§ 2.45 p.m.
§ THE MINISTER OF STATE, DEPARTMENT OF HEALTH AND SOCIAL SECURITY (LORD ABERDARE) rose to move, That this House takes note of the Consultative Documents on the National Health Service Reorganisation in England and Wales. The noble Lord said: My Lords, I very much welcome the opportunity to introduce this debate this afternoon and to consult your Lordships on the proposals for the reorganisation of the National Health Service. It is never easy to choose the right moment to hold a debate of this kind, but I believe that we have chosen the right moment this afternoon. The Consultative Documents for England and Wales are just what they say—consultative—and we are still engaged in consultations. We have received a tremendous amount of written evidence from a very large number of interested organisations, and my right honourable friend and I are now engaged in further meetings with many of them to clarify the issues and to ensure that we have taken the full import of their advice. To this process I am sure 7 that your Lordships' House has a great deal to contribute and I therefore very much welcome this debate and am most grateful for the large number of your Lordships who intend to speak this afternoon.
§ I have received two specific regrets from the noble Lords, Lord Rosenheim and Lord Normanby, both of whom are extremely well qualified to speak, and I know that we shall all regret their unavoidable absence. The views that your Lordships express this afternoon will be given the most careful consideration. Because of the number of speakers in the debate it may well be that I shall not be able adequately to deal with a number of points that are made. I hope therefore to be forgiven if I do not deal with certain specific points, but I promise that they will all be considered and that where there are questions to be answered we will answer them in writing.
§ We have already announced that unification of the health services will take effect in April,1974, to coincide with the new local government reorganisation. We intend to publish a White Paper about the middle of next year, but before that my right honourable friend will be making announcements about particular matters such as the future boundaries of health authorities and arrangements to safeguard the interests of those working in various branches of the Service. My right honourable friend the Secretary of State for Wales intends to follow a similar timetable. There may be some impatience at the time-consuming process of consultation and study, but the National Health Service, with its three-quarters of a million staff, is an enormous and complex enterprise. It is most important that we get the administrative structure as nearly right as possible, and to do this it is essential that we use the experience, wisdom and ideas of those running the Service and take full account of the reaction of the public for whom the Service exists.
§ The consultations that have already taken place have in fact produced a great deal of constructive criticisms that will enable us to improve on the framework outlined in the Consultative Documents. Improvements in the management of the Service can come about only through a 8 close working partnership between the central Departments and those working in the field, with a continuous flow of information and ideas between them. In the separate English and Welsh Management Studies, for example, detailed investigation and analysis is being undertaken by study groups consisting of departmental officials, management consultants and National Health Service officers, reporting to a Steering Committee made up of senior officials, National Health Service members and officers and outside experts. On the basis of preliminary investigations, these teams are formulating provisional proposals for management and for the internal organisation of health authorities, which will then be tested, and where necessary modified, through detailed field investigations.
§ The Joint England/Wales Working Party, which has been set up to advise on the ways in which health and local authorities can best co-operate, offer one another assistance and complement one another's services, is chaired by a Deputy Secretary from my Department and its members are drawn from local government, the National Health Service and the Government Departments principally concerned, including of course the Welsh Office. Local authority associations readily responded to the invitation to nominate representatives and have indeed themselves been pressing for a joint study of this kind.
§ This Working Party, when it met in August, set up three sub-committees to study in detail particular aspects of collaboration and a steering committee to co-ordinate their work. The tasks of the sub-committees are to examine respectively the personal social services, environmental health in relation to the National Health Service and future arrangements for the school health service. At a later stage special studies may be made of other matters such as the effective and efficient use of staff, buildings and other resources, the financial implications of collaboration and the application to London of arrangements recommended for the country as a whole.
§ The London Working Party, of which I am chairman, has the same wide spread of membership as the group established by the previous Administration, which will be well familiar to the noble 9 Baroness, Lady Serota. Its examination of preliminary proposals threw up important issues of principle affecting the teaching hospitals, which have been examined further by the Department. My right honourable friend and I propose to discuss these with representatives of the London and provincial teaching hospitals and following this we shall put revised proposals to the Working Party. As conclusions emerge from all these studies there will be consultation with the interests involved, including consultations with the staff interests on matters that affect them. My Lords, I have dealt in some detail with these studies since the comments that we have had on these Consultative Documents have contained a good deal of speculation about them and the way in which they are working.
§ There has been some criticism of the brevity of these Documents and their preoccupation with effective management. We did not set out to provide a comprehensive treatise on the National Health Service, but we concentrated on those aspects where our proposals differed from those of the previous Government's Green Paper, and those that required legislative decisions. This does not mean that we have lost sight of the doctor or nurse at the patient's bedside, but the doctor and the nurse can no longer work in isolation. The needs of the patient require them increasingly to work as part of a complex health and social service team; they need the support of a wide and often costly range of facilities, supplies and services. Since the needs and opportunities for improvement in health care universally outstrip resources, priorities have to be ordered and services co-ordinated to achieve the best results with the money and people available. Here lies the role of management. Organisation is a part of management and effective management is therefore the dominant theme of these Documents dealing with the reorganisation of the National Health Service.
§ It has been suggested that there is something incompatible between effective management and the kind of treatment and care that patients need. In my opinion this is based on the false assumption that effective management must be equated with some narrow concept of industrial management. The application of modern management techniques has 10 brought, and will increasingly bring, benefit to the National Health Service, but the style of Health Service management must clearly be geared to its basic aims of providing a high standard of treatment and care and must be adapted to the requirements of a predominantly professional service. Health Service management which is not concerned with the needs of patients as individuals is not achieving its objectives and is certainly not effective. It is the patient who gains from efficient management and the patient who suffers, if, for example, through ordering of priorities his admission to hospital is delayed, or if he is kept in hospital longer than is necessary because community services have not been developed and co-ordinated to meet his needs.
§ To achieve effective management in a service as large as this, it is clearly essential to decentralise decision-making. At the same time Ministers have to discharge their responsibility to Parliament for a centrally financed service. The Consultative Documents therefore stress the importance of combining the maximum delegation downwards with accountability upwards.
§ Area health authorities are to be the operational units responsible for planning and organising comprehensive health services. This is an essential part of the management structure, both in the functioning of the Health Service and in enabling close collaboration between the Health Service and local government at area and county level. But resources have to be allocated between these authorities, their performance monitored and their activities co-ordinated, and some services need to be planned or organised on a wider basis than an area. In England, the size of the country and the number of authorities is such that these tasks cannot adequately be performed from the centre. A regional organisation is needed and we believe it can best be run by people from within the regions rather than by civil servants. We have therefore proposed the establishment of regional health authorities with boundaries corresponding broadly to the present hospital regions.
§ In Wales, on the other hand, because of its much smaller size there is no need for a regional authority. The area authorities will be few enough to permit 11 a satisfactory relationship between them and the Secretary of State, to whom they will be directly accountable. There are. however, various executive functions which area health authorities might discharge but which for maximum efficiency, economy and expedition are best carried out for all Wales. For example, the design and execution of major capital works, the provision of computer facilities and specialised management services. In England, these are likely to be undertaken by regional health authorities, while in Wales it is proposed to set up a Welsh health technical services organisation, accountable to the Secretary of State through a small managing board, to serve both the area health authorities and the Secretary of State.
§ These proposals have been widely accepted by bodies commenting on the Consultative Documents. More controversial have been the proposals that we have made on membership. We have proposed that area health authorities should normally have 15 members, including the chairman, and that most of them should be appointed by the regional health authority, after consultation with interested organisations, including the main health professions. There would be at least two doctors and a nurse or midwife on each area authority, because these professions are involved in virtually every aspect of the provision and management of health services. There would also be representatives from the corresponding local authority. The selection of the other members of the area health authority would be influenced by their potential contribution to the management of the service.
§ The members of the authorities will set the policies and provide the leadership. Executive management within the agreed policies will be the responsibility of their officers. A strong management structure will be matched by strong professional advisory machinery and effective public representation. The Documents envisage that professional advisory machinery will be established at both regional and area level. This proposal has been widely welcomed among the health care professions, and we are actively studying ways in which it can best be implemented. The medical and nursing professions are also considering the sort of 12 advisory machinery which might most effectively bring their experience to bear on the decision-making processes of the health authorities.
§ The public will be represented in the new Service by the community health councils. There has been some misunderstanding about the councils' place in this scheme that we have in mind. They will not be ineffectual bodies whose views can be disregarded by the health authorities. On the contrary, we intend that they should confront the area health authorities with the views of the local communities, so as to ensure that the authorities take the fullest account of those views in running and planning their services.
§ Most health areas will need to be subdivided into districts for management purposes, and since local interest and concern will centre on the district services, rather than those for the area as a whole, there will normally be a community health council for each district. The power of the community health councils will have to be effective. They will be consulted and asked to advise on area plans for health service developments, including proposals for major variations in the pattern of services affecting patients in the district. I am thinking of such proposals as those to close hospitals or parts of hospitals, to change their use or to introduce new services, and the siting of hospitals and health centres. The councils will be entitled, on their own initiative, to express their views on the working or development of district services.
§ LORD AVEBURY
My Lords, will the noble Lord forgive me? He has mentioned the closure of hospitals, on which at the moment the Secretary of State has to give approval, and he said that the community health councils would be asked to express an opinion on this. What obligation will there be on the Secretary of State to pay any attention to their views?
§ LORD ABERDARE
My Lords, it would be a strange Secretary of State who did not pay attention to all the views expressed on these matters. This happens at the moment. As the noble Lord will know as an ex-Member of the other place. Members of Parliament are consulted, too, and the Secretary of State 13 gives most careful consideration to all the views expressed on these sorts of matters. But in this case the community health council will have a preliminary chance of expressing their views on the plans put forward by the area health authority long before the proposal reaches the Secretary of State. Their members will have the right to visit hospitals and other National Health Service institutions. They will be provided with accommodation for their meetings and secretarial help, and they will publish reports on their work. The suggestion has been made that area health authorities might be obliged to publish a formal reply to reports by community health councils. This would certainly ensure that attention was paid to their views, and we are carefully considering this point.
In the Consultative Documents it was suggested that area health authorities should appoint the members of the community health councils. It has been pointed out since, I think with some justice, that such a method of appointment might weaken their effectiveness in working on the community's behalf. My right honourable friends have open minds on this. They have suggested an alternative possibility: that some members might be appointed by local government and that others might be drawn from voluntary organisations and consumer bodies. We are very ready to listen to any views on the membership and functions of these councils which will help to make them effective organs of informed community opinion. We are confident that, given the right organisation, they can secure public participation and provide a spur to good management much more effectively than would be the case if there were an uneasy mixture of management and representational elements on the governing bodies themselves.
My Lords, there are other themes in these Documents on which noble Lords may wish me to comment, and I hope that at the end of the debate I may be able to say something about some of these matters that are raised. But I should like before I conclude to refer to the important implications for the staff of the Service. We owe them a great debt for the efficiency and humanity with which they have played their part in the existing National Health Service, and it is, 14 after all, on them that the success of reorganisation will very largely depend. Most of the staff will continue to do the same job in the same place. Within the family practitioner services the contracts of the general practitioners, dentists, pharmacists and opticians will remain unaffected. There will, however, be the uncertainties of changing to new authorities, and for many staff, particularly those engaged in the administration of the present services, there will be some measure of change, perhaps substantial change, and there will certainly be a great deal of work.
For reorganisation to achieve its objectives, it is clearly essential that staff should know that their interests arc being properly safeguarded, and that they should be kept informed not only of the measures that are being taken to assure their future but also of the decisions that are being taken on the pattern of the Service. This is a task in which we welcome the co-operation offered by the unions and staff associations concerned, and it is our intention to keep in close touch with the Staff Side at all stages. Last month my right honourable friend met the Staff Side of the General Whitley Council and discussed the general staffing implications of reorganisation and arrangements for consulting the staff interests and keeping them informed as the planning of reorganisation proceeds. Particular matters for discussion will include compensation and protection for transferred staff.
On October 29 we circulated to staff and management interests a consultation paper outlining our proposals for staff reorganisation. As my right honourable friend said in another place on July 1, we intend to appoint National Health Service Staff Commissions in preparation for the reorganisation. They will be responsible for advising on the procedures to be used for filling, in particular, the more senior posts in the new bodies, and on measures to safeguard the interests of staff. The Commissions cannot be set up in statutory form until the necessary legislation has been passed, but my right honourable friends intend to appoint an Advisory Committee to undertake preparatory work pending the appointment of the statutory Commissions. They would be similar to the body that proved so useful in London government reorganisation, and to the new 15 bodies for local government proposed to be set up under the Local Government Bill. We are consulting the interests concerned about this and we shall listen very carefully to their comments.
The proposed National Health Service structure will, we believe, supply the framework within which real advances in the integration of health services can be achieved. It will not of itself produce integration, but it will establish area health authorities whose task it will be to develop a balanced and integrated service, and it will have the management structure and advisory machinery enabling them to fulfil this task. The new structure will not in any sense be the present hospital service writ large, much less a takeover of the community services by the hospitals. The importance of preventive medicine, of the general practitioner and of community services generally will increase. To translate this generalisation into effective working arrangements of benefit to the patient is a formidable task, and in carrying it out area health authorities will need to make the fullest use of the energies and imagination of the present staff of the service. The present local authority administrative medical staff will have a key part to play in their new role of community physician. For them, as for other Health Service professions, reorganisation will present a great challenge and offer enhanced opportunities.
My Lords, our role as legislators in the health care of the nation is a limited but important one. Legislation cannot of itself create the kind of Health Service we want, but it can either place obstacles in the way of the most effective pattern of health care, or it can provide opportunities for, and stimulus to, progress. Our aim is to develop a legislative framework that will remove the obstacles which present legislation has placed in the way of effective integration of health services and their co-ordination with local authority services, and will at the same time provide the foundation for more effective management and deployment of resources. My Lords, I beg to move.
§ Moved, That this House takes note of the Consultative Documents on the National Health Service Reorganisation in England and Wales, —(Lord Aberdare.)16
§ 3.12 p.m.
§ BARONESS SEROTA
My Lords, may I first thank the noble Lord, Lord Aberdare, for giving us this opportunity to discuss the fundamental organisation and administration of one of the greatest of our social services, affecting, as it does, the present and future health and wellbeing of every man, woman and child in the country, and also for his very careful and clear exposition of the Consultative Documents setting out the Governments proposals for a new and unified Health Service structure.
Although his right honourable friend the Secretary of State asked for comments on the Consultative Document that he issued on May 17 by the end of July, thus giving organisations a bare 10 weeks in which to make their views known on these vital issues, I was very glad to hear from the Minister that the observations which noble Lords will be expressing to-day from their considerable experience of many different aspects of our health care system will not be too late to affect Government decisions and the principles on which the White Paper (which we now understand is to be issued some time in the middle of next year) and the subsequent legislation will be based. All I would say is that if there is in fact time for our comments to be taken into account it is, in my view, even more regrettable that all the many interested organisations were not given a more reasonable period of time in which to submit their considered views. I am sure they will be glad to have the reassurances that the noble Lord has given us to-day.
Like the Minister, I do not intend to rehearse again the overwhelming case for integration, or for the need to match an integrated and unified Health Service geographically to the proposed new local government system embodied in the Bill which is already under consideration in another place. Your Lordships will recall that we debated these subjects in considerable depth, and at some length, only 18 months ago when we were considering the second Green Paper setting out the proposals of the previous Administration. Two successive Governments, regardless of Party, have now agreed on the need for change, after more than a decade of public debate. I certainly am convinced, and I believe most other noble Lords 17 who are speaking in the debate are convinced, that it is essential, at this stage in their development, to unite the three main streams of health care on the one hand, and the formerly fragmented personal social services, on the other, and to develop them into coherent and complementary community-based and nationwide systems of health and social care which can respond sensitively and flexibly to the total needs of the individual patient, and develop services in which the prevention of ill-health and the prevention of social distress and breakdown can receive a new emphasis, and in which patient and consumer benefit are the paramount objectives.
The question, therefore, for us to-day is whether the Government's proposals will achieve this. In so far as they endorse the principle of integration and the need to match the unified Health Service geographically with the new local authorities at least at area level, as indicated in paragraphs 3 and 8 of the Consultative Document, there are no differences between us. So I would only thank the noble Lord for giving us to-day some indication of the composition and methods of working of the Working Party set up by his right honourable friend to consider in detail the crucial and difficult issues involved in this collaborative exercise. I would simply ask him whether, when they have come to the end of their deliberations, their Report is to be published for all of us to see in due course.
Here, I am afraid, is where the area of agreement ends, both on matters of principle and in their general application. I personally found the Consultative Document flimsy in every sense, from the principles on which it was based to its actual physical presentation. After almost a year of preparation it is sketchy, vague, and, above all, completely inhuman, and so dominated, almost to the point of obsession, with the term "management" that the patient is not even mentioned once. I know that the noble Lord has to-day changed the note, if perhaps not the tune, but I so well recall the noble Baroness, Lady Brooke of Ystradfellte, in the debate to which I have just referred, reminding us, in her usual forthright way, that, "It must never be forgotten that the Service is for the patient and not for the administrator". I am sure we are 18 all looking forward to hearing from her further to-day. Her range of knowledge at regional board, hospital management committee and local house committee level is such that I am sure she has a great deal to contribute to the future of this great Service.
When I had read the word "management" almost thirty times, I began to wonder how one could use one word to mean so many things and I was eventually reminded of Humpty Dumpty saying, in Alice Through the Looking-Glass:When I use a word it means just what I choose it to mean, neither more nor less.The noble Lord has sought to explain at the outset of our debate just what he and his right honourable friend mean by the words "management" and "effective management" in an all-pervasive and universal social service like the National Health Service, but I should still like to ask them how they intend to measure performance. Will it really be in terms of patient benefit? I deplore the apparent intention—although the noble Lord again has sought to correct it to-day—merely to borrow direct management techniques developed for industry and commerce, on the assumption that they will necessarily produce better services for sick people who, above all, must be seen and treated as individuals in their family and neighbourhood setting. Are the commercial profit and loss tools of measurement relevant or even applicable in this context, or is the "lame duck" principle going to be applied, under the new dispensation, to those parts of the Service that are not regarded as viable? I am not surprised at all that there are some members of the health profession who are concerned about their clinical freedom in the brave new management-dominated Service outlined in the Consultative Document. Surely we need to develop quite new tools of measurement for measuring effectiveness in a social service. I hope that this is one of the matters to which the expert study group, to which the noble Lord referred, will turn its attention.
Of course we shall all agree that the more effective use of resources through good management must be one of the major objectives of a public service which makes immense demands on skilled manpower and scientific equipment as it continues to develop. But management is not my Lords an end in itself: it is 19 only a method of achieving defined objectives and implementing chosen priorities. Since values ultimately determine policy, the real question surely is: who is to define the objectives and decide the priorities? Should they be people responsible to their professions and to the public, or should they be individuals appointed purely for their management ability and accountable solely to Ministers?
The noble Lord reminded us that the Consultative Document states fairly—I would say it almost boasts too loudly—that the essential basic difference between this Government's proposals and those of their predecessor is the emphasis they place on effective management; hence the almost total exclusion of direct professional and democratic participation in the planning and day-to-day running of the Service, both at regional and at area board level; and hence the decision in paragraph 16 to continue the present unsatisfactory and completely undemocratic system of Ministerial appointment to the proposed new regional authorities, compared to the Green Paper, Mark II, proposals to create area boards comprising one-third nominated by local authority members, one-third by the health professions and one-third only appointed directly by Ministers for their special knowledge and experience of the Service itself. Now, apparently, the area boards are to comprise some local authority members—the number is still unknown; one from the university, and two where they include a teaching district, and the rest, as the noble Lord reminded us, appointed by the regional authorities.
