many benefactions in the past, are now likely to appear to be less worthy of sup-port if the hospitals with which they are associated were to be relegated to the status of district hospitals. This is only too likely to happen if too much emphasis is placed on their district responsibilities and the finance available to them is to be made dependent on this. These are fears that have been expressed in many quarters over the present proposals, and if they appear to be exaggerated I should like to know what provisions are to be made against this happening.

A third way in which medicine is sup-ported is, of course, by financing specific research projects, many of which are being carried out in our hospital medical schools. Here there are skilled teams of full-time academic research workers who are able to use the funds provided to the greatest possible advantage—a most important point, incidentally, when approaching any potential donor.

This brings me to the proposals contained in the Green Paper as they affect the staffing of our medical schools. Here again there is considerable cause for anxiety. For many years now there has been an increasing discouragement to those thinking of entering an academic medical career. I have gone into the reasons for this in previous debates and do not intend to cover the same ground again. There is now, however, the additional factor of the proposed changes in the relationship of the university and the Health Service.

Throughout the Green Paper there is an indication that university influence in the management of the area boards, now to be responsible for the university teaching hospitals, will be much less than the importance of the hospitals as teaching institutes would warrant. If this were to be so, it would be a thoroughly retro-grade step and would undermine further the morale of medical teachers in our universities. At all costs, this must be avoided if the continuing loss of academic medical brains to more satisfactory conditions abroad is to be halted—and, as I know personally, it is still continuing. The recommendations of the Todd Report, that academic influence and whole-time work in our training hospitals should be increased, will not be fulfilled. In fact, the question of the future of the medical teacher is at the very root of the future of the Health Service.

Nor is he only of vital importance for our country. To our medical schools there come students, both undergraduate and postgraduate, from all over the world and, in particular from the Common-wealth. In a very practical way, there-fore, the medical teacher is giving aid to the developing countries—the subject of the debate that we had last week. I make no apology, therefore, if I appear to be flogging the subject of university representation and influence in the Health Service reorganisation after other noble Lords have already referred to it.

There is one other matter that is giving considerable concern to many in our universities engaged in clinical practice and research. It is, as the noble Lord, Lord Cottesloe, has said, that if there is too much emphasis on area responsibility it will be increasingly difficult for them to obtain from other areas the cases they need to carry on their clinical observations that add so much to knowledge of disease, and to use to best effect their specialised skills in treatment. For this reason, the principle of area responsibility will have to be applied with great latitude in the case of our great under-graduate and postgraduate hospitals if they are not to feel increasingly frustrated and demoralised. As the noble Lord, Lord Cottesloe, has said, their identity must be preserved, and the special part they play in the development of medicine, both in this country and throughout the world, in teaching and research must be fully recognised by the provision of adequate finance, quite apart from that required for them to meet their area responsibilities.

In the 25 years of its existence, in spite of all its imperfections, the Health Service has done much to improve our health standards. It would be tragic if the dangers inherent in the proposed re-organisation were not fully recognised.

6.5 p.m.

BARONESS SWANBOROUGH

My Lords, like everyone else I want to pay tribute to the noble Baroness who made this debate possible and, not unnaturally, I want to take my stance on the question of voluntary service and the volunteer and what he contributes. To me the Green Paper seems to forecast great opportunities for voluntary service of all kinds. It is to-day, I believe, an accepted fact that the contribution that can be made by thoughtful and sympathetic volunteers to the comfort and welfare of patients in hospital can accelerate recovery, and that this work in hospital has a counterpart in the many jobs done by a variety of bodies, through the various domiciliary services for the sick and the frail at home.

The Green Paper is a wonderful opportunity for linking the one to the other, and there is no question that all voluntary services, and the participation of every sort of volunteer, will be available to play a part in helping to care for the sick and frail and in promoting the health of the community. But I would enter a very strong plea that those who know much of the commodity which is voluntary service should be consulted on the methods of working—on the links to be forged and the long-term channels of communication between the ultimate authority and the voluntary services themselves.

As I understand the suggestion, it is that services shall be organised according to the skills required to provide them rather than by the categories of users. In paragraph 39 this is instanced by the fact that arrangements for the day care of children under five years of age, and child-minding, will come under the social services department. From experience I should be a little worried that health visitors who do so much for these groups and for the elderly people may now, under the new idea, become a part of the area health board. Home nurses and health visitors are to be found on the ground, and they operate at a different level from the child-care officers, and nearer to the need on the ground. Welfare officers, who often work from an area office covering several local authorities, have of course a different sphere of activity. In the small towns and villages it is undoubtedly the health visitor and the district nurse who have their ears to the ground and know what is going on; who know who is becoming frailer, and what are the needs for outside help, which they in turn know how to obtain.

There is an infinite number of cases where a law-abiding family looks after its own responsibilities in the way of children and old people, and in consequence does not attract or require the attention of a social worker. But often, nevertheless, such people can be in dire need or distress, due to the illness of a member of the family or to a series of different reasons. It is the health visitor who on her rounds gets to know, and who finds out when a mother is at breaking point and should have a holiday; and it is also the health visitor who knows how to arrange for such a holiday. It is the work in the local field that is of such tremendous importance, and it would per-haps be regrettable if she were more extensively used in her professional skill and, in consequence, there were a great loss to the smaller community.

Those who work with and for the statutory authority understand and appreciate some of the many problems which confront them, and especially those who are planning; and all of us recognise some of the many difficulties. One of the constant preoccupations of all concerned is that of the old person in hospital who cannot vacate a bed because there is no place to which he or she can go, and of those in old people's homes who should be moved to a bed in hospital if only there were a vacant bed to go to. This is another link which will need infinite patience and great understanding in the forging.

It is suggested in Chapter V of the Green Paper that the medical social workers (whom we used to know as almoners) might transfer to local authorities. Speaking from a voluntary worker's point of view, I can say that this would greatly extend the work that could be done by volunteers on the ground for patients leaving hospital, as well as for patients in hospital who are worried about their families. The machinery at present is often slightly cumbersome, and when the medical social worker located in the hospital has informed the local authority it may sometimes take time for the information to filter through to the appropriate home nurse or health visitor. In consequence, the patient who has per-haps been discharged at a moment's notice does not always get the local support soon enough, and all too often has to return to hospital. Far more could be done by voluntary bodies if they were given the opportunity, in time, of getting a home ready, arranging for a hot dinner or meals-on-wheels, or even just seeing about a friendly visit.

Few volunteers envisage the sum total of what their contribution could be—and the vast majority of volunteers enter the field of voluntary service for a multitude of reasons. The problem to be envisaged, and to be kept in mind, is that whatever the channel through which the individual has started in to serving the community as a volunteer, the potential of that person must be watched and developed and enriched, so that the individual him-self becomes a strength within the community. Because of the changes adumbrated in the Green Paper—as indeed with the proposed changes in local government and in the workings of the social services—it will be of the utmost importance to keep all those likely to participate not only involved in but enthused with the prospects of service; and to attain this objective it will be essential to explain fully the end product of the individual's effort to the individual concerned. The help that can be pro-vided, both physical and non-physical, by volunteers is tremendous, but it must not in any way be allowed to be sporadic or without standards: it must of necessity be well organised; strong in its content and free from any kind of nepotism.