I was very glad to hear that the noble Lord and his right honourable friend have taken note of the widespread criticism which they have received on this aspect of their proposals. But we are told in the Consultative Document that the reasons why the Secretary of State considers it inappropriate for the new health authorities to be composed on a representational basis, as outlined in the Green Paper Mark II proposals, are because they…will have important and complex management functions to perform, demanding of their members skill and experience of a sort that will enable them to give guidance and direction on regional or area objectives to their staff…20It would therefore be inappropriate for the authorities to be composed on the representational basis…Like many of your Lordships, some of whom will be speaking in the debate to-day, who have served as members of local authorities, I take the greatest exception to the thesis that democratic control and efficiency are, by definition, incompatible in a public service. If we really believed that, thousands of people throughout the country would not give voluntarily of their time and energies to providing and seeking to improve services such as health, education and housing for the communities they represent. If we really have no faith in the efficiency of democracy, why on earth do we have local government at all, and why are we about to reform and revitalise it? If, as the noble Lord said, management ability is to be the criterion for selection and appointment, can the noble Lord perhaps describe to us the kind of person he and his right honourable friend have in mind?
For example, would a mere housewife who is presumably concerned with the day-to-day management of her home and family, qualify? Does the noble Lord really think that people of the high managerial ability that he appears to be looking for will give the time needed to manage the Health Service without any payment whatsoever? I recognise that it is really the dominant Treasury concern, to continue direct central control over public expenditure financed by taxes and contributions, that lies at the heart of these proposals. But I believe, in spite of all the noble Lord said at the outset, that they are based on a total misconception and confusion of the policy-making role of the appointed or elected members on public bodies, and of the day-to-day management functions of the full-time administrative and professional staff.
I shall not detain the House by enlarging further on this major point of difference, but I sincerely hope that the Minister and his right honourable friend will take account of the very widespread criticisms which they are receiving on every side, regardless of Party, from all who are concerned with the future development of the Service, and will think again 21 about the membership of these authorities. In spite of the noble Lord's reassurances, I still find the proposed membership and functioning of the community health councils, as described in paragraph 20 of the Document, toothless and vague and really lacking any real powers. Furthermore, they are surely no true substitute for real local participation in the administration of health services, as set out in the proposals in the Green Paper Mark II. As to the suggestion in paragraph 20 that, in the present Government's view, our proposals would leadto a dangerous confusion between management on the one hand and the community's reaction to management on the other,I can only say that I must be used to living dangerously, because surely this is exactly what democracy is about.
The other main area outlined in the Consultative Document, apart from the proposed structure and organisation in this very crucial issue of membership of the new Health Service authorities, on which I wish to touch to-day concerns the all too brief and vague references in paragraphs 21 and 22 to the future of the family practitioner services. They are, without doubt, the absolute foundation of any progressive Health Service which seeks to be community, rather than hospital, oriented and dominated. I hope that the Government will give full consideration in this context to the two excellent Reports which have recently been published, one by the Secretary of State's own Central Health Services Council's Sub-Committee on Group Practice; and the other by the Planning Unit of the B.M.A. on Primary Medical Care, which set out in some detail the way forward in this field. The objective here must surely be to enable the family practitioner to provide the essential continuity to the health care of each individual patient and family, with his health team mobilising the range of services needed for both caring and curing across the administrative frontiers.
The main growing point here is the development of group practice and health centres. The last Government's health centre building programme resulted in the 17 health centres that we inherited in 1964 being expanded to some 191, with a further 99 under construction and 69 22 in planning stages. I was delighted to hear the noble Lord tell us last Monday, that some of the additional £118 million which his right honourable friend has cleverly managed to extract from an always unwilling Treasury is to be spent on the development of health centres. I hope he will be able to tell us at the end of the day just where the Government see the health centre building programme in terms of priorities, and whether they are prepared to continue the previous Government's policy of never refusing loan sanction for a viable health centre development.
I looked in vain in the Consultative Document for a sign that relationships and attitudes between family doctors and hospital doctors were as powerful an influence for the changes which we consider necessary in the pattern of health care as the administrative structure, but merely found instead the somewhat ambiguous and rather vague references to the general practitioner's contractual relationships being exercised through a separate statutory committee at area level, with direct links with central Government for finance, and to the fact that the area health authority would be closely concerned with plans for the development of the general practitioner services. This scarcely sounds like the integrated community-based system we all believe to be necessary if we are to develop the more balanced and more effective services in the community. Can the noble Lord tell us, for example, whether any family doctors as such will be appointed to the new regional health authorities, where the critical decisions under this dispensation are undoubtedly going to be made; or, are they merely going to be relegated to their own separate statutory committee?
My Lords, there are many other matters that I should have liked to mention, but although our new clocks have not yet been installed I am very conscious of the large number of noble Lords waiting to speak and I have little doubt that they will take these matters up far more effectively than I could. When discussing the future of the Health Service, like the noble Lord I am always deeply conscious of the great numbers of men and women whose skill and services are essential to. its very existence, let alone its future development. Fortunately, the Briggs 23 Committee will be reporting, I hope some time this year, on the results of their study in depth on the role and function of the nurse in the integrated service of the future; and I know that my noble friend Lord Garnsworthy will be speaking later on in this debate, from his great knowledge and experience, of the problems of reorganisation as they affect staff and as they affect training, basic and in-service, inter-professional training and, indeed, about the Whitley system, which was the subject recently of an Unstarred Question in this House.
To my mind, some of the most serious omissions of all include the lack of any reference to the need for a Health Commissioner or similar machinery to deal with complaints, especially after the recommendation of the committee which inquired into Farleigh Hospital and which reported only last April thata health commissioner, given the widest possible powers, should be appointed urgently to meet public anxiety about the investigation of complaints in the Health Service".Nor is there any indication from the Government whether they intend to recognise the remarkable and outstanding achievements of the Hospital Advisory Service, under the able direction of Dr. Baker, by extending similar services to other hospitals and health service institutions in the new Health Service in the future. I have mentioned only a few of the areas where the Government's proposals fall short of creating the truly integrated and consumer-oriented service which we all wish to see; and my noble friend Lord Champion, who will be speaking later on to-night, will be dealing specifically with the proposals in the Consultative Document as they relate to Wales. I am certainly envious, my Lords, of their proposed one-tier system, with the areas being the prime units both for planning and for providing the services, their budgets being directly allocated by the Secretary of State.
I would only conclude by expressing my very deep concern that we should not lose this opportunity, which may not occur again for many years, to create a truly flexible and modern comprehensive service for future generations. I was glad, therefore, to hear from the noble Lord that this is a truly Consultative Document, and that the Government have taken note, are taking note, and will con 24 tinue to take note of the widespread criticism it has received, and are prepared to think again before we see the promised White Paper on which the legislation will be based.
§ 3.34 p.m.
§ LORD AMULREE
My Lords, like most other noble Lords in this House I, too, welcome the idea that the National Health Service is to be integrated into one, and I was hoping that when this Document came out it might contain a little more detail than it does of the way the integration is to be brought about. But I am bound to say that I read the Document with a feeling of considerable disappointment, because its views appear to be rather limited and. though possibly one is asking too much at the present time, there appears to be singularly little reference to patient care. My Lords, we must not exalt the management expertise above all clinical experience, because I am sure your Lordships will agree that it is the work and the morale, as one might say, of the individual doctor, whether he is working in practice, whether he is working in the hospital service or whether he is working in the community service, that will really determine the success of the Health Service in the future.
Perhaps I am wrong—perhaps I read more into the Document than I should —but I wonder whether management ability should be, as it appears to be, almost the sole criterion for the selection of the members of the health authority. Management surely must be coupled with some knowledge of the needs of the area and with independent sources necessary to decide in what kind of way these needs can best be met. Therefore I hope it will be true that the majority of the members of the authority will be taken from among local people. As to whether they be appointed by local authorities or not, I have no particular views, but I think they should certainly come from among local people, with knowledge of what the local needs are in their part of the world. That is why I rather regret the disappearance of the boards of governors of the teaching hospitals, and of the management committees. I have not a great deal of knowledge myself of management committees, although I did serve on one for a short period of time. Many noble Lords who are to speak will 25 know far more about them than I do, but I feel that their value was very great because they were composed of local people dealing with local problems.
§ LORD ABERDARE
My Lords, I am sorry if I am interrupting unduly, but I can give the noble Lord the absolute assurance that these will be local people; that they will come from the area. They are not going to be imposed from elsewhere.
§ LORD AMULREE
My Lords, I am very pleased to have that assurance. It takes some of the disappointment from me. But it is not very clear in the Consultative Document because, there again, one wonders (as indeed I think the noble Baroness did, too) what exactly is going to be the purpose of the community health council, and what will become of the annual report which they are called upon to produce. There is not a great deal of point in producing a report if nobody is going to take any notice of it. It occurred to me, seeing that there is no mention in the Document of dealing with complaints about the Health Service, whether the community council might possibly be a body which might deal with that sort of problem.
The other thing which disappoints me about the Document is that there is no mention, or not a great deal of mention, of the change in the position of the general practitioners, and of their being integrated more into the Service. So far as I can see at the present time, the proposal is that they should carry on in roughly the same kind of way as they are doing at present, and that they will be more looked after by something like the executive committees than by being part of a really integrated Health Service. The same thing applied, I thought, to the school health service, although the noble Lord said something about that which may make a change. But the same thing also applies to the occupational health service, and to that small service, which I should have thought would have been part of the Health Service a long time ago, the prison health service, which so far as I know goes on in the same kind of way.
Those, my Lords, are my criticisms of the Document, but I must say that I have one or two things that I should like to say in favour. One of the first things is 26 that I am sure it is a good thing for the teaching hospitals to be associated with teaching districts and to have community responsibilities. That, I think, has been the practice in Scotland from the start of the Health Service; and certainly in London one or two of the teaching hospitals assumed this function some time ago. They found it advantageous because it brought more into the community, because it brought a larger number of patients to be treated—and you must have patients to treat if you are going to teach young doctors to practise medicine.
One would like to see the Service begin to take more responsibility for chronic and long-term illness. It has always seemed to me a mistake that the hospitals should appear to be (as they do at the present time) a place to where acutely sick people should go to for a short time and then be rapidly discharged so what might appear to be the sole criterion for the success of a hospital is the speed or size of its turn-over. Sick people require treatment, whether the sickness is short or long; and I am rather sorry that there has not been much mention of that particular subject in the Document we are now discussing.
Of course, there is the good news which came the other day when the Government announced that a considerable amount of money was going to be given to the care of elderly and of the mentally sick. One is pleased to see money given in that way, given in quite big sums to specific objectives and not generally spread rather thinly over a large number of subjects. It is good at the same time to know that the old workhouses are at last going to be pulled down. It is time that this was done, and one cannot help levelling some criticism at the local authorities for not carrying out what was enjoined upon them by the National Assistance Act 1949. At last it looks as if that is going to be put right; but provision will still be needed in quite a big way for long-term sickness or chronic sickness. One was very pleased to find in the Bonham-Carter Report some time ago that there was going to be a place for geriatrics in the new district general hospital. That, I am sure, is right but I think it means that more accommodation will be needed for these elderly persons than can be given in the district general hospitals.
27 I wonder whether one should also mention (I know that it is not in the Paper) the use of the smaller hospitals in the country, the so-called cottage hospitals, the so-called general practitioner hospitals. Could not these be put more in the care of the general practitioners as places where they could treat those of their patients whom it was not possible to treat in their own homes? This would save them from being sent a long way to the district general hospital. We need to have a pretty close tie-up with the district general hospitals, so that the best kind of medical treatment and care may be available, when required, to people in smaller hospitals. Another point of importance about that is that it would be a good thing for the general practitioner to feel that he had a hospital where he could treat patients when required. It might also have some kind of effect on the number of doctors who want to go abroad and practise in other parts of the world.
We were told at one time that it was no longer economic to run these little hospitals; but I think that that view is changing now. Certainly it would be wrong to run the National Health Service entirely on economic and business management lines. While the Service must be efficient and effective, one must look a little beyond that aspect. As the noble Baroness said, one does not want to bring the techniques and rules of industry and business into running the National Health Service. What is needed is something more of humanity and compassion. I agree that the economic side and the managerial side is important, but it should not play too big a part in developing the Service along the lines that we are discussing at the present time.
§ 3.45 p.m.
THE LORD BISHOP OF LICHFIELD
My Lords, I took the libery of putting down my name to speak in this debate because since the appointed day for the National Health Service Act I have had the privilege of serving, almost without a break, either on the board of governors of a hospital or on a Regional Hospital Board, and in past years on the executive council; so I am deeply interested in this subject. I should like to thank the noble Lord, Lord Aberdare, for introducing this Motion to-day and for the manner in 28 which he did so. I should like also to take the opportunity to express the gratitude that many of us feel to the noble Baroness, Lady Serota, for the part she played when she was a Minister of State at the Department. We remember with gratitude many of the things that she did in those days.
I find myself in general agreement with the thesis of the Consultative Document that more integration is obviously now needed in the National Health Service and that at the present time its various components are too much in watertight compartments. But I think we ought to keep a sense of proportion in this. Efforts have been made (I think more than is generally recognised) to overcome this difficulty of the watertight compartment. For instance, in the region in which I serve, that of Birmingham, a very large number of general practitioners have appointments in our hospitals. But after more than twenty years there is an obvious need for an overhaul of the Service.
Before we look forward, however, I think it might be right to look back and to say that without doubt there has been a transformation since the appointed day in 1948. Of course weaknesses remain, and there is need for some improvement—and may I say that the additional money now forthcoming will be most welcome in regard to improvements at some of the smaller hospitals. But it is right that we should remember what has been achieved. In my view, our National Health Service is without question the best in the world. Let us remember that all our people have access to the best possible hospitals and medical treatment. The new buildings which have been erected and the improvements which have been made to the old buildings have been possible only as a result of the influx of large amounts of public money; they could never have been done in any other way.
Above all I should like to pay tribute, as has already been done today by previous speakers, to the staffs, of all categories, of the Health Service. We now have more of them; they are well trained and better deployed. Occasionally, with much publicity, there are critical references to the treatment of patients by staff. In this imperfect world that sort of thing will sometimes happen, 29 and when it does it should be publicised and should be carefully probed. But I do not think it is always appreciated how carefully complaints are already probed. I have served for a number of years on the General Purposes Committee of the Birmingham Region, and I know of the way in which the complaints, when they come in, are most carefully looked at; and, moreover, courteously dealt with. I think that that should he said. Although there may be occasionally these difficulties which lead to complaints, what we have to be thankful for is that in general there is a very high level of professional and humane behaviour on the part of the staff. And as I know very well, being a clergyman, many people who have been under treatment in various ways have been extremely grateful for what has been done for them.
So, my Lords, I would plead that, now that we are in this time of uncertainty and change, we should treat our staffs really well. There is much uncertainty among the staffs at the present time. A number are very concerned. It is all very well to say to a man, "Of course, you will help us very much in this transition period, but you may be working yourself out of a job at the same time." I would plead that this uncertainty should be removed as soon as possible, and I very much welcome the proposal about a Staff Commission. As the noble Lord, Lord Aberdare, has already said, it cannot be set up at this stage but there is to be this preliminary work about which I was thankful to hear. Nobody can do his best work when he is feeling insecure. I would therefore ask that every effort should be made—and here I am thinking mainly of the administrative staff—to avoid redundancies. I hope that we shall give compensation on a generous scale, and that people's pensions will be looked after adequately. That kind of treatment now would be only fair to a splendid body of men and women.
To make the new system work, obviously, it has to be fully integrated. I should like to support this Consultative Document, as opposed to the recent Green Paper, regarding the attitude to the regional health authority. I do not think that in the Green Paper the regional authority was given anything like enough prominence. While in the Health Service we must be careful not to let the hospital 30 side come too much into the picture, nevertheless surely it should be seen that the Regional Hospital Boards have accumulated a mass of experience, and it would be a great pity to lose it. Also I believe that the system of a Regional Board and a hospital management committee has on the whole worked very well.
I have heard the objection made that this extra tier of authority is not needed in the sphere of education, where the Department of Education and Science deal direct with the various local authorities, so why should it be needed here? I should not have thought that the two were strictly similar. After all, in connection with education there is the University Grants Committee. Also I should have thought that there are some aspects of the Health Service which need wider application than can be given by the area boards. For instance, might it not be said that the consultative services would come better under the regional authority than under the area board? I should have thought that the same might he said regarding blood transfusions. I would strongly support the proposal, which both the Government and also the Opposition have supported, that the boundaries of the area health authorities and the local authorities should be the same, because that will make it possible for their work to be linked in a way which could not be done otherwise.
I think, my Lords, that the criticism that the document is over-concerned with administration is probably valid. I hope that it will be remembered that integration is needed in all departments of the Health Service and not merely in the sphere of administration. Here I come to what I think is the spearhead of the Health Service; that is, the health centre. This is in the front, and it has to be fully supported by the district general hospital. Of course, this is a new development, and one speculates as to the size of the health centre of the future. One of my friends, in considering this matter, went to Holy Writ, and found that in the Book of Deuteronomy, Chapter 1, verse 15, it was advocated that there should be "captains over tens," and he thought that probably ten was the right number of doctors to have in a new health centre. But there our doctors must be supported by all the ancillary services. In that way our manpower will be used to the best possible 31 advantage; and what one hopes for as we look into the future is a great amount of interchange all the time between the health centre and the district general hospital, with the general practitioners going into the hospital and the consultants and nurses coming out of the hospital into the health centre, so that the patient will receive treatment from a team.
All the members of that team have to be shown that their own contribution is necessary, and I hope that will be strongly pressed forward. At the moment I do not think that the development of health centres is going ahead very strongly. Surely here we see a close liaison between the area health authority and the local authority as being vitally necessary, for the personal social services must be linked with this. This includes voluntary services also. I think that there is still a wealth of good will and desire to serve which is not always being fully tapped, and the community must be encouraged to play its part. The Churches are giving careful thought to this matter. We are passing the whole of our work with regard to hospitals, and so on, under review. We have just appointed a working party on the subject under the chairmanship of that distinguished doctor and Professor of Medicine at Leeds University, Sir Ronald Tunbridge. We hope that this working party will aid us considerably in the part we ought to play in this new structure.
But whatever is done, as we think of this work of the community on behalf of those who need that assistance, let us try to give the attention we should give to the under-privileged. I was glad to hear the noble Lord, Lord Amutree, speak about the elderly. Let us see to it that those who do not know what benefits they can get shall be helped to get them. Let us look after the young and the elderly and all those who need our help. There are many anxious, lonely people about who need our assistance and who need to he shown that in the National Health Service we have not merely efficiency but real humanity. To achieve the results that we want to achieve all the resources of the community must be mobilised. We must aim at real participation by the community and so I should like to say how strongly I support the idea that there should be this community health council.
32 The new official set-up, as we see it pictured in the Consultative Document, obviously will be very different from the old, and the emphasis is very much on managerial expertise. We have heard the criticisms that have been made with regard to the method of the appointment of members. I would support some of that criticism to a considerable extent, but I believe that if we have this new, rather managerial, set-up it will be workable only if the community health council is shown to be not just window dressing. So the members of that council have to be carefully chosen and appointed. They must be seen to matter, because, as we all know, the word "consult" can mean a lot or it can mean almost nothing at all. I therefore attach considerable importance to the statement in the Consultative Document that the community health council should furnish an annual report. It is also very good that its members should have access to hospitals.
May I ask that in regard to the community health council the Churches should be allowed to play a continued part? In the past we have done so, and I have mentioned my own personal experience. In this new set-up I think that people like me are going to fade out of the picture; but we can play our part in the community health council and I hope that we shall be allowed to do so. After all, there is an age-old link between the work of healing and the Church, and I hope that it will be preserved. In general, the National Health Service must be human and understand human problems. Now I am not saying that our administrators arc not human. I have the privilege of knowing a number of them and I know that they are human. Nor am I saying that this new management structure will not be human, because I believe that its members will endeavour as best they can to put humanity into it. Nevertheless, the emphasis is on this management ability, and I would plead that consultations with the community health councils should be a reality, and seen to he such.
The Minister stated in his opening speech, as it is stated in the Document, that the new system is starting in April,1974. In other words, there is little time to lose. I hope, therefore, that it will prove possible to set up the shadow authorities before very long. After all, they have a great deal to do in planning for 33 the future and we want the transition to be smooth. I am sure that all concerned will help in regard to that.
As I come to my conclusion, I would repeat that great things have been achieved in the past and—let it be said with thanksgiving—the health of the nation is extraordinarily good. Much anxiety has been removed from the lives of millions of people. I hope, therefore, that when we have got over the transitional period and the new system comes into being, we shall be able to go forward with hope and confidence, because, as the noble Baroness, Lady Serota, said, if we lose the opportunity now of really doing what ought to be done, we may not get a similar opportunity for years ahead. Those of us who have had the privilege of serving in various places in the Health Service in these last years have been proud to do so and look forward with hope to a still brighter future which will do still more for the welfare of the people of our nation.
§ 4.2 p.m.
§ LORD AUCKLAND
My Lords, due to a very close family bereavement and to commitments arising from this, it was not possible for me to be in my place when this debate opened. I must apologise to the House for not being present. Also, for similar reasons, it will not be possible for me to be here for the closing stages of the debate. But since my family and I have had a close connection with the hospital field over many years, I thought that it would still be appropriate for me to say a few words in the debate, particularly as, due to illness, my noble friend Lord Grenfell is unable to take part in these proceedings.
I shall be brief because there are only one or two points to which I should like to refer. I gave my noble friend Lord Aberdare notice of the main gravamen of my remarks; namely, the communications between the voluntary bodies and the professional bodies in the light of this Consultative Document. There are a number of noble Lords who, like myself, serve on the house committees of hospitals. As your Lordships will know, I serve on the house committee of one of the seven mental hospitals in the Epsom area, a hospital about which my noble friend and the noble Baroness, Lady 34 Scrota, know. I should like to endorse the tribute paid to the noble Baroness by the right reverend Prelate the Bishop of Lichfield for the work which she did when in Office and to add my tribute to the splendid work which my noble friend Lord Aberdare is doing now.
The success or failure of this Document, which I believe in almost every way is an admirable one, will depend on this co-operation between voluntary and professional bodies. It is important for voluntary bodies to continue, not only the house committees but also the leagues of friends of hospitals and so on, always, of course, with the condition that the professional bodies must have the final say. Clearly the hospital secretaries and other administrators must have the final word on any projects which are envisaged. This is particularly true to-day, when we have more and more psychiatric wards in general hospitals, which mean more work for the staffs of both bodies. Surely it is here that the work of the voluntary committees, in liaison with the professional bodies, will really come into its own.
May I add my tribute to the Government for allowing the extra £118 million to be spent on the National Health Service? Of course, those of us who know the older hospitals will recognise (though I do not wish to be at all cheese-paring here) that in the last resort this will only skim the surface. One has only to visit and to go down the long corridors of a hospital like Leavesden, in Herts, to see how much renovation is needed.
While we pay the utmost tribute to the devoted staffs who work these hospitals, not only the nurses and doctors but also the chaplains and all others, we must also recognise the problem of getting recruits for these old hospitals, particularly when we read, as we sometimes do in the newspapers, or see on television, accounts of improper treatment of hospital patients. Nobody condones such conduct, and it is right that these cases should be brought to account in the appropriate circumstances; but they should not be blown up, as they often are, by some of our communication media, though we may accept that perhaps they do it with the best of motives. But for the morale of the Health Service —and I believe that on the whole the 35 morale of our Health Service is very good, despite the difficulties which it faces—these outbursts do no good at all.
I think that the idea of these community health councils is an excellent one. The more the general practitioner is able to come into contact with the hospital service and vice versa, the better, because in the long run it is communication between the two which counts. May I finally say that it is the various boards, combined with the voluntary services, which I hope will continue, which will give the working of this Consultative Document the success which it deserves to achieve.
§ 4.10 p.m.
§ BARONESS SUMMERSKILL
My Lords, I am sure that I am speaking on behalf of the whole House when I extend to the noble Lord, Lord Auckland, our sympathy on his great loss; and I want to say how proud we are that, nevertheless, he has been able to come here and make an important contribution to this debate.
I regard this Paper we are discussing to-day as a rather curious document, which places undue emphasis on management. This suggests to me that it has been drafted by individuals more familiar with the office desk than with the consulting room couch or doctor-patient relationship. There is so little reference to the needs of the patients, and the part which key workers, like doctors, nurses and those millions in the National Health Service can play.
Therefore I regard the title of the Paper, National Health Service Reorganisation, as a complete misnomer. I feel that those responsible for this concept of the National Health Service have little insight; otherwise they would recognise that it is at the top where the blame should be placed for managerial inefficiency, which I believe is of a gross kind, and to which I propose to refer. For example, spending millions of pounds on institutions for the aged before providing a comprehensive domiciliary service indicates to me waste and inefficiency. It is really putting the cart before the horse—and a very expensive cart at that. In doing this, there is a lack of understanding of the needs of the aged 36 sick, who pray at the end of their day, as they have never prayed before, that they may die in familiar surroundings and, if possible, with at least one relative by their side.
I attach great importance to domiciliary care, and it seems unrealistic in this Paper to separate the administration of health visiting and home nursing from that of the home help and other social care which, according to the Paper, will remain the responsibility of local authorities. I should have thought that, particularly in the interests of the aged, there should be close co-operation between the home nurse and the home help, both on the personal and the administrative level. We all know that in most houses where there is a chronically sick person the main thing that the member of the family chiefly responsible for the sick person wants is a good home help. I think she should be regarded as an integral part of the nursing service. There should be, in my opinion, this common administrative control.
We were told on the radio last week—I remember it was early in the morning—that the hospital casualty services in the Isle of Thanet were closed, and that an accident emergency would have to be taken 18 miles to Canterbury for treatment. As everybody knows, that is when time is the very essence of the exercise. This deplorable state of affairs cannot be traced to the failure of managerial responsibilities in the Thanet Health Service. It is in my opinion an indication of the failure at the Elephant and Castle level, where every effort should be made to provide more doctors.
I have been in Parliament for 30 years and I remember the Willink Committee being set up. We all sat hopefully thinking that now a recommendation would be made and that more doctors would be provided. On the contrary, the recommendation was that the number of medical students should be reduced. This was years ago, and still we are desperately short of doctors. According to The Times to-day, the junior hospital doctors are once more in revolt because they are having to work 100 hours per week. They are so exhausted that the hospitals feel that the doctors are unable to give the best treatment to the patients. In the third leader of The Times emphasis is again laid on this question.
37 I believe that 400 doctors are emigrating every year—although I hope the number is less. We educate them, and they emigrate. To the people who say that women doctors marry, I would point out that it is men doctors who emigrate, and women doctors who remain at home with their husbands and continue to practise. That is an important point. With 400 doctors emigrating every year, efforts are made to encourage doctors to come here from other countries; and we have them coming here with so poor a command of English that sometimes in a busy out-patient department or casualty department the patient does not know what the doctor is talking about. We encourage them to leave the undeveloped countries, where their services are so desperately needed. And yet—and most people who have heard me before will know precisely what I am going to say now, including, I hope, the noble Lord, Lord Robbins—we still allow prejudice to deny a medical education to British women. I only discovered this year that this prejudice is so strong at Leeds University that in order to prevent girls from getting places in medical schools they have to attain a higher level in "A"-levels than the boys who apply. What a disgrace! Prejudice and custom so dominate the thinking of these highly intelligent and highly educated men that they have privately conspired together to insist that the girls who apply should be even more brilliant than the boys before they are considered. Rather than have women doctors, we take these doctors from these desperately poor countries, where sometimes they have one doctor to 50,000 people. As I have said over and over again, I do not know how many years it takes to change prejudice and custom in this country.
Again, I would say that the absence of managerial efficiency at the top was illustrated by the proposal that prescription charges should be related to the cost of the drugs. This would have been dismissed as socially undesirable and administratively near-impossible by any general practitioner who had spent some years seeing many patients. The Ministry would have been told that this was a non-starter. But committees were setup, doctors all over the countries were asked for their opinions, and the time and cost of these protracted discussions 38 on this subject must have been immense, before the Minister admitted that he had been wrongly advised.
Then, the shortage of nurses and those engaged in professions ancillary to medicine is due to the failure to pay them adequately, which again stems from managerial inefficiency at the top.
§ LORD PLATT
My Lords, if I may intervene for one moment I would point out that the shortage of nurses in the United States of America is absolutely tremendous.
§ BARONESS SUMMERSKILL
The noble Lord and I have had this exchange at least half a dozen times: I make a statement about nurses, and he rises and talks about the United States. He must have learned, in his long life, that when one is pointing to an injustice it is not an excuse for that injustice to point to something that might he happening in another country, of which we are not quite sure. So perhaps we can end this perpetual discussion.
§ LORD PLATT
The point is that it is always related to the amount that we pay the nurses, which in the United States is immense.
§ BARONESS SUMMERSKILL
It is a silly waste of time arguing this: but has the noble Lord ever been to Los Angeles?
§ BARONESS SUMMERSKILL
I suggest that he should go and see what young girls do there. There are a great many other things besides emptying bedpans.
I agree with the Consultative Document that the need for the integration of the Health Service is long overdue. Yet it seems from this document that the school health service and the occupational health service (and I attach a great deal of importance to this, because the incidence of accidents and disease to-day in the factories and workshops of our country is really shameful) are not to be integrated. I think that these services, and of course the Prison Service, should be integrated; but they have been ignored. And I would point out that the relationship between the hospital and the general practitioner will remain unaltered, although time after time in various debates we have urged that the 39 general practitioner and the hospital should work more closely together.
Next, I come to the hotly debated question of nomination versus election. I think that most of us who reach this place have at some time come up through local authorities. I myself came up through a district authority, then a county authority and finally I was nominated as a candidate for Parliament. So we know something about these things. I should have thought the authors of this Document ought to have learnt that nominated individuals, anxious to retain their seats, frequently acquire over the years a timidity and the thinking habits of the bureaucrat and are less prepared to press for fundamental change than the elected representative. It is a very curious psychological fact that the elected representative is willing to be bold and to go out once more in the streets and try his or her luck, but if you nominate an individual he develops after a time such a pride of place that he is filled with fear and thinks, "I must behave myself so that I shall be nominated next time". This is a most important psychological reason why we should press for the elected representative.
Those of us who have been in Parliament for many years can estimate, looking at this Document, that many years will pass before these proposals are implemented, so that nothing will be lost by taking them back now. I have observed, to his credit, that the right honourable gentleman the Minister of State for Health and Social Security, when an argument is put forward, reads it, digests it and then decides for himself whether it shall go forward. The prescription charges are a case in point. There was tremendous pressure from all sides, and particularly from the Treasury; yet he judged the proposals to be a mistake and withdrew them. I suggest that the Minister might read some of the essays on the Next Decade in the National Health Service in Challenges for Change, which was commissioned by the Nuffield Provincial Hospital Trust. May I just put on record the four important points that I think should guide him? The four proposals put forward in the Introduction were:(1) To develop a philosophy of health services where the rights, the duties and the 40 expectations of every individual should be set out without political or professional bombast.What a lovely word, my Lords!(2)To define "a series of objectives for the National Health Service", including a theory on administration to attain them.(3)The monitoring of the quality of health ca re.—My Lords, how comprehensive that could be and how well that would meet so many of our doubts and misgivings!—(4) The development of a coherent manpower policy.And I would add to that the allocation of finance on a more practical basis.
May I just recall to the House that last week none of us knew what was coming about the millions for the institutions—and I am not blaming the Health Service: they are lucky to have got money—but every politician knew that it was given to us overnight because the Treasury felt that they had to do something about unemployment.
§ LORD ABERDARE rose—
§ LORD ABERDARE
My Lords, I am sure the noble Baroness dragged that red herring in just to get me to my feet.
§ LORD ABERDARE
I must correct that statement straight away. It is not so. These plans were laid a very long time ago, and it is the other amount of money, that for the infrastructure, which is concerned. We managed to get another £22 million for the health services.
§ BARONESS SUMMERSKILL
In answer to that, may I just say "touchè"? I must say, my Lords, that the criticism of this Document is not of a Party political nature. The conference in July, convened by the Royal Society of Health, was attended by hospital governors, matrons, general practitioners and local government officials; and they revealed that those closely connected with the administration of the Health Service were critical of the proposals. So I hope that the noble Lord will not feel aggrieved and feel that this is a Party political attack. It is quite clear that the criticism is coming from all directions. Therefore, in view of this, I would advise the Minister to scrap these proposals.
§ LORD ROBBINS
My Lords, before the noble Baroness sits down, may I press her on one point? She alluded to discrimination between men and women in university entrance examinations in regard to medicine. If such discrimination does take place, I assure the noble Baroness that I share her horror and contempt for those who practise it. But can she give us a little more evidence?
§ BARONESS SUMMERSKILL
Certainly. If the noble Lord had been in his place he would have heard the Question that I put in the House. I am shocked to hear of his ignorance. I think he should know me better than that. I am an old Parliamentarian and would not make a statement like that unless I was sure of my facts. This came from Leeds Medical School. I had a letter from there telling me that these were the facts. I put down a Question in the House and asked if these were the facts; and I was assured that this kind of thing would not be continued anywhere else.
§ LORD ROBBINS
I apologise to the noble Baroness for not being in my place on that occasion. I share her sentiments one hundred per cent.
§ BARONESS SUMMERSKILL
Good. I am glad of the noble Lord's sympathy, and I am only sorry that, after that one inquiry, the investigation for which the noble Lord was responsible was not followed through; and I hope that the noble Lord will not only share my sentiments but also join in the pressure. When it comes from a woman—and the same woman—year after year, those who matter sit back and laugh and say, "That's all right; we have a majority in the House", because it is male. Perhaps the noble Lord will join with me and help in the attack so that his granddaughter and my grand-daughter will not experience the same situation.
§ LORD ROBBINS
My Lords, I come from an institution which has never discriminated between men and women.
§ 4.28 p.m.
§ LORD COBBOLD
My Lords, I am sorry to interrupt this fascinating discussion. May I just mention first that I am 42 speaking to-day, not as Lord Chamberlain, which office I hold until midday to-morrow, but as Chairman of the London Undergraduate Teaching Hospitals Committee and of the Middlesex Hospital Board of Governors and Medical School Council. I spoke in your Lordships House in March, 1970, in the debate introduced by the noble Baroness, Lady Serota. I do not wish to go over all the same ground, but I should like to recall one phrase which I then used: 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.
Turning to the present Consultative Document, may I first express our thanks to the noble Lord, Lord Aberdare, and to the Secretary of State for their readiness to listen to our comments. We have had long discussions and are shortly to have more. In all these discussions our object has teen and will be to make constructive suggestions about the way in which the teaching hospitals can make the best possible contribution to a revised Health Service, both in the care of patients and in medical teaching. The observations which I have to make to-day follow generally the line which we have taken, and shall continue to take, in these discussions. It may perhaps be of interest to your Lordships that two suggestions which we put to Ministers in the early summer had the unanimous support of the chairmen of all the London undergraduate teaching hospitals. They have since been considered by the various boards of governors individually, and though in one or two cases there are some divergencies, there is overwhelming support for the suggestions we have put forward from the great majority of the boards concerned.
There is wholehearted support from the London teaching hospitals for the objectives of the Consultative Document and for integration of the Health Service. We have in particular welcomed the greater emphasis placed in this Document than in earlier proposals on the importance of medical teaching and research, on the particular difficulties in the London area, and on efficient management. The criticisms and suggestions we have put forward are not in any way directed against the objectives of the Consultative Document, but are wholly in the field of 43 method and timing. I will deal with these three issues in order.
First, as I say, the Document recognises the importance of teaching and research. We have felt, however, that when it comes to method there is need of new thoughts. There is scarcely any reference in the Document to the relationship between the teaching hospitals and their associated medical schools. I must add that I have been a little disappointed to hear so little mention from earlier speakers on the two Front Benches, or elsewhere, about medical training, with the exception of an appeal for the ladies from the noble Baroness. If we do not have good doctors in the next generation we shall not have a good medical service, and what are we talking about? At the present time, with cross-representation between the responsible boards and school councils, and with day-to-day contact on the academic, medical and administrative sides, teaching hospitals and schools function practically as a single unit. In our view, which we believe to be shared by the University of London, this unity is essential to proper medical teaching. We have little doubt that this unity would be eroded by a transfer of responsibility from boards of governors, with their direct contact with the Department, to area and regional authorities not directly on the spot and inevitably and rightly more concerned with local affairs than with the national responsibilities of medical teaching.
Secondly, there is the special position of London, which is, as I have said, fully recognised in the Document. Nevertheless, it appears to be contemplated that, largely for the sake of uniformity, the same general pattern should be applied to London as to the rest of the country. If one were starting from scratch and setting out to build new hospitals, it might well be desirable to arrange for teaching hospital areas to be coterminous with boroughs. But as things are, this is to go against the facts of life. Several London boroughs have two, three or more teaching hospitals; some have none. All London teaching hospitals take patients from across borough boundaries and from outside London. Unless one knocks down a lot of hospitals and builds them elsewhere, which is clearly in no 44 body's thought, the doctrine of coterminosity is not just applicable to London. Again, the London graduate teaching hospitals train some 50 per cent. of the country's doctors and therefore have a national responsibility as well as a local responsibility. Admittedly this percentage may change over coming decades. But this, I suggest, is an argument for an experimental period in London rather than for immediate uniformity throughout the country.
Thirdly, there is efficient management —always an important element in any public service. However, I agree with some speakers that in the matter of the care of patients efficient management in hospitals is not the only criterion. On the subject of efficient management I have to say that the London teaching hospitals part company. so far as they are concerned. with the proposals adumbrated in the Consultative Document. The chief executive officer of a teaching group is in control, subject to his board of governors, of some 3,000 to 5,000 people: medical, nursing, administrative, clerical, and domestic. It is a job which needs absolutely first-class men, with authoritative support on the spot from the board and chairman, and with a clear chain of command. The Consultative Document appears to suggest that in future he would have some responsibilities to a management committee, some to an area chief executive and, through him, some to a regional authority. This, with respect, would not he efficient management and would not attract first-class people to hospital administration. I would ask the noble Lord, when his London committee reconvenes, to give particular attention to this aspect.