I do not believe that the organisation of voluntary service on the scale envisaged can be undertaken by people who have not had a great deal of experience in volunteer management; and I beg that those who have worked as a volunteer and with volunteers may be brought into planning at an early stage and not when everything has been finalised. The potential for taking responsibility among volunteeers is great and should not be ignored. The use of volunteers could be without limit, but an essential side of this work is the organising of rotas, the looking after volunteers, the arranging of a leader for each group, the giving to volunteers themselves of the feeling that they have the personal support of who-ever is in charge of them. My Lords, voluntary service in its finest form is the gift of a modest person without wish for adulation, but with the instinctive hope that what he can give is something of use. This has to be taken into consideration—not by exaggerating the contribution but by showing factually that ordinary work by ordinary people on an extra-ordinary scale can benefit not merely the community but the country itself.

6.14 p.m.

VISCOUNT ADDISON

My Lords, I should like to add my thanks first of all to the noble Baroness, Lady Serota, for giving us the opportunity to debate this subject and for so logically and usefully describing the Green Paper and some of the thinking that lay behind it. At this stage of a long list of speakers it is inevitable that points should get re-iterated. Perhaps if they do, it may be a measure of their importance, and they may be none the worse for repetition. So please forgive me if I repeat and emphasise one or two points that have been made, although there are many that have not been touched upon which can be left for later speakers, because it is an enormously wide subject.

Though the nature of the document as that of a Green Paper is emphasised, it seems that firm decisions on Government policy must be accepted on three main principles: first of all, administrative control of area health authorities by the Secretary of State with no intervening statutory authority; secondly, public health and social services continuing to be administered by local authorities; and thirdly, that the number of new health authorities will be coterminous with unitary areas and metropolitan districts as defined by the White Paper on the reform of local government, the Redcliffe-Maud Report, which your Lordships debated last week and yesterday. In these circumstances it seems to me that a very good case may have been made out for a return to the old idea of a Ministry of Health with a fully employed Cabinet Minister at the top, by reason of the immensity of the centralised function when it is remembered that direct control of, responsibility for, and relationship with, no fewer than about ninety area health authorities will result.

I appreciate that about fourteen pro-posed regional councils are to be inter-posed, but those bodies will have no executive duty, only advisory duties in a planning and similar capacity. Whom will they advise, and will anybody listen to and act upon the advice proffered? It must be assumed that they will, but I would ask the Government—and I go a long way with Lady Brooke here—to have another look at the regional coun-cils to see whether they cannot be given at least a decent set of teeth with which to masticate the somewhat indigestible planning fare with which they seem likely to be faced.

Up to the present the Regional Hospital Boards have been responsible for the planning of the hospital programme, which, of course, has had its effect on other aspects of planning of a more local kind. On the whole, I think the policy has worked well, though there have been many difficulties and progress has been inevitably slower than one would like. Boards have not always received full backing by the central authority, but I do not wish to be over critical. Capital has been a scarce commodity, and every capital project has had to have the necessary maintenance flow only to be found by the closing down of smaller, obsolete units, often units regarded with a nostalgic affection by the local populace but, I am afraid, also as a source of revenue for part-time consultants and small-time empire builders. What I am concerned with, my Lords, is that the experience of the Regional Board planning teams should not be lost. The central Ministry authority has had only limited experience in this field, confined to the two so-called "Best-buy Hospitals"—good prototypes, but as yet untested. I have a fear that many good men, architects, engineers, surveyors and the like, might be tempted away from the service which they have done so much to help to create.

I wish to make a short speech only, but there is much that I could say, so I am happy to think that most of the points on which I have notes have either been mentioned or are points that will no doubt be raised by later speakers. The first function of the health authority is to provide service to the community, as the noble Lord, Lord Cottesloe, stressed. Also it has the vital duty to train medical and nursing staff. And although I, for one, would wish to see the teaching hospitals closely integrated with the district service, which I hope will be developed and extended, care must be taken to retain the image of, for instance, a "Bart's" man or a "Guy's" man and so on, because wherever he may go in the world his is the hall-mark of a well-trained and qualified medical man. Again, the certificate of a State Registered Nurse is in itself a qualification to be jealously guarded and in no way devalued.

I think the proposal to pay chairmen of area health boards may need further consideration, because it presupposes an executive function. The duties are described in the Green Paper as "heavy responsibilities", and to my mind this might constitute an attempt to grapple with the problem of the seniority of the twin lay and medical chains of command which exist at Regional Board level and, to a lesser extent, at the present hospital management committee level. In my view, the chairman of the area health authority will gain little from a pay packet, and I even believe that a good, strong volunteer chairman would carry greater weight and probably more influence. Of course, it is very important to pick a good man, and in my view the Minister must be quite free in this respect and not subject to local pressures.

It is said that the present make-up of hospital management committees and Regional Board membership is undemocratic and self-perpetuating. I am glad to be able to speak just after the noble Baroness, Lady Swanborough, because that was a point on voluntary service which, if I may say so, she dealt with so adequately. It must be admitted, I agree, that in part they are undemocratic; but in a long experience I have found them a body of devoted, hard-working people who generally got more "kicks than ha'pence", and I have never found any evidence of political influences, one way or the other. I say that, having worked on a board of governors, a Regional Board and a hospital management committee under, altogether, I think, four Conservative Ministers of Health and two Labour ones. Mr. Enoch Powell was a very good Minister and so was Mr. Kenneth Robinson, and I cannot think they have very much in common politically.

It is possible here also to run the risk of losing much expert knowledge and experience, more especially, perhaps, at the Regional Board planning committee level, and care should be taken to pre-serve some of these very good people with a valuable contribution still to make. Some might make good paid chairmen of area authorities if they could be persuaded to take on the job—perhaps that is a point worth considering.

The investigation of complaints by the various health authorities has attracted a good deal of attention and I agree with comments in paragraph 95 of the Green Paper to the effect that the methods of investigation and the extent to which investigations have been pursued by the health authorities have not always been fully appreciated by the public. It is not always recognised that the lay element in the Regional Hospital Boards and hospital management committees constitutes a very effective means of watching over the interests and problems of the individual patient. It can be accepted that justice must be seen to be done, and to this extent I think the proposals to give greater publicity to procedures will have a good effect. The Minister is to be congratulated on some very clear thinking in this regard.

One point occurred to me while I was having my tea this afternoon which I wonder whether the noble Baroness could clear up for me. I am not sure whether provision for family planning, which is now to be a task of the local health authority, is to be an obligation on them, or permissive. That is a point I should like to have clarified. In conclusion, my Lords, I think that the Government and the Department have tried hard and have produced an enlightened set of proposals, and at the same time have kept a few options open. It will be interesting to see what future developments will result from present debates and discussions and in what form the forthcoming White Paper will emerge.

6.25 p.m.

LORD GRENFELL

My Lords, we who are deeply concerned with hospitals have had little time to prepare for this debate and to discuss it with our colleagues in hospital management commit-tees, and no chance to discuss it at all with our Regional Boards. I called a special meeting of my hospital management committee last Wednesday, but it had to be cancelled owing to the fact that most members would have had to arrive on snowshoes. For these reasons I hope it will be understood that my remarks to-day are my own, in consultation with my group secretary; and maybe the most operative phrase in this Motion is, "takes note of" the Green Paper.

This Green Paper is designed to pro-mote discussion on a Health Service which will form a firm foundation for the health of our people for many years to come. The integration and the designation of services between area boards and local authorities will require detailed discussion with those concerned with the present services at all levels; and it is in my opinion of paramount importance that, so far as is possible, agreement should be reached on the future services. Agreement will entail detailed discussion, and I am deeply concerned by the note at the bottom of page 29 stating that comments and suggestions should be made to the Ministry "not later than the end of May". May I stress again that this Green Paper is deeply controversial and in order to come to a decision we shall need agreement that will be really lasting. This will require more time. Will the noble Baroness therefore make urgent representations to the Secretary of State to postpone this period of discussion until the House rises for the Summer Recess, after which we shall re-turn, refreshed, to consider any further debate and eventually legislation which will affect the whole country for many years?

I now turn to the Green Paper in detail, and I reiterate that what I am about to say represents my own considerations and is not necessarily my final conclusion after I have had a chance to discuss this document with my management commit-tee and Regional Board. In Chapter l.l(iv) the statement is made that: it was intended that the different parts of the service would be co-ordinated in health centres. I trust that this decision will not be put off until the proposals for the National Health Service are finally agreed. We have waited too long for centres to which worried parents can go to have their children assessed by consultants, who can either reassure them or give them good advice on the medical future of their child.

It would be impossible for me to deal with every aspect of this Green Paper, but paragraph 12, on page 4, deals with patients whose families prefer to keep them at home. The only answer to this, which I have spoken about many times, is massive support to the families at home, both in visits from social workers (who are badly underpaid) and in monetary funds, to help the families in their exceedingly difficult task. On page 5, the role of the family doctor in connection with the hospital doctors is discussed; and in paragraph 15 it is stated that: … the family doctor must be provided with the tools to do his job and this means full access to pathological, radiological and other diagnostic facilities which are provided at the hospital …". I cannot for the life of me see why we need to alter the whole of our system in order to carry this out. If the money is given to the hospital, the people there will be only too pleased to give this ser-vice; and if no more money is available I cannot see how regarding this as a service to the district can make any difference.

I now turn to page 8, paragraph 24. My Lords, I have never been a particularly Party-political person, but I must admit that there is one sentence in this paragraph which makes my blood boil. I will read it to your Lordships: Members of hospital management committees, as agents of agents of the Secretary of State, have a particularly slender democratic basis. I look upon this statement as a grave insult to men and women, in all walks of life, who have for many years given up their time to devoted work on hospital management committees. I have on my management committee parents of the mentally handicapped, doctors, nurses, consultants, educationists, members of local authorities and devoted members who have served for many years; and to say that these people have "a particularly slender democratic basis" is not only insulting but completely without foundation. I hope that if, as stated in the Green Paper, the Secretary of State wishes to engender the concept of voluntary work in the Health Service he will un-reservedly withdraw this statement. It would appear that my ideas of democracy and those of the Secretary of State do not in any way coincide. It would appear that anything in the way of de-centralisation is anathema to him, and I feel sure that the noble Viscount, Lord Montgomery of Alamein, would agree with me that if every battalion commander had had to refer to him person-ally before making a decision, the desert campaign would have had a very different result.

Having now returned to my normal blood pressure may I turn to the proposed area health authorities and district committees? The composition as detailed in paragraph 25 is suggested as one-third appointed by the health professions, one-third by the local authorities and one-third, plus the chairman, by the Secretary of State. This will need careful consideration, but there appears to be a fear of a preponderance of the pro-fessions rather than of the populace on these authorities. Some, like my noble friend Lord Addison, will be disturbed that part-time salaries will be paid to chairmen. The present system appears to work well, and there must be a fear that once a chairman becomes salaried by the State he no longer has the freedom of manœuvre and action that he has in his present situation as a voluntary worker.

My Lords, I now turn to paragraph 35, on page 11, and I note that, The area health authorities will be responsible for … hostel services ". As the noble Baroness has said, I am tempted to believe that the still small voice of Grenfell has at last been heard. But, my Lords, what on earth do the subsequent sentences mean? Who is to decide when a patient no longer needs the continual care of the psychiatrist; and what is to be the procedure for the transfer to the local authority?

Now a word on the highly controversial question of the district committees. Paragraph 53 states: It is … proposed that most of the health area authorities should establish district committees. What does this sentence mean? Does it mean that an area can decide for itself whether the public in that area are to have any participation in the working of the hospital service? I entirely disagree that where the authority is small it will be able to administer its services satisfactorily without any district committees. The district committees will be commensurate with the hospital management committees in the present set-up, and there are many duties which these management committees carry out, both functional and in the entertainment and inspectional world of the district, which it would be quite impossible for the members of an area committee to carry out, whatever its size.

In paragraph 54 it is stated: The district committees will be served by the officers of the area health authority. There will be no need for them to have separate budgets. No powers will be delegated to them by statute. I know that the noble Baroness believes that the district committees should be sub-committees of the area committees. I believe that this would be disastrous. As suggested, the chairman and half the committee will be drawn from the area. What independence will there be? And will the staff in the hospitals have any real interest in such a committee? I think not. If the district committee has no officers of its own, and no budget, maybe the noble Baroness, Lady Serota, can clarify the situation as to what functions, if any, will be delegated to them. If, as I believe, few powers will be given, I cannot myself see local people taking an interest. I cannot see the whole-hearted co-operation between the hospital management committee and the league of friends, who work so closely with the group secretary and his staff; nor can I see the functions of house committees, in which I know the noble Lady believes.

Finally, my Lords, may I turn to paragraph 80? To my mind there will be strong resistance to the transfer of individual hospital funds to the area health committees. These funds have been built up through contributions from people having faith in a certain hospital and in the work it has done, and to my mind they should not be used for other pur-poses. It is unlikely that the public will continue to donate funds unless they can give direct to one hospital which has given really good service. I have been critical of this Green Paper, as I was of the last. I believe sincerely that it will bring a large measure of bureaucracy into a Service which is founded on common sense and loving kindness. I am convinced that the present system can be extended to embrace the functions envisaged in this Paper without all the changes which bring the dead hand of the State to the hospital services.

6.37 p.m.

THE COUNTESS OF LOUDOUN

My Lords, I should just like to say a few words on the importance, in my view, of the role of the social worker and the psychiatric social worker in the future structure of the National Health Service. We are all subjected to stress and strain at some time or other during our life-time, and many of us are unable to cope with them. The social work services in the hospitals are seriously understaffed and inadequate, and many patients are discharged without due consideration being given to their social situation and their after-care needs.

Social workers in the Hospital Service welcome the statement made by the Secretary of State for Health in the debate on the Local Authority Social Services Bill in another place last week, that social workers in the Hospital Service will be employed by the local authority social service departments and seconded to the Hospital Service. I consider that it should be obligatory for the personal social service departments in the local authorities to provide a social work service to the hospitals and to the general practitioners, in order to achieve continuity of care of patients, for whom hospitalisation is becoming increasingly a phase, rather than the major period of treatment.