To sum up, my Lords, what the London teaching hospitals want is to play their full part in a revised Health Service and to fulfil their national and local responsibilities as efficiently as possible. There have been big developments in the past few years, all leading in the direction of an integrated Service. We have been happy to take on district responsibilities —we work easily with local authorities —and this co-operation could be solidified by changes in the personnel of boards of governors; there is fruitful contact with the regional boards and the machinery of joint consultative committees is increasingly effective. We mostly have 45 close contacts with hospitals outside the Inner London area and are anxious to extend those contacts. My Lords, I well understand the desire of Ministers for decentralisation, but I would suggest that the new regional health authorities in London will face a very heavy and complicated task in their first years. I believe that it would be a mistake at this stage to add to that task a somewhat blurred responsibility for managing teaching hospitals, or to attempt to force London prematurely into a pattern which may well suit the rest of the country.
If I may end on a positive note, I would ask Ministers to consider a two-stage operation for London. I believe that in the first stage, perhaps for an experimental five years, the Department must, either directly or through a central planning body, maintain and even increase its responsibilities in London. I believe that they should retain for this period the existing broad structure of hospital administration, but give strong impetus to the developments that I have mentioned; that is to say, district responsibility, contact with local authorities, relationships with regional authorities, with outer London, and further afield. As the two noble Baronesses have mentioned, it is also obvious that the whole basis of relationship between hospitals and general practitioners needs a thorough review and probably an experimental period. With five years' experience it might well prove sensible in stage 2 to move further towards the concept of a uniform structure throughout the country. The London undergraduate teaching hospitals will continue to do their best to safeguard their responsibilities to the community, both in the care of patients, and in the training of doctors for a future Health Service of the highest standards.
§ LORD ABERDARE
My Lords, before the noble Lord sits down may I say that I am extremely interested in his idea of a five-year interim period. What would happen in those five years to the health departments of the London boroughs, and the medical officers of health? Does he envisage any move there?
§ 4.39 p.m.
§ LORD COTTESLOE
My Lords, the Consultative Document proposes a major revolution in the organisation of the National Health Service. As Sir Keith Joseph is at pains to point out in his Foreword, all the existing Health Service bodies will be swept away: the regional hospital boards, the hospital management committees, the boards of governors of teaching hospitals, the executive councils that administer the general practitioner services, the local health authorities that administer the domiciliary services—all will be swept away. They will be replaced by an entirely new structure based on area and district committees as outlined in the Document.
The purpose of this revolution is to create greater efficiency of management by decentralisation and by the integration of the three branches of the existing Services: the hospitals, the general practioner services and the domiciliary services. Let me say at once that we all unreservedly accept the concept of total health care through an integration of the three branches of the Service. But, as my noble friend Lord Cobbold pointed out in an earlier debate, and has to-day repeated—and it cannot be too often repeated—if you are throwing an existing organisation into the dustbin it is not a bad thing to make certain before you do so that the organisation you are going to put in its place will function better—not only better in theory but better in practice: that is the acid test. The more that I and many of my colleagues examine these proposals and their implications, the more doubts we feel. It is not that we regard the existing organisation as perfect—of course it is not; of course it is very far from that; but, with all its faults, it works, and on the whole works well. It looks as though the proposals outlined in this Document, whatever their virtues in theory, will not work better in practice, and in some respects will work worse; will be less efficient and perhaps also less humane. I will come back to that point in a moment.
First I must say a word about integration. If integration is to be effective it must be integration at every level right down to the grass roots. The point was 47 well developed in an article by Mr. Geoffrey Smith in The Times of November 12. Now the weakest point of the present set-up, I think it would be generally agreed, is the lack of integration of the general practitioner service, the family doctor, with the hospital service. What does the Consultative Document propose? One would have expected the general practitioners to be the first to welcome the proposals, to be delighted at the prospect of their full integration into the Service by being administered by the area health authorities. But they were not and, in response to their strong objections to anything of the kind, the Document proposes in paragraph 22 a Committee set up by the area authority but dealing direct with the central Department to administer the contracts of the family practitioners. The Document even says:with a composition like that of the present executive councils".My Lords, "a rose by any other name …". In fact, this is the executive councils, the weakest link in the existing integration, all over again. If the proposed integration does nothing to improve the present system at its weakest point, that surely must cast grave doubts on whether the major revolution that it proposes will in practice lead to an overall improvement on the system now existing. I am bound to say that I hope the Government will give the most serious consideration, even now, before they throw the whole of the existing system overboard, to whether a better way of improving it would not be to strengthen at every level the links, formal and informal —and they are many—that have over the last quarter of a century been established between the three branches of the existing Service.
If I may now turn to the particular aspect of these proposals in which I have a special interest, the proposals for the teaching hospitals, I should like to welcome the intention, of which the Minister has told us, to hold further consultations with those concerned. The arrangements now proposed for teaching districts—they are set out in Appendix I—go some way to meet the very strong objections raised on behalf of the teaching hospitals to the proposals set out in the two previous Green Papers. They go some way in 48 particular to meet the difficulties of the provincial teaching hospitals. London, as the noble Lord, Lord Cobbold, has pointed out, presents special difficulties with problems of its own, owing to the great concentration of teaching hospitals, both undergraduate and postgraduate, in the Metropolitan area, and to the fact that the population they serve has largely migrated outwards from the centre.
As to the postgraduate teaching hospitals, they are all in London and they give consultant training not only to great numbers of doctors in this country but to an even greater number of doctors from abroad who come to London, drawn by these hospitals, from every part of the world for specialist training and research. They come in such numbers that more doctors come to London each year from overseas for this specialist training than the total output of new doctors of all the medical schools in the United Kingdom. I am glad that the importance and value, nationally and internationally, of the work that these hospitals do—they are a mixed bag: some large such as Hammersmith and the Maudsley; some quite small such as St. John's Hospital for Diseases of the Skin and the National Heart Hospital, now being merged with the Brompton as a cardio-thoracic centre —is appreciated and that they are, as stated in paragraph 25 of the Document, to be the subject of separate consultations. That is very necessary.
I should like to ask the Minister whether he can confirm my understanding that, for a transitional period of up to five years from the coming into effect of the proposed reorganisation in 1974, these hospitals will retain their own boards of governors, as at present, so that their special problems and their special place in the reorganised Service can be fully worked out before any new pattern for their administration is brought into being. As I say, they are a mixed hag and they will not all need to be treated in the long term in the same way. Some can stand on their own feet; some require to be closely associated, while retaining their own name and identity, with others, or with an undergraduate hospital and school.
The London undergraduate teaching hospitals, with their great traditions and honoured names, provide the greater part of the general hospital services in the 49 central area of London. They present special difficulties in the proposed organisation, so much so that of course the Minister, as we know, has continued, under his own chairmanship, the Working Party sot up by the noble Baroness, Lady Serota, in the last Government, to examine the particular problems. I think we should all like to know how that Working Party is progressing, and no doubt the Minister, when he comes to reply, may be able to tell us something about that. In particular, I should like to ask him how it is proposed to arrange the London teaching districts; whether it is envisaged that in London, where the geographical areas are small, there will be, rather than teaching districts, teaching areas, so that in the Metropolitan area the organisation will have one tier less than elsewhere. That seems to me to be both natural and highly desirable. Then, what about the principle of coterminosity, to which the noble Lord, Lord Cobbold, referred—a principle by which Mr. Crossman at one time set so much store but which I think he finally concluded could not be applied universally within the Metropolitan area? Do the present Government take the same flexible view? If so, it would enormously ease some of the more intractable problems of London.
How far can the Government meet the four cardinal requirements of the London undergraduate teaching hospitals, put forward unanimously by them, as set out in paragraph 4 of their memorandum of July 8 submitted to the Secretary of State? Those four cardinal requirements were: first, a direct statutory relationship with the Department and direct financial allocations—in effect the retention of something like the existing boards of governors; second, a direct relationship with their own medical schools—which is a prime necessity for teaching hospitals; third, a responsibility for the employment of their own staff, especially higher medical and administrative staff; and fourth, control over their own endowments. As to the endowments, of course, Appendix 2 to the Consultative Document deals with them in a way that is, in general, reassuring. But the memorandum of the undergraduate teaching hospitals set out constructive proposals for a system that would incorporate the other points, and I hope that the Minister may be able to tell us this evening that some 50 such proposals are acceptable to the Government, or, if not, that there will be some arrangement for a transitional period for London to ensure that satisfactory arrangements can be worked out before any new system is finally brought into being.
I am, of course, especially concerned about the arrangements for my own particular hospital, Hammersmith. I apologise to the House for speaking about it, but it is the only general postgraduate teaching hospital in the country and, for that reason, has certain different features from other teaching hospitals. Clearly, it must continue to give a district service in addition to its high-powered national and international service. We all want that. Also, it will clearly have to look to the Westward, to a sector stretching outward from the centre of London, because that is where the population is. But, whereas what are known as the Todd pairs of undergratudate hospitals, like twin stars, can in some cases, if not in all, be the nuclei of teaching areas, an undergraduate and a postgraduate teaching hospital are in many ways, by their very nature, so different that I am convinced that such a pair would not make a happy working partnership. Such a pair would not be "twin stars"; it would be, if I may change the metaphor, a shot-gun marriage. As a very wise and experienced professional man said to me the other day, for Hammersmith it would be "the kiss of death". I hope that the Minister will consider whether Hammersmith Hospital could not rather itself be the focus of a Westward sector, with other district hospitals already existing in that sector, even if such an arrangement involved (as I think it must inevitably involve) some minor infringement of coterminosity.
My Lords, I could raise many other matters, but I think I have said enough on this occasion. Let me finally turn back to my opening remarks and urge the Government, before they implement the very sweeping proposals that we have in the Consultative Document, to consider most earnestly once again whether the integration of the Health Service in the interests of efficiency and humanity could not really be better effected by improving and strengthening the lateral links between its branches at all levels than by 51 throwing overboard the whole existing system in order to replace it by something that may very probably, in practice, work not better but worse: in fact to proceed by a process of evolution rather than by one of revolution.
§ 4.54 p.m.
§ BARONESS MASHAM OF ILTON
My Lords, it is because I believe that our nation's health should be of prime priority that I want to add my tiny contribution to to-day's debate, and I thank the noble Lord. Lord Aberdare, for this opportunity. When one has so nearly lost one's life, as I have, it is difficult not to understand the full value of life and how important it is for those who are not fortunate in having complete health to be able to develop to their full potential, and for those who are totally helpless to be protected. I will for ever be grateful to the National Health Service for the treatment I have received under its care.
As patron of the Yorkshire Faculty of the Royal College of General Practitioners, and also being associated with a medical research trust, I am greatly interested in the reorganisation of the National Health Service. I should be grateful if the Minister would clarify a part of the Consultative Document which states:At regional level they imply an organisation with the primary responsibility of overall planning of services and allocation of resources to the areas within the regions.Does this mean that patients will no longer be sent for treatment other than to hospitals in their region?
Uniformity in medicine throughout the country looks good on paper, but in practice can it ever really happen? Is every region going to cover every speciality? For example, are there to be 14 hospitals in the 14 regions all dealing with tropical diseases? The geniuses who specialise seem to draw other enthusiastic doctors to work with them as a team, and if they are not going to be able to work together it will surely mean that the standard of research will be lowered. In the years to come, are our famous specialising hospitals, such as Queen Charlotte's, the Great Ormond Street Children's Hospital, the National Spinal Unit at Stoke Mandeville, and 52 many others, to go? These are not only a status symbol of our high standard in this country; they bring us international prestige in world medicine. These hospitals have taken years to build up, and because they may not fit into 14 regions it would be sad to see part of our heritage vanish with the stroke of a pen. But it is good to hear that trained managers will consider, in collaboration with local authorities and voluntary organisations, the total need of their areas; and it is excellent that a strong and binding link between the Departments of Health and Social Services has been recommended. I hope wholeheartedly that these Departments will get round the table together and grow closer and closer, sharing the problems and finding ways to overcome them, rather than criticising each other.
So often I have heard of patients blocking acute beds in hospitals, it being impossible to discharge them as they have no suitably adapted homes to go to. Unless there is full co-operation and communication it will always be the patient who suffers in the end. General practitioners should find it helpful to be given better facilities for working in collaboration with other parts of the unified National Health Service and with the personal Social Services. I hope that health centres will be able to cater for many services which seem to be lacking at the present time. One which comes to my mind is the need for patients with bladder and renal complications to have their urine tested efficiently. At the moment, patients living in rural areas send the specimens to hospital through the post. This seems to be an inadequate and haphazard method. On arrival, the urine is too old for satisfactory examination. In America, it is possible to get these tests carried out at a drug store. I hope that the health centres will be equipped to deal with this kind of necessity.
For many years I have thought that the inmates of penal institutions are better able to state their grievances than in-patients at health institutions. Penal institutions have Boards of Visitors who are interested members of the public appointed by the Home Office who see that fair play is maintained. I have always found that there is good cooperation with the staff, who can depend 53 on the Board's support at times of criticism from outside. Occasionally terrible things can and do go on within Health Service hospitals, and nobody seems to question them until the Press brings them out into the open, by which time a great deal of harm has occurred and bad publicity results. Perhaps the setting up of community health councils will do something to help the situation.
My Lords, emphasis has been put on the preventive as well as the curative aspects of illness, and this is excellent. Every one of your Lordships has two things in common—being horn and dying. The midwifery service seems to be rather good, but nothing has been mentioned in the Document about dying. I hope that dying is not looked upon as a failure. Dying in dignity, with as little stress as possible, should he one of the services given under the National Health Service. I hope that the Ministry will look closely at the conditions in which people die and the facilities given to this important aspect in their hospitals.
I am sure that no sensible person would ever dispute the fact that good management is essential to run a large organisation, especially one so complicated and important as the National Health Service. But to this new-look, efficient and vigorous Service I hope that the Minister and his Department will remember to add a dash of T.L.C. A great many of the people who will come under this great Department will be the old and the frail, and the mentally ill and the dying. Some of your Lordships may not know what T.L.C. means, as it has not been mentioned in this Document: it is "tender loving care."
§ 5.2 p.m.
§ LADY RUTHVEN OF FREELAND
My Lords, I also should like to add my thanks to my noble friend, Lord Aberdare, for giving us this opportunity of discussing the Consultative Documents. I expect many of us who have worked with hospitals for some time have been worried: the Document came out in May and we knew nothing more about it until to-day. To me it was a very bony structure, and thank goodness what the Minister has said has clothed it a little, but really not quite enough. I wondered whether I should speak about the parts of the hospital service which I know about—I was on the board of governors 54 of a post-graduate teaching hospital, a regional board and seven hospital management committees, three being psychiatric—but I decided to speak on something quite different. I want to look at the Consultative Documents from the point of view of the person who is the most important element of the whole Health Service, however organised, but who is not mentioned at all in the Documents that is to say, the patient. I was delighted that the noble Baroness, Lady Serota, mentioned this aspect, too.
I feel I should explain to your Lordships why I think I have a right to speak for the patient. I am the Chairman of the National Association of Leagues of Hospital Friends, which is a central organisation to which are affiliated nearly 850 individual leagues of hospital friends working in some 1,400 hospitals throughout England and Wales and in parts of Scotland. In quantitative terms, we estimate that about 70 per cent. of the beds in the National Health Service in England and Wales are served by affiliated leagues. These leagues vary in size and the tasks they undertake, but I may summarise their objects as being to benefit the patients and former patients of their hospitals who are sick, convalescent, disabled, handicapped, infirm or in need of financial assistance, and generally to support the charitable work of their hospitals by providing service and amenities for both patients and staff.
The activities of leagues of hospital friends fall into two main categories: fund raising and personal service. As fund raisers, they have about one million member subscribers, and they also approach the general public through a wide variety of fund-raising activities. As a result of their efforts they are able to make gifts to their hospitals worth £1½ million a year, gifts ranging from Christmas cards and birthday presents for friendless, long-stay patients, to major facilities such as recreation centres, intensive care units, physiotherapy departments and even operating theatres. About 80,000 friends are actively engaged in giving personal service to their hospitals. Here again the range is wide and varied: visiting patients, running trolley shops and canteens, entertaining long-stay patients, and many other services in the wards and other parts of their hospitals. As National Chairman of this organisation. 55 which is, I think, representative of the community from which the patients come, I feel I can claim to be representative of those many people in the community who are concerned for the welfare of the sick and those who care for them, and that I may speak for the patient.
The Consultative Document lays great emphasis on management ability. Paragraph 14 says:Management ability will be the main criterion for the selection of membersof the new regional and area authorities. I think there is a great danger in taking this too far. In the world of business and commerce it is comparatively easy to test the reaction of your customers; you have a product, and so long as customers buy your product in sufficient quantities then your product is good; when people do not, then there is something wrong with it. I cannot see how this type of customer reaction can work in the Health Service. People do not go to doctors and hospitals because they want to but because they have to, and it is impossible to measure the efficiency of the Service by the amount of business that it does. People have to turn to the National Health Service when they are ill because, for the vast majority, there is no alternative; there is a virtual monopoly in the Health Service. How can you measure its efficiency by the volume of complaints and criticism that is received from the customer? Because it seems to be the case—and I am sure your Lordships who have worked on regional boards and hospital management committees et cetera will know this—that in hospitals, at any rate, unless a very major mistake has been made and an inquiry has to he instituted, patients do not complain. Most patients are so grateful for the care and attention they receive from individual doctors and nurses that they do not like to complain about the things that do not go right for fear of appearing to be ungrateful to the individuals who have been kind to them.
To a large extent the point of view of the patient has been catered for, up to now, by including ordinary men and women as members of the boards and committees running the present hospital service. But for the future the Document quite categorically separates the management and the representational functions; 56 management is to manage and the presentation of the needs of the customer is to be something quite apart. This is indeed a brave concept. Whether or not it works to the satisfaction of the patient seems to depend on the effectiveness of the new community health councils (paragraph 20 in the Document). The obvious importance of these councils is not made clear in the Documents. My noble friend, Lord Aberdare, did say a word about what these councils would consist of, but I should like to know a little more than he has told us about their role and methods of working. I would ask my noble friend whether he could explain more to us about these councils. From reading the Documents, it appears that they are to be set up by the area health authorities, but is it right that management should appoint its own critics? Is there not a danger that the watchdog may degenerate into a lapdog? These councils are to be consulted on the development and operation of the local health services, but do they have to wait to be consulted, or are they to have the right to initiate their own approaches to the health authority on any matter which they think is their concern and will be of benefit to the patient? They are to produce an annual report, which I think is excellent; but do they have to wait until the end of the year before they report that everything or anything is going wrong in the hospital?
There are many more questions one could ask about these new community health councils, but in the end it all comes to this: that although the Document deliberately separates management from the community's reaction to management, the two elements are in fact interdependent and equally important. After all, you cannot know whether or not you are running an efficient Service unless you know that the community is satisfied with it. But the Document is vague about the functions of the councils and their methods of communication with management. What I think one is left with is the impression that the councils will not have much of a role, and will have only a tenuous communication with management. Certainly the councils as described in the Document are not likely to attract people of the right calibre as members. I wonder whether in the new Health Service there is a place for the voluntary organisations, and I am hoping that some 57 of our leaders or representatives might be selected far service on the community councils. Unless these Councils are given more and stronger teeth, however, none of us will wish to serve on them, although, as I said earlier, we do represent the community for whom the Health Service was conceived.
I am encouraged by what the Minister has said to hope that these Councils will be strengthened. I note with pleasure that in paragraph 5 of the Document it is stated that collaboration with the voluntary organisations will continue. It is at the level of the community that I feel we could help, and the Document faces these, our voluntary organisations, of which my national association is only one member, with new challenges and new opportunities. Up to the present, the three parts of the Health Service have been run in separate compartments, and the voluntary organisations have tended to follow suit. But there is now to be this very welcome change to the new concept of continuity of patient care, whether by G.P., by local authorities, or in the hospitals. I should like to ask my noble friend whether there should not be continuity of care across the whole spectrum of the voluntary organisations. This is something that needs to be discussed within and between voluntary organisations, and between them and the statutory bodies concerned.
Finally, I must remind your Lordships' House that the Health Service, whatever its organisation, exists to serve the patient, and for no other purpose. It is disappointing that the Consultative Document, although it has plenty to say about management, does not mention the patient at all. I hope very much that the patient's point of view has not been entirely forgotten, and that the community health councils will be made into really effective bodies, attracting as members men and women of the highest calibre, and capable of seeing that the community gets the Health Service it needs. Before I sit down, may I add my thanks to my noble friend Lord Aberdare for the Statement he made to your Lordships' House on November 22? I was unable to catch his eye, so I could not say how delighted I was to hear that the Secretary of State has been able to produce a good deal more money to be spent on the psychiatric, subnormal and geriatric parts of the 58 Health Service. I have always been particularly interested in those three parts of the Health Service, and I am very glad that this additional money has been allotted to improve these services. I would stress the hope that if any of this money is given to local authorities it will be explicitly earmarked to this purpose.
§ 5.15 p.m.
§ LORD GARNSWORTHY
My Lords, like the noble Lady who has just resumed her seat, I, in common with all Members of your Lordships' House, welcomed very much the Statement made last week about the considerable amount of money to be made available for the improvement of the Service. The noble Lord, Lord Aberdare, in moving the Motion, anticipated a wide-ranging debate, and I think he is getting it. He also anticipated that he might be asked a number of questions. He is getting those, and I expect that before I finish I shall be asking one or two more. May I say that when the noble Baroness, Lady Masham of Ilion, was speaking, I felt that she had not only our attention but also our particular sympathy when she touched on the subject of dying. She put it in a way that all of us would wish to echo, and I believe that in saying what she did she rendered a very distinct service.
My noble friend Lady Serota, who was the second speaker in the debate, made a speech that I thought was extremely well-informed and, at the same time, very probing. I should like to give my support to the many points that she made in regard to the structure of the Service and its accountability (if I may put it that way) to the customer. She referred to the time-table laid down for consideration and comment by those representing interested organisations within the Service. It was a fairly tight time-table, and one hopes that it was not intended as an indication of future procedures. If goodwill is to be obtained—and surely this is a Service where goodwill is vital—there must be effective consultation. If there is to be effective consultation—that is to say, consultation with staff interests—there must be adequate time. The Consultative Document was issued on May 17 this year, and comments were required by the end of July. The position was made no easier by the very few copies of the Document that were then available. I understand that the Staff side of the General Whitley 59 Council had five copies to cover distribution to 47 organisations. I speak this afternoon with particular concern for the interests of those engaged in the Service, and indeed I have a very special interest to declare, because I am associated with the National and Local Government Officers Association which caters for so many of them.
Before developing that particular aspect of the subject, I should like to raise one or two points concerning membership of authorities. I had intended dealing at some little length with paragraph 14, but the noble Lady, Lady Ruthven of Freeland, has already reminded your Lordships of what paragraph 14 sets out. May I ask the Minister, when he replies, not merely to give us some general definition of what it is that the paragraph is aiming at, but particularly to give us a definition of the words "management ability"'? A great many people are puzzled as to what the Secretary of State will be looking for. As has been said by a number of other speakers this afternoon, there is a point at which the interest of the consumer should be quite clearly protected. I think it is very important not only that it should be protected, but that it should be seen by the consumer to be protected, because there arc many people to-day who feel that they have no representative, and they do not know where to turn when they arc dissatisfied with the service which they are receiving.
Certainly, it seems that to-day too many people are appointed by somebody or other to one of the various committees, and this is one of the really great weaknesses of the present system. My noble friend Lady Summerskill spoke about the nominated members of the various boards and of the timidity which they develop. I suppose I am not the only one who has heard members of management committees and boards saying how unwise it is that they should press points too hard and for too long. While my noble friend was speaking, I was reminded of the title of one of George Bernard Shaw's plays and I thought much of it was Too True to be Good. I think it would be an advantage if all members of the area health authority were elected. But if the Secretary of State is immovable —and one gets a growing impression that too many people in charge of Depart- 60 ments of State are becoming immovable and ought to take a little more notice of the advice that is tendered not only from this side of the House, but, frequently, from the other side—then I hope he will give really adequate consideration to nominations from professional bodies and trade unions operating within the new Service. In other words, they should be able to nominate who they think ought to represent their organisation.
I have a number of specific points which I want to put to the Minister and, despite what he said at the beginning, I hope that he will be able to comment on them, because I have given him notice of at least four of the five of them. The right reverend Prelate the Bishop of Lichfield touched on my first point, that concerning appointments of staff to posts in the new authorities. Those already in the Health Service surely have a claim here, and I know that they would welcome an assurance that all posts will be filled from their ranks; that is to say, no vacancies will he advertised outside the Service, unless and until an employing authority has demonstrated to the Staff Commission that it cannot satisfactorily fill a post from existing staff.
My second point concerns those who, for any one of a variety of reasons, may find themselves downgraded in the new set-up. Clearly, such people will be victims of reorganisation and it ought to be made quite clear, as early as possible, that if they are downgraded they will receive the pay attached to their previous higher graded post, and such future increases as may be negotiated for it. My third point is on the subject of training arrangements. I thought the noble Lord, Lord Cobbold, was going to develop this point, but he did not develop it in the way I hoped he might do. I suggest that this is the time to set up a central training board to co-ordinate all training. Can we be told this evening whether the Secretary of Slate has anything at all in mind in regard to this matter?
My fourth point is that there should be no further mergers of hospital management committees until the future of the Service is more clearly defined; in other words, in this field there should be a standstill. Mergers inevitably mean unsettlement for staff, and I suggest that it is desirable to avoid repeated changes 61 within a short space of time. We get no better service—rather the opposite is to be expected—if staffs face repeated harassment as a result of mergers between now and the coming into operation of the new Service, and then, after a very short time, have to compete again for posts following reorganisation. Finally, my Lords, I can see no reference in the Consultative Document to any review of the Whitley machinery covering the Service. The House debated this matter recently, when the noble Lord, Lord Reigate, initiated a debate on an Unstarred Question on October 21. I have no wish to repeat all that was said on that occasion; it is sufficient now to inquire whether Her Majesty's Government have given any further attention to what was said in that debate and to ask the Minister when he replies to state whether or not there is any intention of undertaking a review of the 'Whitley machinery. This would seem an appropriate time to do it, now that the whole Service is being considered.
If the Minister can give an assurance on those points, it will be warmly welcomed by those whose futures are inevitably affected by the reorganisation envisaged in the Document before the House. If I press the Minister for replies to those questions this evening, it is because I think the answers are important not only to me but to a very great many people who have invested their lives in the Service. They are entitled to know, and a public statement replying to the points I have put is justified.
§ 5.28 p.m.
§ LORD REIGATE
My Lords, it is an exceptional pleasure for me to follow the noble Lord, Lord Garnsworthy, my old friend and foe. Hitherto, I have always proposed, and been followed by his seconding, a vote of thanks to the returning officer on the occasion—five times—of my successful election. So I think it is only fair that, for once, I should have the latter word, if I may so put it. With some of the points which he raised I am in agreement; with some I am in mild disagreement, and I shall come to these in the course of what I have to say. One of the difficulties with these debates on the National Health Service, as I know from much past experience, is that they are all very wide-ranging. A variety of aspects are mentioned which do not neces- 62 sarily make a coherent sequence in speeches. I offer a worm's eye view, as chairman of an undergraduate teaching hospital. I use the word "worm" carefully, before I am accused of having "pride of place", which I think was the phrase used by the noble Baroness, Lady Summerskill; and I should like to say that I support every word that was said by my noble friend and colleague Lord Cobbold and, of course, by my noble friend Lord Cottesloe as well.
We have now had two Green Papers and a Consultative Document. In parenthesis, perhaps I might say that I think the phrase Consultative Document is a dreadful one. It is symbolical of inflation that we now have even more syllables than in the simple phrase "Green Paper". If necessary, it might have been called a "Pale Green Paper", but please not a "Consultative Document". It has already been abbreviated, in jargon, to "C.D.", and some people think that might be spelt "seedy". We have now had, as I said, three documents, and, from the point of view of those of us who are concerned with the teaching hospitals, each time we have to start afresh to educate our masters, the Ministers, as to the reasons for the independence which the teaching hospitals claim. They all seem to arrive in Office and to be wrongly briefed to begin with; and I should like my noble friend to remind the Secretary of Skate of the words which his predecessor, Mr. Crossman, used at Southampton some two years ago, when he said that he had discoveredhow rightly sensitive teaching hospitals and universities are to any changes, that they may be submerged in a remote regional structure or lose the intimate contacts with the Secretary of State which give them a valuable feeling of independence".Those words could not be bettered, and I hope that both my right honourable friend and my noble friend will ponder those words and not be in too much hurry to destroy a: cherished, and essential independence. Otherwise, I would not wish to repeat what my noble friend Lord Cobbold has said.
As to the Consultative Document, it is, I think, good to end, or to get near to ending, the uncertainty which has now hung over the Health Service for nearly eight years, but I must say that I have very grave doubts about the timetable. It is two years and four months until 63 the appointed day, when the reorganisation of both the local government system and the National Health Service is due to come into operation, and I cannot but feel that this is going to impose an enormous and almost intolerable strain on all those concerned, particularly in the National Health Service. Until both Bills are through Parliament—and we have not yet had a White Paper—inevitably there will be uncertainties which will impede the reorganisation; and if you study the Consultative Document I think you will note that there are at least six major problems or issues which are awaiting the outcome of various reports of expert studies or working parties, or which are (a new phrase which has crept in) demanding special consideration. These include some most intractable and insoluble problems, particularly that of London.
These proposals for integration or unity are admirable in theory, and having made my genuflection towards the theory of integration may I leave the arguments for it there. But I echo what has been said by others: the Consultative Document does not postulate a real unity. The general practitioners are left outside the authority of the area health authorities; the executive councils are to deal direct with the Department, and are to have separate finance. In other words, my Lords, they are to enjoy the freedom which is to be denied to the teaching hospitals. One of the alleged faults of the present system is this divide between the general practitioners and the hospitals. In practice, this is often exaggerated, and depends very largely on personal relationships. None the less, I accept the need for integration; but, as they stand, the proposals accentuate this schism. Nor, my Lords, is there real unity unless the school health service is, in my view, totally integrated with the National Health Service.
I am glad to see the noble Lord, Lord Amulree, back in his place because I enjoyed his speech very much, particularly as I think I agreed with every single word he said. Equally, I feel that unless you include industrial health in its present vestigial form of a health service—that is to say, the medical inspection of the factories and the control and prevention of occupational disease, which are func- 64 tions admirably suited to the area health authorities—then, again, you have gone nowhere towards the integration that is sought. The noble Lord, Lord Amulree, mentioned the prison medical service. I would gladly see that integrated as well, but even what I have said involves the Secretary of State wresting powers from the Department of Education and Science and the Department of Employment and Productivity, which I think is quite enough for one Secretary of State to tackle in one Parliament, and if you added the Home Office (who are notorious empire builders, if I may say so) you would not get anywhere at all. But I agree with the noble Lord and all others in what they have said, and until this is achieved I think the words "unity" and "integration" are, frankly, a mockery.
My Lords, I have studied most of the Press cuttings of the comments on the Consultative Document, and I have read the debate in another place. There are two recurrent themes which have in some measure reappeared to-day and which are worth mentioning. One is that the National Health Service is hospital dominated, and the other is that it is run by a self-perpetuating oligarchy. The latter phrase, "a self-perpetuating oligarchy", comes from a speech by Mr. Crossman in another place. My Lords, I was last re-appointed in the post I fill as chairman of a hospital by Mr. Crossman, and I can only say that I never felt that I was self-perpetuating. I received the invitation from him, which I accepted. I have the greatest affection and respect for Mr. Crossman, who, with his inquiring mind, was an original and very good Minister. I must say my affection and respect are enhanced by the fact that he sits on the Opposition Benches. But I was rather startled to read in that debate that he said—and it has a lot of bearing on the matter of the relative merits of nominated and elected members—in column 613:We can appoint whom we like, but we cannot get rid of him. We are not allowed to…".[OFFICIAL REPORT, Commons, 1/7/71]Every appointment is for three years, so that in six years Mr. Crossman and Mr. Kenneth Robinson could have transformed this "self-perpetuating oligarchy"; and, indeed, they did make 65 many changes. But what an extraordinary confession of Ministerial impotence, to get up and admit, in his own words, that he has been as clay in the bureaucrats' hands! I really hope that we shall hear the last certainly of the phrase "self-perpetuating", or any suggestion that nominated members are more timid than elected members. Are elected Members of another place—and I appeal to those who have been in another place —never sensitive to the opinions of Whips? Are they never sensitive to reelection, as nominated members are said to be sensitive to the horrors of not being re-appointed? Is a nominated member really any less likely to be timid than an elected member, who may have his Party in another place to consider? Of course not. I think this is grossly exaggerated, and the issue as between election and nomination must be on quite different grounds.
§ LORD GARNSWORTHY
My Lords, I intervene only because I should not like it thought that what the noble Lord is now saying is accepted. I think he is strangely out of touch with the great many people who have been nominated on various boards at different levels.
§ LORD REIGATE
My Lords, like the noble Lord, I can speak only from my own experience. I do not think (and I would almost ask for a reference from the Department) that in some of my approaches to them I have been timid; and I have never found members of my board timid. Far from it! Nor, as my noble friend reminds me, would Queen Charlotte's be described as timid. So I hope that we can get away from that.
The other comment was made originally by Mrs. Shirley Williams, for whom I also have the greatest respect, when she said that the National Health Service was hospital-dominated. This is an interesting phrase and one that demands analysis. She quoted some figures; she said that 62 per cent, of the expenditure went on hospitals and 9 per cent. on general practitioners. I have not checked the figures, but I think she underestimates the amount that goes on hospitals. But I must say that I regard these statistics as meaningless. It is quite obvious that an acute general hospital must be more costly. In parenthesis, may I say that I 66 could not agree more with the noble Lord, Lord Amulree, when he referred to acute hospitals tackling the problems of geriatrics and long-term patients. From the point of view of teaching hospitals, we must all have geriatric facilities. But the money goes on the acute wards, where there is a ratio of approximately three staff to one patient. This covers not only doctors, who are comparatively few, and not only nurses; but all the ancillaries to medicine—the cooks, the cleaners, and all the hundreds of people who are needed to keep the hospital going. So it is inevitable that, in numbers of staff employed (and this must have a bearing on the organisation) and in the cost, the hospital service is bound to bulk largest. But that does not mean "domination". If you must use a phrase, talk of "hospital preponderance"; for it is bound to bulk largest. But that is a very different matter from "domination".
The Secretary of State stresses, as everyone has said, good management. I think that, looking at the present Service, we all realise that there are good patches and bad patches. If we study the statistics from the point of view of the efficiency we see how much more is done by hospitals to-day than was done some years ago. One hesitates to use the words "output" or "throughput" or "productivity" when dealing with the care of patients. But when one spends, as the boards and committees do, millions of pounds, one has to examine the priorities very carefully and it is important to watch what is proved by the statistics about the use of the hospitals.
My Lords, I was looking at the figures of one hospital in my group, an acute hospital. I noted that in four years the average stay of patients has declined from just under 15 days to just over 10 days. That is not done only by improved treatment and new drugs; it is also done by good management and good administrative techniques in getting the incoming patients there at the right time and, if necessary, placed in other homes or convalescent homes as may be needed. I hope that we may get rid of this idea of hospital domination of the Service, which somehow suggests that there are in the hospitals surplus resources that could be transferred from the hospitals to other places. It would be regrettable if unification were to mean only a check on the 67 remarkable progress that has been made in the hospital service in the last 23 years.
One last point, my Lords. I echo what the noble Lord, Lord Garnsworthy, said before me. I raised in this House the question of the Whitley machinery, and I pointed out some of the inequities and inefficiencies that exist. I must say that I got a very "dusty answer" from my noble friend. I hope he will recall that no-one spoke in favour of the status quo. I regret his refusal. I think I know why it is. I do not think the Department of Health and Social Security want an inquiry; they never have wanted an inquiry. This does not apply only to the present Administration. Frankly, to put it metaphorically, I think they have a horrible feeling that if the stone is lifted up, horrible, nasty things will crawl out from underneath. On this subject, I hope that the Secretary of State and my noble friend will read the book to which the noble Baroness, Lady Summerskill, referred. It is called Challenge for Change and is published by the Nuffield Provincial Hospitals Trust. In particular, and in relevance to what I have said, I hope they will read Chapter 9 on the staffing of the National Health Service: it is not uncritical of the Consultative Document, and it is not uncritical of the Department's errors for many years past. If the Ministers will read it, I think that they, in turn, may reconsider the request for an inquiry into the Whitley machinery. To sum up, I believe that unification and integration are valueless and will not work unless there is a contented staff.
§ 5.45 p.m.
§ LORD HAYTER
My Lords, I am certainly not going to attempt to speak on behalf of the Management Committee of the King Edward's Hospital Fund to-day because no less than half of that Committee sit in your Lordships' House. If your Lordships are able to identify them personally, you will see what a difficult job I have and what spirited meetings the Committee has. I find myself at medical conferences and the like speaking on behalf of the taxpayer and patients. Several speakers have noted that the word "patient" does not occur at all in the Consultative Document, and that the word "research" occurs once in the Document and once in each of the appendices. My 68 point is that the ultimate success of the National Health Service depends on the quality, quantity and aims of the research and development applied to it. I want much more attention to be given to the idea of setting up some identifiable and publicly-accountable body charged with three purposes: one, the overall strategy for health and welfare services research; two, to review the progress and priorities of research; and three, to co-ordinate the efforts of Government, voluntary organisations, hospitals, universities and industry.
On the first point, this work is going on but it is not in the hands of a body such as the Medical Research Council or the Social Sciences Research Council; yet the sum involved is some £5¼ million and it is in precisely those areas we have been talking about in this debate. It is research into the services themselves, the use made of them and whether we could make more effective use of them; the special developments, the new techniques which have been brought to bear in some of the hospitals on an experimental basis and not yet introduced as a general service, and also in the research and development in medical equipment supplies and appliances together with hospital buildings. There is a certain amount of ignorance in the field as to what is going on, but certainly the last two categories are of tremendous importance in our export of hospital equipment and hospital know-how.
Such a body could assess the priorities to which I have already referred. Why do we spend twice as much on research and development of equipment as on research into hospital building and engineering? A famous book called Portfolio for Health, which set out the Department's research and development programme in relation to the Health Service, appeared recently for the first time. It was not published by the Department. It was published for them by the Nuffield Provincial Hospitals Trust.