It is essential that each hospital should have seconded to it one or more professionally qualified senior and experienced social workers of sufficiently high calibre to be able to participate in teaching and treatment at all levels in the hospital; to interpret and co-ordinate the needs of the social service departments to the hospital administrators; to make known hospital needs to the local authority social service departments, and to supervise the less qualified workers deployed in the hospital social work department. Psychiatric social workers share a common training, though a specialised one. In practice they work in many fields—teaching, administration, probation, child and community care, as well as in the orthodox settings of child guidance clinic and hospital.

The hospital social work department provides excellent training facilities for all social work students in giving them the experience of working in an inter-disciplinary team. Qualified social workers wishing to specialise in medical and psychiatric social work will need to work under supervision in a hospital social work department for a period of two years. Training at these two levels will develop understanding in the local authority social service departments of the needs of the medical services, and thus enable the two services to work in close collaboration. It will also help the local authority social service departments to develop the after-care services needed for hospital patients. There will always be need for specialised social workers. In the mental health field, such workers will need, over and above their basic social work training, a thorough know-ledge, understanding and experience of the problems of the mentally disordered and their families, and the treatment of these conditions in a clinical setting.

The success of the social service departments will depend to a large extent on the way other disciplines use them and understand the scope of their work. It is essential, therefore, that the hospital team should contain a social worker so that all disciplines can experience the sharing of work as a member of a team, and that hospital medical staff know what services are available to their patients after they leave hospital care.

It must be considered how best psychiatric social workers can meet the needs of patients in a reorganised service. A weakness in the position of hospital psychiatric social workers is that experienced workers are continually leaving the service and are not being replaced. There are many counties without a psychiatric social worker employed in the Hospital Service. The number employed in the Hospital Service has remained static for 12 years, although the number of qualified psychiatric social workers has more than doubled in the same period. The Seebohm Report made it clear that such skilled groups as psychiatric social workers were very small but highly influential fish in a very large sea.

6.43 p.m.

LORD MILVERTON

My Lords, I am venturing to offer some comments on the subject of this debate because the reform of local government presents an opportunity, which is unlikely to recur, to bring the health services as a whole and local government together in one comprehensive structure, with advantages both to the health services and to local government. The views I am trying to express are those which I share with the Association of Municipal Corporations, one of whose vice-presidents I have the honour to be, and I hope will therefore attract a little more attention from Government than might be given to my own lonely voice crying in this wilderness of reorganisation.

The second Green Paper is a depressing document from the point of view of those who feel that the unification of the National Health Services should take place within the reformed government structure. There are two main reasons for taking this view. The first is that important local services should be subject to oversight by elected men and women answerable locally. The Association has, in my view correctly, argued that representative government itself is strengthened where public services are made the re-sponsibility of elected bodies, and it is diminished when important services are made the responsibility locally of ad hoc bodies such as the Secretary of State is now proposing.

Elected members have in general two outstanding advantages over nominees, simply as representatives of the consumer. First, the obligation to seek election itself makes it probable that elected members are, and will remain, in close touch with the needs of their constituents and will feel a keen responsibility to meet those needs. Secondly, precisely because they are elected at separate elections, elected members are sufficiently independent of central Government to voice local needs firmly and are less likely to be representative of particular interest groups. Even where the bulk of the financial resources needed for a service is provided by the Treasury, there is no reason to suppose that nominated people will be better guardians of public money than elected people, who frequently in other contexts are concerned with the allocation of re-sources in the light of financial circum-stances.

The second reason is that there are close relationships between local authority services, particularly the personal social services which are the subject of the Local Authority Social Services Bill, and the health services, and by making each group of services the responsibility of totally separate authorities the possibility of insufficient co-ordination and inadequate joint working is increased. This point is clearly acknowledged in paragraph 42 of the second Green Paper.

My Lords, none of these arguments are new, and they were, of course, advanced to the Government by the Association, and indeed by others, after publication of the first Green Paper. But they have been rejected, and as the Secretary of State makes plain in his foreword to the Green Paper, the Green Paper is firm on the point that the National Health Ser-vice will not be within reformed local government. It is interesting to see that on page 7 of the Green Paper two reasons are given for not unifying the Health Service within local government. The first is: The professions believe that only a service administered by special bodies on which they are represented can provide proper assurance of clinical freedom. It does not appear from this statement that the Government have examined whether this belief is a justified belief. The truth of the matter is, of course, that the relationship between doctors and the responsible authority is in no way prejudiced by the responsible authority being an elected local authority.

The second reason is that the transfer of financial responsibility to local government would not be possible because the independent financial resources available to local authorities are insufficient to enable them to take over the responsibility for the whole of the Health Service, and that such a transfer of financial authority would seriously complicate the problem of giving local authorities a greater degree of financial independence. The White Paper on Local Government Reform says little in detail about future local government revenues, but merely announces that a Green Paper on local government finance is to be published. However, it is made plain that the probable local tax will continue to be rates in some form.

In the view of the Association, financial decisions follow from rather than govern administrative relationships. If' the Government considered it proper to bring the National Health Service within local government, an appropriate financial structure could no doubt easily have been evolved. It is particularly regret-table that this financial argument has been advanced before the Green Paper on local government finance is available, and before it can be asssessed in the light of any proposals the Government may decide to make. It seems unlikely (although we have not yet seen the Green Paper) that the situation will arise in which the whole of local expenditure is met by local taxation. Some element of central grant will continue, and its precise proportion will obviously be deter-mined by the nature of the services which local government is to provide. If the Health Service had fallen within local government, central grant would have to be adjusted to take this fact into account.

The education service is an extremely expensive one, but it has been found perfectly possible to accommodate it within local government. Neither of the two reasons advanced by the Government for excluding the Health Service from local government are particularly convincing, the first less than the second. But even if there were to be an acceptance of either of these reasons, it is interesting to see that local authorities are not to have even a majority representation on the new area health authorities. One recalls that in the Report of the Royal Commission on Local Government in England there was a short section on the National Health Service and local government which contained this paragraph: If there prove to be overriding reasons why nominated boards should run the National Health Service, the new local authority should at least appoint a substantial proportion, if not a majority, of the board members. At the core of each board will be a powerful professional bureaucracy. The body to which that bureaucracy is responsible should contain a strong contingent of elected representatives aware of public opinion, and sensitive to it. No overriding reasons have been advanced in the Green Paper.

But even if the contrary view were taken, the recommendation in this paragraph remains valid and the proportion of local authority appointees mentioned in paragraph 25 of the Green Paper, to wit one-third, is by any standards far too low. If one assumes that some separation is inevitable, complete operational separation between the area health authority and the local authority must, in the view of the Association of Municipal Corporations, be avoided. Professional and technical services, such as legal, accounting, architectural, engineering, supplies and business officiency ser-vices, might be provided on a common basis. Indeed, there is some acknowledgement of this in paragraph 43 of the Green Paper.

The chapter headed "Local Participation" needs to be viewed with a little scepticism, because the reference to the district committees suggests that they will have an active and useful function. But this is open to question. It is made clear that these committees will not have their own separate budgets and will have no powers by Statute. Instead of giving rise to a greater degree of participation, such committees may merely become a buffer between an area health authority and the public. It is also not clear how these district committees are to be made up, because the reference in paragraph 54 to a composition of a chairman and half the membership appointed by and drawn from the area health authority leaves one in doubt on where the other half are to be drawn from and who is to appoint them.

It is worth comment, too, that the proposals in the Green Paper represent an absolute increase in the powers of central Government, partly at the expense of local government and partly at the expense of the existing ad hoc authorities. In the case of local government, the personal health services become the responsibility of the Secretary of State. This is an absolute loss to local government. The Green Paper also, however, contains the statement: The central Department will need to concern itself more closely than in the past with the expenditure and the efficiency of the administration at local level. Paragraph 90 of the Green Paper reads in this way: In order to maintain an effective direct relationship with about 90 area health authorities the central Department will need consider-able reorganisation. There will need to be strengthened regional offices and much more interchange of staff between the area local authorities and the central Department. Again in paragraph 91 of the Green Paper appears the phrase: Certain functions which are at present per-formed by Regional Hospital Boards will in future be performed by the central Department. It is quite clear that to local government not only is there a loss of function, but there is a loss of local initiative in toto, and a move of power to the centre. So, my Lords, I conclude with the hope that the Government will seriously reconsider this question, and remember, too, that effective democracy is rooted in opportunities for effective participation and can be preserved and strengthened only by the personal interest which is stimulated thereby.

6.59 p.m.

LORD VIVIAN

My Lords, in opening this debate, the noble Baroness, Lady Serota, whom we have to thank for the opportunity to discuss the Green Paper, paid tribute to the family doctor by saying that the National Health Service centred around him. How right the noble Baroness is! And through this most welcome remark, can it be that one can discern a hope of bringing the family doctor, or the general practitioner, back to play his all-important role within our major and teaching hospitals? I earnestly hope that this is so, and, speaking as almost the last of a long list of speakers, I shall confine myself to this one issue.

With regard to the family doctor, the Green Paper makes little mention of the vitally important role which he can and should perform within our major and teaching hospitals. I find this omission disturbing. I can assure Her Majesty's Government that a very large number of people who have benefited through hospitalisation within the National Health Service have one main wish, and that is that the Government will make it possible for their general practitioners to visit them in hospital. I can also assure the noble Baroness that among general practitioners there is a very large wave composed of those who also rightly feel that it would be greatly to the wellbeing of the patient if, during hospitalisation periods, they were enabled to keep in close touch with their patients.

I hope that when the Minister of State, the noble Baroness, Lady Serota, winds up the debate, she will comment on the present privation which so many of us feel we suffer and which, to me, appears to be unnecessary. To my way of thinking, until now the Secretary of State for Social Services has seemed to acquiesce in the practice of making the general practitioner unwelcome in our main hospitals, although I have not been able to discover that this is a defect of the National Health Service per se, since there appears to be nothing in its regulations definitely to exclude our general practitioners.

It may be helpful to distinguish between the National Health Service—22 years old—and the medical profession, old by as many centuries. If the cause of our privation is not in the National Health Service, then we must, I suppose, look for it in the profession. A fresh eye on the medical profession and who is who within it discerns anomalies. Specialists have appeared and multiplied only in the most recent centuries. One of the early ones was the inventor of the obstetric forceps, and it is said that in order to protect his secret he went about carrying only one blade and insisting on operating alone. The second blade he concealed in his cloak. He was an itinerant.

It was recognised that whereas such people had desirable skill, they were not subject to the public scrutiny that surrounds a static family doctor who works, as it were, in the market place, exposed to the gaze and criticism of all and sundry. In order to protect the public from charlatans, the medical profession devised a rule of conduct whereby in the interest of the public specialists would be consulted about patients only by family doctors, and not by the patients directly. The effect of this rule was to establish an hierarchy with the patients at the top, hiring and firing family doctors as their chief servants, and the family doctors choosing among specialists as their servants. Specialists, therefore, were under-servants to the patient. Yet, as things have turned out to-day, specialists live among riches and power and in the limelight, and the family doctor, or general practitioner, finds himself in relative obscurity.

This paradox of the specialists, junior in the sick-room yet powerful in the out-side world, need not matter. Some noble Lords here to-day are private patients, while other noble Lords are National Health Service patients, and some, like myself, have experience of both roles. We know that as private patients we may enjoy the ethical hierarchy to which I have already referred. Our family doctors will accompany us through thick and thin, choosing our surgeons, assisting at our operations, managing our convalescences, restoring us to our families as soon as may be, and be every ready to stand down themselves at the end of each illness.

I can see no valid reason why we should not enjoy exactly the same attention when we are National Health Service patients—and, indeed, in cottage hospitals we do. Yet in all the big hospitals, and especially in teaching hospitals, there is a devastating difference. Deserted by our family doctors, we find ourselves left with specialists towering over us—and not only towering but often accompanied by a retinue. We have the right to speak up for ourselves, but we do not do so. Instead, by some psychological phenomenon, we come to feel as though we are children in the hands of parents. Telling ourselves that the specialists probably know what they are doing, we decide not to speak up, and we resign ourselves to whatever may be coming to us.

But such resignation is not easy. We ask ourselves why we should not be allowed to have our family doctors in the same manner as the private patients do. If we were able to do so, they would be in a position to explain to us the nature of our illnesses in words that we under-stand, words that that same doctor will answer for in years to come. He would interpret to us the intentions of the surgeon, and liaise with our families at home. All of these things are pastoral functions and only half of what a general practitioner usually does. He also watches over diagnosis and treatment, forever on his guard against the mistakes which can and have unfortunately been made in some major hospitals.

Many general practitioners have noticed that their absence from hospitals renders specialist "X" far more important than when they were able to bring him to our bedsides in private consultations. There are some who have written of and hinted at power-game tactics, whereby the specialists have driven general practitioners from our major hospitals for the sake of increased power and freedom from supervision. If this is true, it is an affair not of the National Health Service but of the profession itself. But it may be that the Minister is in a position to help general practitioners to set their own house in order. Would it not be a simple device to provide space on all case notes for the family doctor's comments? A coroner, noticing that the general practitioner had foreseen the death of a patient and advised a change of treatment to forestall it, might ask why the G.P. had been overruled. Publicity which would ensue in the national daily newspapers would, I hope, establish in everyone's mind the fact of their entitlement to the attendance of their G.P. when in hospital, and public! demand would possibly shake the general practitioners out of whatever restraint now keeps some of them from our bed-sides when we are hospitalised.

There are some who may say that it would be virtually impossible for G.P.s to spare the time to visit their patients in hospital. I refute this suggestion, for if your Lordships take the trouble to work it out as a statistical figure you will see that it shows that with close on 500,000 people in National Health Service hospitals at any given time, with 24,000 general practitioners on the Register, the figure of patients in hospital for each G.P. would amount to around 21.5. I hope the noble Baroness will check the figures, because my mathematics are not of the best.