Turning to the review of progress and priorities of research, I went to a conference organised by the King Edward's Hospital Fund last week on the health and welfare services. I found myself profoundly depressed; depressed, I think, by the lack of co-ordination, the variety of views that people had and the losing 69 sight the whole time—as has been emphasised time and again in this debate—of the fact that everything has to be measured in relation to the benefit of the patient. How important it is to get the specifications of our aims right! What is the objective of the Health Service to-day? What, indeed, is health? I think it has something to do with the quality of life in the majority of circumstances that surround the individual. If that sounds a bit complicated, I would say that if you happen to have the misfortune to lose a leg you are a happy and healthy person in all circumstances except cross-country running and other activities that you cannot indulge in. If you happen to be a diabetic you are a healthy person in all respects except for such occupations as being an air pilot. But let us get that definition right and follow it right through.
There is a tremendous ignorance of what is actually happening in the Health Service to-day. We have the numbers of staffs, beds and hospital stays, but do we know the whole? We know little or nothing about what is happening to the patient when lie is in hospital. The King's Fund did an investigation on in-patient satisfaction, which was a beginning—not a very satisfactory one, but there is something in it. We certainly know nothing about what happens to the patient after he leaves hospital. Indeed, my Lords, I think you will find that statistics of deaths and discharges from hospital are all lumped together—a horrifying thought that gets back to some of the points made by other speakers earlier on.
We have the problem of the child in hospital and we are beginning to realise that to do things for a child in a physical way in hospital is a waste of time if in that process you have not allowed the child to have his mother with him and have therefore set up a mental state which may last for a long time in after life. We had the problem of the length of stay in hospital which was referred to by the noble Lord, Lord Reigate. We do not really know what it means. On the maternity side there are these wide differences in the length of stay in different maternity hospitals and I suspect that right at the back of it all is the fact that the mother does not want to go home because she has not the home help 70 which would make all the difference to her health—her real health.
But there is a change of outlook in many of these things throughout the Health Service and some of it is very properly outlined by the Secretary of State in the Foreword to this Document. There is no precise borderline between health and sickness. The public somehow feels that medical care must be better, but this has never been evaluated. Despite what was said by the noble Lord, Lord Reigate, we do have an obsession with hospitals. I think the motto should be. "Keep the patient out, but, having got him in, get him out as soon as possible." I was sorry that we did not have the debate on hostels originated by the noble Lord, Lord Grenfell. That was the whole point of the matter. There are many people in hospital to-day who ought not to be there at all: that is why for so many years the King's Fund ran those halfway homes which served such a useful purpose. The education of the public is the key to it all.
The Royal College of Physicians is perfectly right to say that it is part of the medical function to discourage smoking. Preventive medicine is the answer in a situation like that. But this National Health Service research council, if founded, should embody all those concerned with patient care and should have large horizons. All industrial experience, indeed all logic, points to the need for independent, ultimate publicity—a thing which is very rare on the research side in the Health Service at the moment—and free discussion; and I think there is obvious advantage in including industry in those efforts. For when we come to co-ordinate the efforts of the Government, industry, the universities and the voluntary organisations there are many people more qualified than myself who ask the question, "Should the Department be the sole promoter of such research, as it is at the moment?" I only know that in my own business I have invented a phrase that has held good all these years: an inventor is blind to the imperfections of his own invention. It is easy to sidetrack departmental research into something which is administratively convenient. I put down, as an illustration of that, the point about children in hospitals. If the result of research meant 71 that you were spending a lot of money on reorganising children's wards, perhaps it would be better, from the Department's point of view, to leave it alone.
There is this new Green Paper coming out, A Framework for Government Research and Development, and we shall probably be debating it in due course. I should not wish to be thought dogmatic on this subject, whatever the outcome of these discussions. I am suggesting that the Department of Health should have direct control of some fund for sponsoring its own projects. My point is that the Department should have some money and some power, but not all the money and all the power. I hear that there are claims that Departmental research must remain "in the hands of the responsible executive Department". My thoughts go back to a cutting from The Times which I saw, describing what happened in 1934 when the Secretary of State for Airadvised by the Air Ministry, wrote that 'we do not consider that we should be justified in spending any time or money on the jet engine'".Scientific investigation, he explained, gave no indication that jet propulsioncould be a serious competition to the airscrewengine combination.If this Consultative Document is right in its change of emphasis in relation to health problems as a whole, and I think that it is, then it says too little on research and development, which is the key to part of the problem we are discussing to-day. It is a subject of vital importance and one that should not be left to the exclusive control of a Government Department.
§ 5.57 p.m.
§ BARONESS BROOKE OF YSTRADFELLTE
My Lords, I think that those of us who have sat through this debate so far would probably agree that the noble Lord, Lord Aberdare, and his right honourable friend in another place have had a bit of a "pasting" this afternoon. I would call to him, as the spectator at a Welsh Rugby match once called out to one of the players, "Never mind the ball, Dai—get on with the game!"Before I say the few things that I want to say I should like to pay a tribute to the work undertaken by the noble Baroness, Lady Serota, when she 72 was in the position now occupied by the noble Lord, Lord Aberdare. Noble Lords on both sides of the House know that she had the health of the people and the happiness of the patients and staff at heart. She gave wholeheartedly to that work and I for one have a great admiration for what she achieved during the time she was in Office.
My Lords, I should also like, if I may, to refer to the extreme humanity in the speech of the noble Baroness, Lady Masham of Mon. The Consultative Document has been "ribbed" because the word "patient" did not appear in any of its pages. Quite frankly, my Lords, I have not been through it with the analytical tooth-comb which some people have used but I will take it that it does not. I thought however, that in Lady Masham's speech we had all the humanity and compassion for patients and for their friends that is characteristic of this great Health Service of ours. One last personal note. I am so very sad that the noble Lord, Lord Grenfell, cannot be here to take part in the debate because he has been such a strong supporter of national health in these debates over the years, with his considerable knowledge as chairman of a great management committee.
I wish to touch on two different subjects in connection with the Motion which is being debated. The first one concerns the immediate future and the "getting on with the game." In May of this year the Secretary of State for the Social Services said, on the first page of his Consultative Document thatthere must be early decisions so that the enthusiasm for reform does not wither away".As the principle of the unification of the National Health Service is now generally accepted, the great thing is that there should be an early end to the present state of uncertainty. During the last decade those working in the Service have made substantial progress towards functional unification, but I can see real grounds for fearing that this movement may lose its impetus during the months ahead because of the personal insecurity of those whose future will remain uncertain until Government decisions are definitely announced.
Many people in the Service were disappointed to find that only Scotland is 73 to be legislated for during the present Parliamentary Session. It may be that it was because one of the Ministers on the Scottish front happens to be a woman and she is determined to "get on with the game". This presumably means that England and, I regret to say, Wales will have to wait until late 1972 or early 1973 before a Bill can be placed before Parliament. This is very worrying, because the time-table, as we have already heard from other speakers this afternoon, is going to be extremely tight, if the reorganised Health Service is to come into being on April 1, 1974. As the result of the implementation of the Local Authority Social Services Act, the reorganisation of the social services which came about earlier this year caused a pretty considerable unheaval. The Health Service is an even bigger organisation and the scope for administrative confusion in 1974 will be vast, unless it is known precisely where we are going at least two years in advance. It is most important that the White Paper should appear without fail by Easter, 1972, and that legislation should follow as rapidly as possible.
The change of administrative framework will not by itself achieve anything but it will provide a firm basis on which to build a revised Health Service, in which the priorities can be looked at across the board in terms of scarce resources both of manpower and of money. I think that the decision to make the new local authorities and the area health authorities coterminus is right, and it is to be hoped that a high degree of autonomy will be granted to the area health authorities, as there is great concern lest there should simply he a takeover at regional level. There are powerful forces in favour of giving wide authority to what would he little more than reconstituted regional hospital boards and if this should happen the result might be disastrous for the community health service, on which we must depend for the great bulk of health care in this country—disastrous, because conflict between the high powered managements at regional level and at area level may suffocate the patient altogether.
Having made those general points, I should like to refer to those at present employed by local health authorities in the field of public health. When reorganisation 74 comes about, very nearly all those working in hospitals and in general practice will carry on with essentially the same duties, whereas the public health service as we know it to-day will cease to exist. Those who are working at this moment in public health accept the need for a change but justifiably hope that their continuing contribution to the National Health Service will be encouraged.
The Hunter Working Party is likely to make its report upon the future of medical administrators to the Secretary of State early in 1972. That should take care of the doctors. But there are other professional groups in the public health field—the nursing staff, the administrative staff and the clerical staff. I have worked closely with the Queen's Institute of District Nursing for the last 37 years and I know at first hand what outstanding service the domiciliary nurses have given to the community: so have the mid-wives and so have the health visitors. The administrative and clerical staffs have also served the public well. I would make a plea with all my heart that all these groups should be encouraged and not overlooked and that they should be assured of a fair opportunity to contribute their skills and talents to the new organisation on equal terms with their opposite numbers on the hospital side.
The second subject I want to raise concerns the use of voluntary helpers. My noble friend Lady Ruthven of Freeland has already introduced them into this debate. On Page 6 of the Consultative Document there are just ten words in which this invaluable service is dealt with:Collaboration with voluntary organisations, too, will continue to be developed.How our friend and colleague the late Lady Reading, must have smiled at that pious intention. She gave 33 years of her life to the creation and development of one of the greatest voluntary movements this country has ever seen. To quote some of her own words taken from a brilliant treatise upon voluntary service which was written just before she died:Great Britain is a Welfare State and is now in the throes of reshaping the statutory bodies which administer it. During this transitional period many things will have to be altered, many difficulties will have to be faced. The integration of voluntary service into the work of the statutory bodies demands that the 75 volunteer must understand how statutory aid works, where voluntary action participates, and how the volunteer fits into the pattern of the whole.Lady Reading is not here to speak to-day, so I am daring to try and say a little of what she would have said so much better. What she said is just what the W.R.V.S. have endeavoured to do in their contribution to the work of the National Health Service. They have set out to train themselves for intelligent integration. In the first place, the aim has been to prevent the need arising for people to be sent to hospital or institution. Apart from consideration of human likes and dislikes, increasing costs within such institutions are governing factors which emphasise the importance of this aim. The system whereby the W.R.V.S. as a kind of subcontractor to the local authorities carries out community services for which the authority is financially and statutorily responsible is very effective—for instance, Meals-on-Wheels is a good example of what I am saying.
Great efforts are also made to render it possible for people who can do so to leave hospital and to return home, or to go to a smaller hospital or convalescent home which provides less intensive care but where voluntary help can make a practical contribution of compassionate service. The W.R.V.S., the British Red Cross, St. John and the Leagues of Hospital Friends are doing their best to meet the needs of the hospital and domiciliary and social welfare services. Their efforts have met with considerable success, but much more could be done with even better co-ordination between the voluntary organisations and Government Departments. Consultation with the voluntary organisations at an early stage of project planning is essential.
Stella Reading had almost a horror of publicity or personality projection for the service she founded. But during the last year of her life she realised that to provide machinery to enable others to make their contribution to health, welfare and community service was a priority duty for the W.R.V.S. and that publicity must be given to the diversity of jobs available. Accordingly, she arranged for the production of the first printed Annual Report of the W.R.V.S. It was the last document which she signed officially as Chairman before her final illness.
76 It contains an amazing record of work undertaken and jobs done. I will refer only to the section devoted to the service available in hospitals, not only for normal patients but also for the mentally ill and mentally handicapped. There are 522 W.R.V.S. canteens for out-patients or visitors; 742 shopping services and trolley shops; 142 static shops and 27 purpose-built shop-canteen units (do not ask me to tell you the difference between these two categories, because I do not know, but I am sure that both do marvellous work) mainly for the mentally ill. There are 139 library services, and diversional therapy and handicrafts in more than 100 hospitals. The W.R.V.S. will he found at work in 1,311 general hospitals, 113 mental hospitals and 70 hospitals for the mentally handicapped. The hospital car service in England and Wales is organised jointly by St. John, the British Red Cross and the W. R. V. S. in conjunction with the country and county borough ambulance services. In 1970,406,687 patients were driven 5,436,631 miles.
I could go on for a long time recounting the quiet achievements of immense value that are being recorded daily. The future potential is limitless. Of this I am sure that my noble friend Lord Aberdare is fully aware. But the potential will wilt and wither if it is not encouraged and welcomed and made use of by statutory bodies. I have come to the end of what I have to say, except that I believe that I shall carry your Lordships with me when I say that the name of Stella Reading will go down in world history as having done for voluntary community service what Florence Nightingale did for the Red Cross.
§ 6.10 p.m.
§ LORD PLATT
My Lords, in the first place, I am bound to say that the Foreword by the Secretary of State makes rather disappointing and somewhat ungenerous reading, though this has been considerably repaired by the opening speech of the noble Lord, Lord Aberdare, which we very much appreciated. The second paragraph of the Document refers to the "creaking structure" within which doctors, nurses and administrators must work. I should be the first to agree that a little oil could be applied in places, but the Document seems to omit to state the fact that the medical services in Britain 77 are better than those anywhere else in the world—and I make that statement without reservation. I advise almost anyone who is taken seriously ill in almost any part of the world to take the first plane back to Britain. The exception, of course, is the person who needs a repair to some damage done by a previous operation, because they have great experience of that in the United States, where so much bad surgery is done. The Document fails to say these things, but especially I think it is notable that it fails to mention the excellent work done by the Regional Boards of the National Health Service. That has been outstanding. Before we break down the existing structure (though I shall say later that I am in favour of a great deal that is suggested) we have to see in what way the new structure will be better.
For four and a half years I was Chairman of the Distinction Awards Committee for Consultants in the Health Service, and it was my job every year to visit the whole of the 15 (not 14, as stated in the Consultative Document) regions, as well as the sub-centres.
§ LORD PLATT
I thought there would be a snag in it somewhere. I have also visited sub-centres—important places, but not university centres—at Wolverhampton, Middlesbrough, Coventry, Southampton, Portsmouth, Exeter, Lincoln, Carlisle, Bath, Truro, and I could mention a dozen more. Perhaps, therefore, I have a better knowledge of the senior administrative medical officers of the regions, of the chairmen of the boards of governors and secretaries, and of the work done in those places, than almost anybody in your Lordships' House. Wherever I go I find spendid work being done, and done often with great enthusiasm. I have seen excellent new district hospitals in Peterborough, Windsor, Swindon and Hull. I know that the Department does not want to be patting itself on the back all the time, but I think some of those points might have been mentioned in the Document. I have of course come away with the impression that some Regional Boards are a great deal better than others; but I think it extremely unlikely that when we get the new Regional Boards there will not be at least some similar differences in quality.
78 Another point that could be made in the Document, but does not seem to be made, is that some of the creaking that seems to be going on is really due to lack of finance: in other words, palm oil is the kind of oil needed. The recent statement by the Secretary of State, that a good many millions more are going into the Health Service, and in areas where they are greatly needed, is most heartening. But nothing is said of the need for finance being the cause of what is called this creaking. In my view, some of the need is owing to a lack of flexibility in finance, which I assume though I have no knowledge of it—would not be tolerated in industry. One of our difficulties in the Health Service—I have sat on a board of governors for many years and have not seen it merely from the doctor's point of view—is the difficulty of rewarding an outstanding person, possibly a ward sister, a secretary, a pharmacist or a telephonist. You cannot give such a person more money because the scale does not allow you to do so. I should not like to tell your Lordships in the presence of the Minister of some of the "wangles" that we have done by giving people different job names from the ones that they actually do. That point might well be looked into in any reorganisation of the Health Service.
Then, the Document has little or nothing to say about patients, although I will say in its favour that it is not really about patients but about the running of the Service for patients. It has little to say about doctors. But what is more important is that it has little or nothing to say about the general practitioner, except that he occupies a central position in the Health Service. It is rather like the same remark on the voluntary services: the bouquet is there, but nothing more. The best type of general practice has improved out of recognition since the Health Service came about.
I agree, as I think practically everyone does now, that there should be integration and that the so-called tripartite structure—a rather hackneyed term nowadays—should go. But there are a number of things that we have to remember. I have always been a little afraid in all these discussions about the tripartite system as to the position of the general practitioner and whether he will be better off or worse off when he will 79 virtually be competing for funds with the hospital service. The need for new and magnificent operating theatres, the need for new laboratories and so on all seem to take precedence over the everyday work of the general practitioner. This is a matter at which the new organised Health Service must look carefully and make sure that the general practitioner really gets his say and his need. In that respect, I could refer to the question of medical representation, regional and at area levels. I know that my colleagues in other organisations and professions have sent in documents in which they go into details—I do not intend to go into them this afternoon—of representation on the various boards. That in general I support, though I think one can go too far.
What is in danger of being forgotten is that the new area boards (your Lordships will forgive me if I do not use exactly the right term; area committees, or whatever they are) are no longer just hospital committees. If there are to be at least two doctors on these committees (which may or may not seem reasonable) it would seem to me that two very eminent people in the local district hospital—it may be the senior physician and the radiologist—would expect to have those two places. We must leave room for general practitioner representation which is very important if the tripartite system is going to end, and the area health service is going to deal with general practice as well as hospital practice. In contrast to the various omissions that I have pointed out, there is emphasis on management. I am trying to take the best possible view of this Document. In my view it is the best of the three Documents, and I am sure that it is a sincere attempt to do something better. I am sure that the management idea is good if the management is good. Here we come to finance. Are we going to offer the type of salaries to attract good people as managers? Will they be of a status to enable them to talk to the senior surgeon and senior physician and, if necessary, tell them where they get off? People of pretty high calibre are required for this job. My worry is that we shall not get them. We shall get them in the big, most notable places, but shall we get them in all the other areas and 80 the lesser regions? If not, we might be better off soldiering on as we are doing at present. I would rather have no manager at all than a manager for whom I had no respect at all.
I have read most of the comments which have been made by the British Medical Association Joint Consultants Committee, and so on, and they raise a number of points. They point out that the Document is very vague on many issues. This is obvious. On the other hand, if it were too detailed we should be saying that the Department had come to all its conclusions before consulting us. There are important details to be threshed out by intimate consultation and discussion which would not be suitable for me to go into this evening.
We come now to the question of nomination versus election. I am sorry to report to many people whom I greatly respect that, of the two, give me nomination every time. There are cases in which election is right, but I am not one of those people who is frightened of nomination. Any Minister worth his salt consults the kind of people that he should consult, and the appointments are really made by the medical staff, universities and so on, although they are nominated by the Minister. I very much agree that the present regional hospital boards, and boards of governors, are really a confusion of two functions. I pointed this out —as did other people—about ten years ago. They consist of anything between 20,30 or more people, only five of whom take a really active part in the management of the board, the area or the hospital, or whatever it is they have to manage. The others are representatives of local interests, either geographically defined—for example, that the people at Rochdale do not have as good a maternity service as the people at Stockport or something of this kind or they may be representing different branches of professions or age groups and so on. These people will now meet in the new community councils. If these are properly run and have access to the people who have the finance and make the decisions, then this is a splendid idea. The governing body should be a comparatively small one. Advisory committees—I have in mind medical ones, but there will be others—should be strong. The community interests should be separately 81 represented and not mixed up with the management and governors.