The privation I mentioned earlier in my speech is exemplified in the bereavement last year of a family who believe that the death ought not to have occurred. Foreseeing trouble, the family sought to have an operation postponed. The family was overruled by the surgeons, and a mother of young children died. The matter was reported in a national news-paper and correspondence ensued. The original letters are in my possession, and I shall be pleased to hand them to the noble Baroness after this debate, so that she may see them herself. They were not written to me but to a family doctor. I will now quote from a letter written by one of the deceased's sisters. She writes: When I spoke to the consultant surgeon who operated on my sister he became very rude … when I told him about my late sister's family doctor's views he said he was sick of G.P.s telling him what they would do … your sister was my patient while in this hospital. The surgeon's last remark exemplifies a dichotomy that has come into being between the law and medical ethics that operate around us whenever we are committed to hospital.

Ethically, our family doctors are life-long friends whom we have chosen personally. In their turn they choose, supervise and, if unhappily necessary, dismiss surgeons in protection of our interests. It is surely incontestable that this is what we want. And yet, my Lords, the law has so developed as to give the surgeons, strangers to ourselves, dominion over all in hospitals. It happens so much, and it has come to my knowledge that another surgeon at this same hospital succeeded in excluding a general practitioner from the theatre during an operation on one of that G.P.'s own patients. The surgeon has given no reason for his action. Can this be what we really want?

Another sister of the dead mother is a qualified nurse and midwife, married to a foreign national who is a physician and lives abroad. She writes—and I shall now quote a passage from her letter: I fully support your campaign to have the family doctor of all patients in attendance during their stay in hospital. My husband who is a physician feels this, also. This is a time when the patient needs his family doctor most, not only for the benefit of the patient, but also to help the other specialists provide the best medical care for the patient. All too often there are some (surgeons, in particular) who feel that surgery is the answer to every-thing. That is their speciality, they operate day in. day out, but many times cannot see the seriousness of a medical problem that in some cases must be treated first for the welfare of the patient. I believe that my late sister had an acute thrombo-phlebitis on admission to hospital. This would not have happened had my late sisters family doctor been able to see her in hospital. Those who oppose this view must be more interested in their own theory, rather than in what is best for the patient. In the meantime, patients die unnecessarily in hospitals. Surgeons do not keep abreast of medicine, and in some oases do not believe in medicine. My Lords, I have spoken for long enough, and I hope that I have proved my point. It is my earnest hope that specialists will once again get together with general practitioners, for it is my firm belief that the National Health Ser-vice would be very much improved by their agreeing to do so. What specialists need is the family doctor standing in between, receiving the patients' con-fidences and speaking up for them, and interpreting the specialist's pronouncements and intentions in the language of their own homes. If only this could be achieved, then great rewards would accrue. Patients would cease to fear hospitals, litigation would most certainly dwindle, and a medical ombudsman would never be heard of. Patients would take their general practitioners into every department of our hospitals, and thereby keep them up to date far better than lecturers can.

Finally, my Lords, I should like to say that, overall, I feel that Her Majesty's Government have shown great responsibility in the field of national health, and I think it is only fair that we on these Benches should acknowledge the hard work and great research that has been put in by the Secretary of State, the right honourable Richard Crossman, and the Minister of State, the noble Baroness, Lady Serota. If only the Government can devise the means of giving the G.P. the right to visit his patients in our National Health Service hospitals, then they will even improve what is now known as—to quote the words of the noble Baroness, Lady Brooke—" a service which is unique in the world ".

7.15 p.m.

LORD SANDFORD

My Lords, as we look back over our history, I believe, that this nation has many things in which it can take pride; and as we look back over the last twenty years, as the noble Baroness, Lady Serota, did at the beginning of the debate, the birth and growth of the National Health Service is out-standing among the events in which we can take pride. This is the period in which infant mortality has been halved, maternal mortality has been cut by 80 per cent., and deaths of the under-fifteens from scarlet fever, diphtheria, whooping cough, polio and measles have been cut from 800 or so per million to 10 per million. So it is not failure of any sort, or weakness, that brings us to reform and to this debate, but rather pressure to make what is probably the best Health Service in the world a better one still. This is perhaps the moment when those who have worked in the National Health Service or are working in it now deserve our thanks and our praise for what has been achieved and is still being achieved.

But, my Lords, administrative reform, which is what is engaging our attention to-day, is not a panacea. There are two shortcomings with which the Health Service is critically afflicted to-day and which administrative reform will do nothing to solve. I refer of course to the shortage of nurses, whom we do not seem able to get into the Service, and to the shortage of doctors, whom we do not seem able to keep in when we have got them. Nevertheless, I believe that the reforms that are now suggested in this Green Paper will do a very great deal to help in the development of the Service.

The first item to which I should like to refer, and to welcome, is the process of the unification of the three parts of the Service. This is not, of course, a particularly new idea; it was first pro-posed by the Porritt Commission ten years ago. Nevertheless, I think this is the moment to question the criteria by which the benefits of unification are to be judged, and I suggest that there are two primary ones. The first is the needs of the patient, who has not been spoken of very much in this connection to-day. Unification is not worth anything unless it leads to more apt treatment for the condition of the patient being made avail-able to him. The second criterion by which the benefits should be judged is the needs of the citizens themselves—the citizen who pays for the service and needs to be assured that he is getting value for his money, and the citizen who wants a larger scope for his service and a chance to play a full part in it. These, I suggest, are more important as criteria than the needs of the Minister who has to take responsibility for the Service.

Many fears have been expressed, and with good reason, about the degree of further central control which may follow as a result of the implementation of the proposals in this Green Paper. One has only to compare a few phrases from Chapter 6 of the Green Paper with a few paragraphs from the White Paper on the Maud Report to see how these fears arise. In the Maud Report we read a reference to a speech by the Prime Minister in which he said: The reorganisation of local government creates an opportunity, which the Government intend to seize, for achieving the aim of put- ting greater freedom in the way of local authorities. Further down, we read: Reform"— of local government— will bring greater freedom in its train. The Government are also determined to take positive measures to reverse the trend towards centralisation ". That is a statement from one Department of the Government. Here, from the Department of Health and Chapter 6 of this Green Paper, we read, first: The Secretary of State will be fully responsible for all aspects of the administration of the health services "; secondly: The central Department will need to concern itself more closely than in the past with the expenditure and efficiency of the administration at the local level "; and, thirdly: There will be available to the Secretary of State the full range of powers of guidance, and if necessary direction …". So if there are fears about greater central control in the wake of this proposed re-form, it is not hard to see where they come from; nor is it hard to detect in those two Reports a certain ambivalence towards local democracy.

Nevertheless, the proposal to unify the three parts of the Service is to be welcomed. I personally, with some other noble Lords and one or two of the doctors, regret the failure to unite health with social work, in particular, and with other services within the framework of local government. I deplore particularly the break-up of well-established and smoothly working patterns of co-operation between the health and welfare ser-vices which now exist in so many of our local councils. I understand the origin of the doctors' objections, but I must say that they seem to me to be singularly out of date. Their objections surely go back to days before the war, when not only was local government as efficient as it is now but funds were far more stringent than under present conditions. If the doctors' objection is chiefly that of a threat to their clinical freedom, surely the arrangements proposed in paragraph 65 of the Green Paper under this structure are just as valid and applicable to a local authority structure—and I really cannot understand why they are so concerned about this.

I know there is a further argument about finance, but surely, my Lords, the Chancellor of the Exchequer now already collects taxes and disperses to local authorities, for them to spend on schools and education, sums of the same order as are needed to maintain the hospitals and the local health services. But I will say no more now about the subject of schools. On the question of the operation of the health services within a local authority framework, one must of course welcome the matching of the local authority boundaries with the local health authority boundaries, which clearly will iron out a problem that has up to now caused considerable difficulty.

There has been reference during the debate by several noble Lords to the border that is sketched out by the Government in this Paper of the administrative division between the health services and the social work services. As the noble Baroness, Lady Serota, has said, it is indeed difficult to draw the line. I think the way in which the Government have sought to draw it is a good one and can be defended, but if it is difficult to draw the line on paper it is going to be still more difficult to draw it in practice. Yet this is the line which is absolutely crucial for the health of the patient and the welfare of the social work client. It is especially crucial, for in-stance, for the frail, old person who is in care in the community; it is especially crucial for the mentally sick living at home; and it is especially crucial, for instance, for the conduct of child guidance—and one could go on with a number of other points such as these.

I turn now, my Lords, to the scope in this structure for local involvement, concern and participation, and I welcome very much, in particular, the idea of the district committees. I welcome these strictly on the condition that they are given plenty to do, plenty of powers, plenty of resources, plenty of scope for volunteers and voluntary bodies to work with them, and plenty of freedom and independence to use their powers, their resources and their scope in doing what they believe to be best for their locality. I am not among those who argue from that that this can be secured only by statute. I notice that the Government say that the district committees are not to have these powers "conferred on them by statute"—those are the words used. I hope the noble Baroness will be able to explain that these powers, resources and range of activity are going to be conferred upon the district committees, and that, if it is not necessary to do it by statute, it will be done in such a way as to make it quite certain that it is done—because I am quite sure that it must be.

I stress this matter so much because this is the level of local services which corresponds to that covered by the Seebohm teams of social workers; this is the level corresponding to many of the Maud-type local councils; this is the level which will succeed the hospital manage-ment committees—the "self-perpetuating oligarchies" so-called in the Green Paper. I feel that that was an unfortunate phrase to use. It may have been true of a very few, but certainly of the great majority it is most unfair and unfortunate. Specifically in this connection may I ask the noble Baroness: does she envisage that local authorities and local government will have a right to appoint to some of these district committees some of their own officers; for example, members of the social work services? Will members of the Maud local councils have a right to serve on these district committees in the same way as they will have a right to sit on the district committees of the main, local, unitary authorities?

My Lords, the British Medical Journal—unfairly, I would judge—describes these district committees as "mere tools" of the area health authorities, and I fear that they will be just that if they are there only to be consulted. But they need not be "mere tools": they could be the most valuable units in the whole of this new system; and they could play a most valuable role not only in the Health Ser-vice but also in the social work service and in the whole provision of comprehensive, local, personal services of every kind. They could also play a further role in making the whole Service the real care and concern of the man in the street in each local community.

The noble Baroness, Lady Serota, and her colleagues have asked for a wide-ranging and full public debate on the issues raised in this green and white gingham of a Paper. I hope she will agree that this debate has contributed to it. I hope that she and her friends will be able to make good use of it all before she comes back to us later on in her White Paper summer frock, which we shall all eagerly look forward to seeing and which we hope to be able to admire as much as we admire the wearer.

7.29 p.m.

BARONESS SEROTA

My Lords, may I first thank the House for the way in which the Green Paper has been received. I may have a slight bias, but I think in many ways it has been a model debate. We have had some 18 or 19 speeches, speeches which I have found both in-formed, brief and to the point. I think that this is one of the areas where your Lordships have from your own experience so much to contribute and are understandably anxious that the Secretary of State and I should know your views at this early stage. All noble Lords, with the exception of Lord Milverton and Lord Sandford, have ex-pressed support for the decision in the Green Paper that the National Health Service should be integrated but outside local government. If both noble Lords will forgive me, I do not intend to take the time of the House in going back over the arguments which I made at the out-set.

Turning now to the three main areas that have been concerning your Lord-ships, I should like first to deal with the range of subjects which turns round the proposed regional councils, district committees, voluntary involvement and participation at community level and last, but certainly not least, what I called at the outset the grass roots, the basis, of the Service, the role of the family doctor in an integrated Service. Many noble Lords have expressed some scepticism about the proposed function and constitution of the regional health councils. I can assure the House that this is one of the areas, as my right honourable friend pointed out at the beginning of the Paper, that is truly green; and we shall be considering everything said in our debate to-day with great care and also continue this discussion in the light of the comments and consultations that we are having on the Green Paper.

I should stress now that our thinking was based on the principle that there should not be a whole span of regional administration imposed on area health authorities. We were anxious—and here I join hands with the noble Baroness, Lady Brooke—that the general principle for the Service should be that the area health authorities would have maximum devolution of responsibility direct from the centre. Here one comes to the problems which several noble Lords have raised about the role and function of the central Department in the new structure. It is true that as our proposals stand at the moment the central Department itself will assume certain functions that at present rest with the regions. Most important among these, as one noble Lord mentioned, is the programming, planning and extension of our major building schemes and the control of the budgets of the area health authorities. Some noble Lords have suggested that these functions threaten to make the Government's claim that the responsibility is being decentralised an empty one —this was a point that the noble Lord, Lord Sandford, made—and that, contrary to what we are claiming, too much authority was now being drawn into the Minister's hands. It seems to me that this particular suggestion is misconceived.

What is needed, and what we hoped the Green Paper would provide, is a redefinition of roles in the light of the reorganised structure that we propose. Most noble Lords I think will agree that the essential role of the central Department is to set standards and priorities in health care, to ensure a fair distribution of the available resources between the areas and to see that common policies and priorities are pursued in these areas. This must necessarily mean the Department determining budgets and also supervising other capital spending, as it does to-day through its regional boards. But I agree with the noble Lord, Lord Amulree, that the execution of national policy and decisions on means and methods must be sorted out locally and flexibly and experimentally. These things must be decided in Liverpool and Bristol or any other part of the country that is trying to provide services that are designed to meet the needs of local populations; and quite clearly, as we all know, the needs do vary.

We believe that the proposals that we have set out will give our area health authorities a much wider scope for independent decision over a much wider range of service than, for example, our hospital management committees have to-day. I have served on a hospital management committee and I know the problems involved and the work that this involves. But so often one comes up against the divisions that exist in the Service and one is unable as a hospital authority to have the links with the local authority services which we all know are absolutely essential if we are to provide services to meet the whole needs of a person. I would agree with the noble Baroness, Lady Brooke, in her desire to see strong district committees. The insertion of the district concept below the area health authority is not any kind of sop to public opinion, if I may put it that way. Both the Secretary of State and I are convinced that in areas in which there will be sometimes over a million people it is essential that these services, of all services, should be truly sensitive to local opinion.