There are three smaller but important points I want to make, and then I will wind up with a few other matters. Some of my colleagues do not agree with what has been called—a horrible word, which a heard to-day for the first time—"coterminosity". Some of my colleagues do not agree that the health service area should be coterminous with the local authority area. They feel that it should not stride over two local authority areas; that it should be in the closest possible touch with the local authority. But there are certain places in which there will probably be two quite big district hospitals with perhaps a considerable area of countryside in between where it may be better to have two area health authorities within the one local authority region or area. Secondly (and this is more a point of consultation), appointments at registrar level or above should be a matter for the regional machinery and not for the area machinery. Thirdly, we are very interested in the result of the discussions referred to in paragraphs 7 and 8, which are going to put a little more detail into an otherwise rather vague statement on how these health areas are to work. We hope that all interests—and, needless to say, I have medicine particularly in mind—will be thoroughly consulted before any final conclusions are arrived at on this point.
My last three matters are as follows. Integration is not complete, as the social services will remain with the local authority. Some of us think that this will make for, and is already making, quite serious difficulties, especially in certain areas like mental health geriatrics and midwifery. The G.Ps., although by some kind of lip service, written documents, and so on, may be integrating, really appear to be going on as they were before. One is bound to come away wondering whether this desire for closer co-operation between hospital and G. P. is going to come about as a result of these changes. Insufficient is said on the matter of the development of general practitioner services. This is important, because the general practitioners are not good at speaking for themselves. They are widely distributed, there is a vast number of them, and they are not so well organised as a 82 consultant group, for instance, in a large district hospital, and their needs are not so easily made known.
I should like to back up as strongly as I can all that the noble Lord, Lord Cottesloe, and others have said about our centres of excellence, in London in particular, in the special and postgraduate hospitals in particular. I am a little in two minds over the future of the highly specialised hospitals because I am quite sure that in fifty years' time, if not before, they will be out of date. We should have specialties such as the skin, the eyes, obstetrics and so on, in a centre where all scientific services are available and where we can attract the best scientists, the best pathologists, the best radiologists and so forth. Nevertheless, we have centres of excellence in London and these postgraduate hospitals can often be combined with other hospitals and general hospitals and can continue to exist in a somewhat different way. But they are most important; their finances and their interests should not be just lumped together, with somebody saying to them, "You know, your expenses are 40 per cent. more than somebody else's. You must cut down on this and that". We must keep up the idea that there should be some centres of excellence, as there have been in the past; and these, as others have said, have earned a very great reputation for this country and for British medicine.
§ 6.31 p.m.
§ LORD AVEBURY
My Lords, I begin by declaring an interest in that I am an adviser to G. D. Searle, a company which specialises in the delivery of many aspects of health care, from pharmaceuticals to gamma radiography, to multiphasic health screening systems. I want to take up one or two points which the noble Lord, Lord Platt, has made in his very thoughtful contribution—and it is quite an ordeal to have to follow the noble Lord, who is so eminent in this field. I agree with him when he says it was a pity that in the foreword to the Consultative Document the Secretary of State did not pay some tribute to the medical staff we have in our hospitals, who are indeed the best in the world, as the noble Lord has said. It would have been fitting if he had not only done this but also paid tribute to the fact that we have the best nursing 83 service in the world as well. This has been brought out in the interchange between the noble Baroness, Lady Summerskill, and her sparring partner on the Cross-Benches, when they were talking about the differences between this country and the United States. There is no doubt at all that we have the best medical and the best nursing services in the world, and, as the noble Baroness remarked, anybody who has been to the United States—she mentioned Los Angeles, but one could name many other cities in that country—would see how privileged we have been in spite of the faults in our administrative structure. I am afraid that in the course of this debate we have rather lost sight of that in all the arguments about management and whether it has the right emphasis.
We have, as my noble friend Lord Amulree pointed out, lost sight of the fact that what we really ought to be talking about is patient care. The whole point of reorganising the Health Service is not to present to the nation some perfect administrative structure that will stand up to any examination by management consultants, but to improve what is being done for the patient in the hospital and the local authority health services or in the family doctor services. I should like to come back to this point when I have said just one or two words about the very interesting remarks of the noble Lord, Lord Platt.
He said that the regional boards at present did some extremely good work; and I do not think one can deny that. At the same time, we have a number of superannuated aldermen on our regional boards and hospital management committees who contribute very little. What one is afraid of in looking at any proposals for reorganisation is that we shall get the same "Christmas pudding", or the same ingredients, mixed up in a different way; that we still have, according to the Consultative Document.15 members appointed by the regions and all the persons who are on the regions are appointed by the Secretary of State. This is not necessarily the best way of achieving an efficient and humane Health Service. There should be an element of democracy, not in the sense that other noble Lords have described, which is not democracy at all—the Crossman-style 84 proposals wherein the majority of representatives on the area health authorities or the regional boards are appointed by the corresponding elected local authority —but where they are directly elected. What is wrong with having some people on the area health authority or the regional boards directly elected by people whom they are going to serve?
I am surprised that people can talk about democracy when what they really mean is nomination by people on the local authority who are always politically inclined and who are going to nominate people belonging to their own political Party. Let us be quite blunt about it. We know this happens. We look in our own areas and see who gets appointed to the hospital management committees, who is nominated to serve on the regional hospital boards. They are all members of the majority Party, which happens to be in control in the area, with one or two make-weights thrown in so that nobody can say there is any prejudice. I am afraid that if the majority of area health authorities are appointed in this way, the same thing is going to happen. This is going to be a reward for past service and not a means of selecting those people who are most capable of making a serious contribution to the management of the Health Service, which is what this Consultative Document is all about.
I agree with the noble Baroness, Lady Scrota, that there is undoubtedly an overwhelming case for integration, and we should not argue that again this afternoon. What we need to talk about is the way in which this integration is going to benefit the patient. I should like to mention just two aspects of this question which are of particular concern to me. One is the family planning services. I do not see any mention in the Consultative Document of how they are to he handled: whether they are going to be under the control of the area health authorities or the local authority social services committees. I agree with the anxiety which has been expressed by the noble Lord, Lord Platt, that there can be some overlapping and dichotomy between these two authorities.
I was talking to the consultant in the casualty department of one of our hospitals, and he told me that in many cases patients call in for treatment in that hospital when they really ought to 85 be the responsibility of the local authority social services committee; but they do not get in touch with the chief medical officer or chief welfare officer because they know that the facilities are not available. Therefore the liaison does not exist at the moment, and just by saying, "we will appoint certain people from the local authority social services committees on to the area health authorities", or the converse, does not mean to say that we are going to get efficient communication between the two.
However, to come back to the question of family planning, this is of vital importance because we are trying to find more money for the Health Service. The Secretary of State, in a very welcome statement last week, announced the provision of an extra £118 million for the mentally ill and geriatric services. But if we were to have a family planning service then we could provide this sort of money—indeed, more than £118 million —and should be able to serve the public in a much better way than we are doing at the moment. In a very interesting summary, The Needs of the Health Service, produced by the King's Fund Hospital Centre, there is reference to the amounts of money which could be saved by adequate family planning services. It is claimed that for the expenditure of £40 million a year we should be able to provide effective birth control for every woman at risk and that the saving in terms of maternity and child care and other services would be something between £200 million and £400 million per annum. The difference then of £160 million minimum would not only enable us to provide this extra money for the mentally ill and the geriatric services which the Secretary of State has just announced but would give us at least another £42 million to spend on other Cinderellas in the National Health Service.
The second Cinderella that I want to mention is the accident and emergency service, to which the right honourable gentleman the Secretary of State alluded briefly in his Statement last week. He said that he intended, for example, to provide for increases in key staff for accident and emergency departments. One would like to know how this is going to be affected by the reorganisation. Are we going to have a concentration of 86 the accident and emergency services in fewer and fewer hospitals by the closure of those departments which, it is said, are not viable by the test of management—perhaps they do not pay for their keep, as it were—but which are giving a service, and an extremely important service, to the patient? If they were shut, the patient would have to go much greater distances in order to receive attention.
This is by no means an academic question. One looks at the appalling carnage that takes place on our roads every year, costing vast sums of money. One should not really put it in financial terms, I suppose, but according to the recent report of the Road Research Laboratory the cost of road accidents is £300 million per annum. This very afternoon there has been a pile-up on the Ml in which a hundred ears were involved. At least 10 people are said to have died; the Luton and Dunstable hospitals are treating 28 casualties. An R.A.C. patrol man reported that there was a scene of carnage there, and a lorry driver said that it was just like a battlefield. On our roads this type of severe accident is, unfortunately, occurring much more frequently now as the speeds of vehicles increase. One knows that the speed limit was brought in on motorways some years ago, and this had some temporary effect on the incidence of road accidents. But if we continue to close the casualty departments, and concentrate treatment in the big district general hospitals, we may possibly lose lives through the time it takes to get patients to hospitals.
This point was brought out in a recent "Panorama" programme in which the accident and emergency services were discussed. The question arose of closing the casualty department in Maidenhead hospital and requiring the patients to go to Wexham Park. It was pointed out by some members of the management committee at Maidenhead Hospital that it could take as long as half an hour for an ambulance to get to a patient at the extremity of this area and take him back to Wexham Park for treatment. This is all very well if teams are going out with the ambulances; if the ambulances are properly equipped and serviced by professional personnel able to carry out 87 intubation, to replace lost blood, and so on, while the patient is being brought into hospital. But, unforunately, very few of our hospitals provide such a service. One that was mentioned in the "Panorama" programme was the Derbyshire Royal Infirmary, and no doubt there are many others up and down the country. But is the National Health Service willing to spend the money? I am told that it is extremely expensive, because the teams have to be kept on duty for 24 hours a day, and for most of that time they will not be doing anything because no major road accident will have occurred. The alternative, surely, is not to adopt a policy of wholesale closure of casualty departments but to maintain them at the expense, perhaps, of some degree of managerial efficiency. If accidents continue to occur at the rate that, unfortunately, they do at the moment (and I am not speaking only of road accidents in this connection) the indirect benefits to the community of such a course may be very large indeed.
Another point I want to raise in connection with casualty departments is the absence of any career structure, to which attention has been drawn by the B.M.A.'s Central Committee for Hospital Medical Services. They pointed out in a report which appeared this year that as long ago as 1969 the representative body passed a resolution to the effect that action taken to secure a career structure for people to rise to consultant status from the major accident and emergency centres was grossly inadequate. I think I am right in saying that the Secretary of State announced the other day that thirty posts of consultant status were to be created in casualty departments, so that there would be at least the beginnings of a career structure. Obviously, thirty posts is not enough, if the statement refers to the whole of England and Wales. It does not give enough incentive to the young doctor to remain in the casualty department and to make it his career if he knows that there is little chance of promotion to consultant status. I should like to ask the noble Lord whether, when he replies, he can tell us when these thirty appointments are to be made, and whether there is going to be some machinery for apportioning them as between one region and 88 another. It will be an invidious job, I feel, to say which heads of casualty departments are to be given consultant status.
There are many other parts of the Health Service which are Cinderellas. I have mentioned two of them—family planning and the accident and emergency departments. I hope that at the conclusion of this debate we shall not think that, merely by reorganising the administrative structure and giving another £118 million to what are agreed to be important aspects—the mentally ill and handicapped, and the geriatric services—we have finished the job. A great deal remains to be done, despite the fact that, as the noble Lord, Lord Platt, has remarked, we have the best Health Service in the world. If we want to maintain our reputation in this field we must realise that we must spend a greater proportion of the gross national product on health, and that as standards of living in this country rise the people will expect better nursing care, better medical care and better machinery for administering it.
§ 6.49 p.m.
§ VISCOUNT DAVIDSON
My Lords, the hour is getting late and I will do my best not to add to the lateness. Like the noble Lord, Lord Avebury, I must begin by declaring an interest, though an interest of a very different sort. For the past ten years I have been a member of the management committee of a large group of hospitals for the mentally handicapped in North-East Essex, and for the last five years I have been chairman of that committee. I have also served on the management committee of a general group of hospitals, including one for the mentally ill. What I have to say during the next few minutes will be confined to the problems and the needs of the mentally handicapped from the point of view of a layman who is involved in this particular aspect of the National Health Service, if not entirely within the context of the Consultative Document.
Basically, the problems of the mentally handicapped, however unified and however integrated the National Health Service may be, are different from those of the mentally ill, and very different from those who require the services provided by general hospitals. However 89 much one might wish it were otherwise, it is a basic fact of life that someone who is mentally handicapped will be dependent to some degree or other upon another person who is more fortunate, for the rest of his or her life.
At present, as your Lordships know, these people live and are cared for in what are known as "long-stay" hospitals. Some of these hospitals have hostels attached to them (as in my group) where those who are less handicapped can live in more homely surroundings. Although still under the management of the hospital group they live a more homely life and are in closer touch with the local community through being able to work in various jobs in the locality. The great majority of our patients, however, live in our hospitals, where conditions and surroundings vary dramatically between those who live in a few more spacious modern functional villas, and those who are housed in Victorian workhouses. It is these latter, which unfortunately house such a large number of mentally handicapped people, where conditions of overcrowding with the accompanying risks of disease and fire hazards have for so long placed an almost unbearable burden on the staff, which have given such deep concern and anxiety to the management committees, who have had neither the authority nor the funds for the major changes which were required.
Recently, however, the public conscience has been aroused. All those aspects of the problem of which we who have been so closely involved have been so acutely aware have become public knowledge through the mass media, through community contacts, enlightened visiting, and through Leagues of Friends and voluntary workers. More dramatic revelations, resulting from a limited number of inquiries into allegations of cruelty and other charges, have highlighted some of the conditions which prevail in this hitherto neglected section of the National Health Service. Not for nothing has it been called the real Cinderella of the Service. But I must emphasise that these incidents have been isolated ones and should be considered in perspective against the whole background of the continuing care of the mentally handicapped, which is of a very high standard.
My Lords, we are now at the crossroads. For the first time a positive and 90 constructive policy is being worked out, and it looks as though the financial resources for implementing this policy are being made available. The White Paper published last July, Better Services for the Mentally Handicapped, coupled with that excellent document, Buildings for Mentally Handicapped People, published by the Department last January, provide first-class guide lines for planning future developments.
But it is at a time such as this, when fundamental and radical changes are being proposed, that feelings of uncertainty can develop, and I must confess that the Consultative Document, with its rather vague proposals set out in general terms, adds to rather than subtracts from this uncertainty. So far as the mentally handicapped are concerned, it is generally accepted and agreed that a high proportion of those at present in hospital could and should be cared for in the community, in hostels or in homes, as the White Paper rightly calls them, provided by the local authorities. But this will all take time, and even when the homes are built and ready for occupation I am seriously concerned as to how they will be staffed.
At present the care of our patients is being provided by a body of dedicated men and women, many of whom have given the best years of their lives to this selfless work, working frequently in overcrowded, ill-equipped conditions and at a very modest rate of pay. Many of them are highly qualified and experienced in all forms of care; for it must not be forgotten that the mentally handicapped can be seriously ill, have crippling defects, severe physical abnormalities, be doubly incontinent, be blind or deaf, or incapable of coherent speech or understanding. A conservative estimate of future requirements is that nationally we shall require 35,000 hostel beds and 25,000 hospital beds. The patients remaining in hospital will be well cared for by existing staff, but who will staff the hostels? What provision will there be for retraining in the management skills which will be required for the patients who will be in community care, with the additional welfare and social problems which will be created? What security can be offered for a career in caring for the mentally handicapped in view of this changing pattern? What security for the men and women, qualified 91 and unqualified, nurses, occupational therapists and administrators?
I pose these questions, my Lords, for, having lived for so long with the many day-to-day practical problems in this field, I am convinced that the question of the quality of the staff far transcends other questions such as antiquated buildings and management structure. There will have to be retraining; there will have to be management courses for the staff of residential homes; staff recruitment will have to take place simultaneously with the provision of residential accommodation, with skilled interviewing and selection of candidates for this field of work; salaries and general conditions will have to be protected; full consideration must be given to all staff who may be involved in the transfer of patients from hospital to local authority homes. And, above all, we must ensure that there is no lowering of the high standards of care, which could result from the dilution of the trained staff with too many who are untrained.
Finally, with respect to the noble Lord, Lord Avebury, I should like to say a word about the impending demise of the management committees. For the last 23 years they have given valuable service to hospitals in the National Health Service. Composed of representatives of local authorities and local organisations and of independent lay men and women, they have been able to provide objective advice and present objective views. Their work has been unpaid, their achievements have been unsung and their task has not been an easy one, for they have had to exercise that most difficult of things, responsibility without authority. But their main function, in my view, has been to establish a close relationship between the patients and staff in the hospital and the community which those hospitals serve. They have at times acted as an exhaust valve for pent-up frustrations and emotions which might otherwise have caused unnecessary troubles. I only hope that increased involvement by local voluntarly organisations in hospital work may go some way towards filling this gap. I would mention to my noble friend Lady Brooke that it is only a fortnight ago that we opened in my hospital a brand new canteen staffed by the W.R.V.S.; that is a great move forward 92 and one which we are all very thrilled about. But this is my chief concern: that in the proposed new structure, however professional the management, however efficient the administration, this personal touch, this local contact which is so vital in hospital work and life, may not be quite so warm or so close in the future as it is now. I only hope that I may be proved wrong.
§ 6.57 p.m.
§ LORD MORRIS OF GRASMERE
My Lords, I realise that it is late, but the point I want to make is, I think, very important. I will try to be very short. I am not myself as annoyed as many previous speakers about the word "management" in this connection. Management may mean to me something a little wider than perhaps it does to some other people; I do not know. It seems to me that people have been alarmed at talk of management because they think of management as largely concerned with avoiding the misuse of public funds, perhaps the misuse of money generally. But, of course, management is very much involved in the development of the structure and the handling of medical services, the use of our medical resources. When we have a Health Service in which the morale of the general practitioners, for instance, has for a long time been so low (many of them have persuaded their sons for a long period not to go into the profession); a service in which there has been such immense difficulty in getting nurses, and where it is generally thought that a great deal of the difficulty is that recruitment is difficult because girls do not like the way they are managed and handled—to mention just two instances—it seems to me extraordinary to think that improvement of management is not required.
But even outside the question of preventing, misuse of public funds, there are of course two big spheres of management: the practical management, and the management of tactics and of strategics. We are now embarking on some real thinking—perhaps it ought really to be rethinking—of the structure and handling of the whole Health Service; and surely one should ask oneself, "Where is the weakest part of the Health Service?" A large part of the Health Service is palpably a very great success. I agree with 93 the right reverend Prelate that the hospital service is magnificent and, by and large, does work, except on certain fringes —for example, communication with people after they leave hospital, communication with the general practitioner, and so on. There is the point about the morale of the junior doctors, which is very serious indeed, and it has a great deal to do with management. If the profession cannot manage it, and cannot prevent the junior hospital doctors from being in a suppressed state of revolt, it is time for some other manager to produce a situation in which that does not happen.
I say nothing of the hospitals themselves. The hospital service is, by and large, magnificent. But where is the weak part of the Service? I have not the slightest hesitation or doubt (and I think that here many of your Lordships from your own experience will hear a bell ringing) in saying that the weakest part is the impingement of the Health Service on a great number of families when no member of the family is in hospital. Many people have talked about hospitals, and about nothing else at all, as if the hospital service were the Health Service; yet of course it is not. Probably, it is not even the most important part of it. Again and again people, including statisticians, say that it is far cheaper to keep people well, and, if they show signs of having something the matter with them, to catch it early and prevent it from getting worse, than it is to cure whatever is wrong. Even the statisticians say that. This may be difficult to believe, but that view is generally held. Subject to the skills of management, it is probably true. The Service is weakest at its impingement on the great mass of families of the country when they have not got a child in hospital.