The basic organisational unit in the integrated Service will be the district general hospital and the community ser-vices around it. We see these committees as sub-committees of the area health authority. They would have the vital, day-to-day job of supervising the health services of their districts on behalf of the area authority. We have not yet worked out their precise membership or their detailed functions; but they will certainly include members of the public and members of the health professions working in the district.

There was, I thought, some conflict here between the noble Lord, Lord Grenfell, and the noble Lord, Lord Milverton. One wanted greater professional participation and the other wanted a greater proportion of elected members. These things we shall have to hammer out in conjunction with Government thinking on the Maud districts because, as I have pointed out, we are trying to look at the provision of social services over a whole range of need and trying to create an interdependent set of services as opposed to those in conflict.

Also at this level we see great potential for development of the domiciliary ser-vices and voluntary services which the noble Baroness, Lady Reading, talked about. No one could speak with greater eloquence than she on this subject, nor with a greater practical knowledge. I hope that she felt that the section in the Green Paper which deals with voluntary organisations adequately met the kind of problem that she and her members are facing in the field. 1 believe that in the development of the health and personal social services, the voluntary organisations have a unique role to play and they will be able to extend their activities over the frontiers between the services. I can only say here that where voluntary organisations are anxious to talk and wish to consult with the Department, both the Secretary of State and I are always willing to hear their views on how their role can be extended and developed in the new Service of the future.

The second main area of concern— and this I must say was not unexpected when one saw the list of speakers—was the future of our great teaching hospitals, the undergraduate and the postgraduate hospitals. I can only assure the House that we shall take the most special care to see that the unique contribution of the teaching hospitals and their developing district responsibilities will not be lost to (he National Health Service. Where a teaching hospital forms part of an area health authority the university will have special representation on the authority, in addition to the proposed one-third directly appointed by the health profession. To answer the point made by the noble Lord, Lord Cobbold, I can assure the House that in approving programmes of capital and revenue expenditure of area health authorities the social department must and will ensure that proper account is taken of the needs of the medical and dental teaching services, and indeed of the research within them.

I was delighted that all noble Lords with experience of teaching hospitals who spoke to-day stressed the growing role of their hospitals in co-ordinating their services with the community services and enlarging their district responsibilities. Here we are moving together in the right direction, and we also intend to see to it that the move further along this road is not in any way detrimental to the role of the teaching hospitals in teaching research. Noble Lords will know that the Todd Report on Medical Education specifically advocated that it was to the benefit of the teaching hospitals and the rest of the Health Service that we should move together in this direction.

The noble Lord, Lord Cobbold, rightly pointed out the very special situation that exists in London, and he illustrated, from the proposals in Appendix I of the Green Paper, the difficulties that his teaching hospital in North-West London would face in connection with the proposals for London sketched out in the Appendix. I assure him that we are only too conscious of the complexities of the London situation. We are setting up within the next ten days or so a working party, which I shall chair, to bring into consultation the whole range of interests concerned with London, including the local authorities, the Regional Boads; the Teaching Hospitals Association; executive councils, the Inner London Education Authority (which has a special responsibility in relation to school health), and the University Grants Committee. I hope that together, round the table, we shall hammer out some kind of order from what we all know to be the chaotic provision of health services in the Metropolitan Area.

The noble Lord, Lord Cobbold, asked me to clarify the Government's position in relation to the trust funds which many teaching hospitals, and some non-teaching hospitals, have, and with which they have been able to provide amenities for patients and enlarge their buildings. These funds were generously donated by members of the public in the past. This is another matter for consideration, and we accept that it is most important to respect the very special nature of these gifts. I know that noble Lords will not expect me to go beyond this to-day, but I hope that the assurance of consultation will relieve the minds of noble Lords who have appealed to me to make some statement.

I should like now to return to the community services and to endorse the tribute paid by the noble Lord, Lord Vivian, to the family doctor and his relationship to the hospital service. I will not answer the case mentioned by the noble Lord, who has sent me the papers on it. One of our objects is to reinforce the trend of bringing hospital services and general practitioner services closer together. We want to see general practitioners participating, as so many of them are already, in our hospital medical centres. We want to see that our hospitals provide diagnostic facilities for them, and that they have a direct partner-ship in hospital work.

Several noble Lords touched on different aspects of the community services. The hour is a little late and I might try your Lordships' patience, if I were to deal with them in detail. But I will say that there have been long and hard months of trying to evolve a coherent pattern for our health and social services; to bring together those who should be together and to provide for an interdependent set of services. Every noble Lord who has spoken realised the difficulties and was reasonably content with the pattern that we have provided. It is in this way, as was said by the noble Lord, Lord Sand-ford, that we ought to be able to meet the needs as a whole.

The noble Lord, Lord Soper, mentioned the unmarried mothers, and the noble Lord, Lord Stonham, spoke of the needs of the handicapped. We hope that the reorganisation of the health services and the personal social services will bring together the skills needed to assist people who need social care or support, or medical care, or psychiatric provision, or continuous nursing care.

The noble Baroness, Lady Brooke, reminded us of what will be a difficult period for the medical officer of health, and the remaining part of the local authority health department, during the interim period between, on the one hand, the implementation of the local authority Social Services Bill, and, on the other, the implementation of the reorganisation of local government and the restructuring of the National Health Service. The Green Paper encourages staff in the local authority health services to look towards an integrated Health Service. Already we are in the process of setting up a working party on the role of the community physician. After all, the medical officer of health is the historic officer in local government. That is how local government started, with the development of the public health service; and one sees a continuing role for him, but in a different setting. In the two or three years to come we must be conscious of the difficulties that he and his staff will be facing.

In conclusion, my Lords, I should like to touch on a point which, much to my surprise, has received little attention in the debate. Tributes have, of course, been paid to the staff of our National Health Service, and to the many volunteers who work within it in management and other fields. But no one, except the noble Viscount, Lord Addison, referred specifically to the very important implications that our proposals have for the staff. I would assure the House that this is a matter that is very much in the forefront of our minds. It is one which we shall need to discuss with the staff interests, because the changes we are suggesting are major changes. We say in the Green Paper that there will have to be a National Staff Commission, and I believe that this will have to be set up well in advance of making changes in order to consider what will have to be a very careful process of staff change and reorganisation. It will be a prime responsibility of the Department and of the Government to see that the skill and the experience of those who are in posts are used to the fullest possible advantage.

This will be a period of great anxiety for many members of the staff, but I am sure that, if they believe in the principles of the reorganisation of the Service on the lines we suggest, they will be able to readjust to the changing pattern. I did not want to conclude without mentioning the effect on staffs, because, while it is easy for us to sit on our red leather Benches and talk about the great changes in the National Health Service, for the thousands of members of staffs these changes may in some cases, mean change of job, change of home and change of a whole way of life, if they are to serve the needs of the people in the ways we are now suggesting. I should like to thank the House once again and to say that we will certainly take note of all that noble Lords have said. This has been a most helpful debate, and part of the wider debate we shall now be continuing in association with a wide range of organisations and individuals within the Service.

On Question, Motion agreed to.