We ought to be asking ourselves, when we re-think the National Health Service, whether we are making the best use of our resources. Our medical and nursing resources are magnificent; our resources in some of the ancillary professions, or near professions, or sub-professions, are not as good as all that, but they are pretty good and arc coming on. The resources are good. But what about their use? Much of this aspect has to do with the general practitioner, and I see a good deal of the attitude of a large 94 number of people to the way the general practitioner service is working, because for 8 years I have been concerned with the training of health visitors and community nurses, and in studying their work and what is happening to their work under the development of the Health Service. By and large, the general practitioners have a morale which is not high. We ought to ask ourselves what would be the right use of the general practitioner, of which again we have magnificent resources.
Let us look at the matter as family men who have lived through our lives and looked after our wives, to some extent our sisters and brothers, our children and grandchildren, and played a fairly considerable part in keeping them well and keeping them going. How have we done it? Those of us who have been brought up in the educated classes have done it, to a considerable extent, with the help of medical advice: not medical treatment in surgeries or on hospital beds, but medical advice. We used to think that this was something that the Health Service would do, but broadly speaking we have made little or no progress in it at all. What does the general practitioner do? Why is his morale low? Why does he tell the young not to go into it? He says that they are doing all the wrong things. In other words, he spends his day in the wrong way. The educated classes used to be able to get medical advice and not wait until they were ill. If they were going abroad or taking a new job, or were thinking about a rather exacting profession for their sons or daughters, they took medical advice. How do you bring the benefits of that to bear on the great mass of families in the big cities? I live in a village, and I think that a good number of the families in the village still have sufficient contact with the general practitioner to get many of the advantages to which I have referred. But how do you do that sort of thing with the great numbers of people in the large towns?
I must not take too much time. I have almost taken the time that the Select Committee would allow me. We have made some progress with this matter, but it is very slow, and it has a bearing on the organisation of the Health Service. In the last resort, the clinical care and medical advice of the families in the country is given not by hospital doctors 95 or by the medical officers of health (as is the case in the colonial countries that we have developed overseas); it is given by the general practitioner. Who deploys the resources of the general practitioner in any locality? The reorganisation of the Health Service ought to ensure that this part, which is one of the weakest parts of the Health Service, is well handled.
There is a good deal of talk of integration, as I shall mention in a moment. It is of tremendous importance to make the most of the general practitioner services for a region or a locality. We know very little from the Consultative Document how it is going to be done, who is going to do it, and what the terms of reference are going to be. The terms of reference ought to be ambitious terms of reference. The ambitions of this part of the Service ought to be at least as high, in their own sphere and doing their own things, as in the hospital service, or elsewhere. We used to think that the general practitioner would keep pace with the development of the hospitals, the over-specialisation of medicine, and matters of that kind, through training in the medical schools and following the way that the new generation of young practitioners would actually work, but that expectation has been disappointed and it has been a failure. The medical schools seem to have made little or no impact on the problem, and the general practitioner in this country hardly believes in the function of the general practitioner under to-day's system any more than the Americans do; and I cannot say anything to make it smaller than that.
There is some progress. There are the other medical services, such as the health visitors and the community nurses. Most of your Lordships will know what happens when somebody does not know how to exploit the use of the Health Service and is worried about something, such as about a child's health, a possible hole-in-the-heart, cancer, or whatever it is. The handling of the Health Service, especially if there is something a little awkward or difficult about the relationship with the general practitioner, is a tremendous management job. The sorting out of an individual case and getting it into the right hands is incredibly diffi- 96 cult. I know, because it happened with my own family in the next generation and the third generation. This is where the structure of the Health Service could clearly make a great deal of difference. The health visitors could do a great deal here if they were able to get medical advice for the families with whom they have contact. They are there, in the home, and they are there fairly regularly. They talk to people, they know the children, they know their weaknesses and so on. If they could help to exploit the Health Service, and use the medical resources of the Health Service to help the families, we should be getting somewhere.
But at the moment a considerable proportion of general practitioners, perhaps 40 or 50 per cent.—and I understand this from general practitioners themselves—know hardly anything about the resources of the medical services. They know nothing about the health visitor services or about the other services that are peripheral to them. Furthermore, the health visitors are not, in general, in a position to bring into play the resources of the Health Service, and they are certainly not in a position to bring the general practitioner into play. But it is true that, encouraged by the Department, an attachment of health visitors to general practitioners is developing, although it is going pretty slowly. However, there are far more people who are well but who are possibly going to be ill, than there are people actually in hospital.
Presumably one factor in the economics of the matter is the use of general practitioners. The question is: is the organisation, the structure and the handling, going to be improved; and, if so, how? There are problems about the relation between the medical services, the health visitor and the social services—the. Seebohm departments of the local authorities, which are responsible for welfare. This is a very difficult—indeed, practically impossible—division. I am not complaining about that, because I myself was in favour of the division. But if, as I hope, some body is primarily concerned to see that the reorganisation of the Health Service is a success, the task will not be made more easy by talking about integration and by putting under the same type of authority parts which cannot be other 97 than to a large extent separated. It is not going to be easier for them to work together than it is for some of the medical services to work with the Seebohm services, and in many ways it may be more difficult. There is a big spotlight on this. Everybody knows what the problems are and the members of the services themselves are immensely keen.
Perhaps at this point I should sit down, but before I do so I should like to emphasise one point. I should very much like to hear that a good deal of consideration and management expertise are going to be given to rethinking the services in this part of the Health Service; that is to say, in regard to the impact on the families which have no one in hospital. Can we, for a very great number of families, get from our medical resources anything like the advantages that we used to be able to get for a small number of families; for instance, in the educated classes and, to some extent, in the villages? If this cannot be done, then I believe that a major opportunity to do something that really matters will have been lost.
§ 7.14 p.m.
§ LORD WRIGHT OF ASHTON UNDER LYNE
My Lords, I think there is general agreement that the National Health Service should be unified in the interests of patients, either at home or in hospital. But I am sure that many of your Lordships who have experience of health and hospital work will doubt whether the proposed unification is really in the interests of the patient. Some of us wonder whether, in many thousands of cases, the interests of the patients are to be subordinated to the organisational man and, possibly, to the lobby of county men who, for many reasons not always worthy, wish to cling to their power or to acquire new power. I know that today we are not to discuss the Local Government Bill, which was published on November 4, but it will have such an impact upon the reorganisation of the National Health Service that it cannot be isolated from this discussion. Some very odd results will emanate from the wish to make the suggested new local government boundaries coincide with the reorganisation of the National Health Service; that is to say, to make them coterminal.
98 It will not be the first time that central Government have put forward from separate Departments plans which contradict the principle which each is trying to establish. One wonders whether the two Departments concerned merely glanced at a physical map and then became rather tired of the whole programme and turned back again towards disorganisation. The plans for the reorganisation of the National Health Service are well-known, and were clearly intended to accompany local government reorganisation. As I understood it, the policy was that local health authorities should have areas identical with the new local government areas and based on one or more hospital groups. It meant that many local government units recommended by the Royal Commission, and endorsed by last February's White Paper, would have hospitals within a mile or two of communities in differing counties. Thus the interests of the patients would come first. But the Bill now puts all areas for National Health Services back into the counties' maw to the marked detriment of the patients in the areas concerned.
I will give one example of what is happening here, although I could cite many. In one area in the North, a group of hospitals serves the border communities of two differing counties outside the one in which the hospitals are situated. Clearly, common sense showed itself, for these communities on the borders of other counties were only five to eight miles away from a very large general hospital; and general hospitals like that have served the community since the 1948 Act, and indeed for many years before that. One of these catchment areas is now to be detached from the hospital on its doorstep, and is to be administered by the council of the county in which it is situated, whose nearest hospital is more than 20 miles away, across roads which are almost impassable in winter months, and sometimes completely snowbound. The coterminal theory is clearly not universally valid. While it may be that a user agreement would be valid and could help to alleviate some of the worst problems, it would be a retrograde step and would not foster the establishment of a comprehensive Health Service in the community. I will not try 99 to wring the withers of your Lordships, but perhaps I may be permitted to point out what might be the effect upon a patient of having to face a journey of 20 miles or more through ice and snow in the winter; and, equally important, what hardship there would be for visiting relatives and friends.
§ LORD ABERDARE
My Lords, I want to make quite sure that the noble Lord realises that there will be no effect on patients because of these boundaries. There is no intention of restricting anybody from going to any hospital to which he wishes to go, or to which he is sent by his general practitioner.
§ LORD WRIGHT OF ASHTON UNDER LYNE
My Lords, I am interested to hear that. I will take the Minister's word for it, but I have been told that, as the county council will administer the health services in its area, ambulances and everything akin to them will be organised from (shall we say?) the main county town. If that is so, it means that the people in that area will be recommended, possibly instructed from somewhere, that their hospital is at such-and-such a place, some 20 miles away. I should like to hear more about the fact that in county areas, just across the border, the same sort of service may be rendered by a hospital in another county as has been the case for these last 10,15 or 20 years: because this would be very helpful as regards the patients' care.
This system is a bad thing for the general practitioners, too. They will be under the control of another county, yet all their interests will be centred on a hospital five or six, perhaps seven or eight, miles away, depending on where they are in their county. This is where they will go: they will not go 20 or 30 miles away to a postgraduate centre. It seems to me that the whole reorganisation is one of disorientation, because in point of fact in areas such as these—they are to be found in Derbyshire, in Yorkshire, in Lincolnshire and in quite a number of places—it seems pointless to insist on this co-terminal principle. I am very happy indeed that the Minister has just given us the assurance he has, but I should like to have a talk with him (not to-night of course; he has plenty to do) 100 about this principle, because it is clear from my reading what will happen. From my reading, at least, it is clear that it will be under the control of the county authorities, and there is no mention anywhere that I have come across that patients may go to which hospital they wish. It seemed to me, when considering this problem, that someone had forgotten that hospitals are for man, and not man for hospitals. I trust that the Minister will explain what he very briefly pointed out to me: that terminal areas do not really count, in so far as the patients may go, or the doctors may send them. to any hospital they may wish to. A great many questions arise from this, and I shall be very glad to hear from the Minister about it later.
There are one or two other points—and I do not want to go on at length, because it is getting rather late. What I have had to say has been about hospitals, particularly in these peripheral areas in many parts of this country. I should like now to offer a word or two about the proposed area and regional boards, and perhaps about the suggested community health councils—though I shall have to cut out half of what I had intended to say in order to give others an opportunity to speak. Emphasis is placed upon the need for efficient management, and with this I agree. But if, as it would appear, there will be staff employed by area health authorities, regional authorities and possibly the central Department in relation to general practitioners, the management of area health boards will present a very complex problem. The membership of these boards will also need careful study, and while the need for medical and nursing staff is recognised, I personally feel that the professions supplementary to medicine should also be considered. Membership of such an authority should be broadly based with a wide cross-section of the population being required to serve on a selected rather than an elected basis. This may not suit a number of my friends. The noble Lord, Lord Platt, has gone, but I am with him in accepting that much should be a matter of selection, although I believe that means can be found for both nomination and election.
It will be necessary to remember that in health matters there is no end product 101 of profit: the end product is a happy, healthy individual. We shall need to exercise great care in choosing managerial men or women to serve on authorities, lest we operate a Health Service in a ruthlessly efficient way but to the detriment of the patient. This risk has to be watched very carefully, for my own experience has shown that on the hospital management committee of which I am chairman the least effective people are the so-called business experts and managerial men. I get much more sense out of the pragmatic approach by earthy, "both feet on the floor" people, who see a point as quickly as anyone else. Of course, if it comes to the managerial techniques, work study and so on, this is another matter, and the experts are available. But do not always accept that the expert is right. My own experience in introducing work study into hospitals is that the work study experts are nearly always wrong, and if it were not for the watching brief of the hospital management committee members I do not think it would get off the ground at all—and in my own group we have everyone except those in one department work-studied.
My Lords, may I at this point make a suggestion to the noble Lord's Department concerning management? I suggest that they should offer some advice to hospital management committees or regional boards as to the costing of work study schemes. To-day no one knows whether a work study scheme is successful, whether it is saving money, whether it is losing money, whether it is a viable scheme or a good scheme, because there is no uniform costing. You just cannot compare like with like; and if regions and hospitals within a region are going to be able to compare like with like in the work study field, then it will he necessary for some advice to be given and for some model costing schedules to be given to them.
I am not happy as to whether the number of members on the area hoards (I think the figure suggested is about 14) will be large enough to meet the many committee responsibilities at the moment undertaken by the present health executive councils. On health executive councils at present there are, I think, about 28 members, generally. There are in most cases some dozen sub-committees. Among these are the payments com 102 mittee, the dental committee, the surgery hours committee, the benefits committee —a whole host of them—as well as Case A Tribunals, such as opthalmic, dental and medical services, to name but three. The chairmen of these service committees, under the present structure, are always lay members. With 14 members, how on earth are we to service the many committees that I imagine will be required? In other words, all the committees that I have mentioned will be necessary; but how on earth we are going to get them from 14 members of an area board, I do not quite understand. If I could be given some advice on that point it would be very useful.
§ LORD ABERDARE
My Lords, would the noble Lord like it now? Would the noble Lord mind my interrupting now?
§ LORD ABERDARE
The 14 members are the members of the area health authority. The family practitioner committee will be constituted very similarly to the present committee. So there will be quite a lot of members, many of them appointed by the area health authority.
§ LORD WRIGHT OF ASHTON UNDER LYNE
I see. I do not want a dialogue. but I should like to ask: who is going to co-opt these committees? Will the area board co-opt people to serve on the sub-committees? It seems to me that involvement by the people generally is losing ground. If the existing Governmental views are to persist it will clearly be important to have effective representation so that local attitudes may be known. It may be a case where incorporation within management structure might be a good thing; but thought needs to be given to the appointment of members to ensure that full account is taken of all the views of the public who are to be served.
There is one other point I should like to mention. it is the one raised by Lady Ruthven. She mentioned the advisory councils. I agree that not many people would be prepared to serve on advisory councils unless they believed that careful note would be made of any recommendations that they care to put up. The noble Lady asked whether this was going 103 to be a lap dog or a dog with teeth. I would hope that this advisory council will have teeth. By that I do not mean that it should have the power of doing things or even the power of making recommendations that must be accepted; but I hope that it will be a meaningful committee, one that expresses the views of the people served by the National Health authorities in the districts and the hospitals; and that it would not be merely a supernumerary, as it were, tagged on to make it appear as if the views were being considered. I do not know how the Minister proposes to ensure that the council will be effective, but at least I hope that any advisory council will be put in a position where they must be heard. While one cannot say that notice must be taken of their recommendations, at least one hopes that the Minister will do all that he can to ensure that that does happen.
§ 7.32 p.m.
§ LORD BROCK
My Lords, this is a highly complex matter that we are debating to-day and it is easy to get bogged down in the mass of problems involved. For my own part, I feel that I must be highly selective if I am to make any sense to myself and to contribute anything of profit to the debate. It is clear that Her Majesty's Government have spent immense care and effort in trying to formulate that improved organisation of the National Health Service which is the wish of us all. But I feel that I must consider which parts of the Document I should comment upon as a doctor and which parts are beyond my competence. The general answer I have given myself is that the main mass of the suggested new organisation and administration is a morass in which I could well get lost; and I have no wish to become involved in it. Better and more experienced minds than mine have produced it and I do not feel disposed to make any comment on it except to say that it would appear to be acceptable in improving integration. But the situation is different when I come to consider the recommendations in regard to London and, more specifically, in regard to the London teaching hospitals. Here I find we are faced with major general administrative revisions and profound alterations in the control of the teaching hospitals that would affect the 104 medical performance of those hospitals in such a way as to have a serious effect on medical efficiency. On such a matter I must be deeply involved. It would be irresponsible of me not to say what I think about it.
My remarks are not intended to be aggressive or critical but to be analytical in character and perhaps may be in part informative to some noble Lords. The essence of the new plans seems to be full integration within the regions. I can see no objection to this; indeed I can see advantages when applied to provincial teaching centres and university hospitals, but I can see grave practical difficulties when the same method is applied to London and the London teaching hospitals. London presents an entirely separate problem.
If the Government were organising the country as a whole ab initio, I imagine that the policy of regionalisation could be applied efficiently and effectively to the London area. But we are not starting with a clear field. The complex of the London teaching hospitals is there. It is an established fact and a very real fact. It presents a very difficult and complicated problem of administration that will not be solved by wishing that it would go away. It is important that the revised administration of the London teaching hospitals should not impair their efficiency and medical success. The noble Lord. Lord Cobbold, has emphasised the close interdependence of hospitals and their medical schools. It was widely thought at the time of the Todd Report that unfriendly and unrealistic criticism was directed at the London teaching hospitals and medical schools and that this engendered the recommendations that they should be brought into line with the organisation of the provincial medical schools and teaching hospitals. Doubtless there are justifications for this recommendation, and even possible advantages, but the policy seems to ignore the historical fact of the evolution and the present-day formation of the London teaching hospitals. They just cannot be satisfactorily aligned with the provincial centres which are of a unitary character.
It is necessary to consider more deeply just what is the special problem in London, how it requires different handling 105 and in what way this might be achieved. First of all, each teaching hospital has its own board of governors and has direct access to the centre Department. It is proposed that they should in future be controlled by a district committee and that their contact with the central Department should be via this district committee to the area authority, thence to the regional authority and only then to the central Department: that is four places removed from the centre.
It needs little emphasis to indicate the delays, frustrations and misdirections that are inevitable in such an arrangement. The mechanism may suffice for various mundane matters; but the success, the very position and importance of the teaching hospitals does not rest on mundane matters—it rests on advance and achievement due to teaching and research, as the noble Lord, Lord Hayter, has emphasised. Without these, progress is difficult or impossible. I am sure that your Lordships will agree that it would be very unfortunate if the forward progress of medicine in Great Britain were compromised by impairment of the function and freedom of the London teaching hospitals. This is bound to happen if direct access is lost to the central authority. The noble Baroness, Lady Brooke, referred to the organisation of the regional authority becoming top heavy or with too many distractions. At present, men and women of high calibre and ability are pleased to give their services to the boards of the London teaching hospitals. It is certain that many of them, especially those of high ability and who hold important posts in public life, will not be satisfied to give their time and experience to serve on the equivalent of lesser hospital committees under the direction of several tiers of control. We would have to expect many resignations.
My Lords, in the provinces it is possible to correlate the requirements of the teaching hospital with the regional authority. This is not feasible in London. The overlap of population areas served by each teaching hospital prevents any proper correspondence with the areas of local authorities. It is not even possible to get any adequate correspondence between population areas and the regional areas of the four major regions in London. There is complete confusion between local areas, borough boundaries 106 and the areas served by the 12 London teaching hospitals.
If we examine a regional map of London we see that the surrounding boundary of the composite four regions is largely stable and precise, but that the composition of each of the regions, both internally and in their external relationship, is in the nature of a jig-saw puzzle, the confusion of which is made worse by superimposition and the complex overlapping between teaching hospital areas, borough boundaries and local authorities. It is difficult to see how any logical co-ordination can come from such a confused picture. It is suggested that the affairs of the teaching hospitals should be in the hands of the regional authority which will control the available funds. The decision as to how these will be allocated must inevitably be the subject of local pressures. Funds for the teaching hospitals should not be subject to local pressures but should be controlled at national level which, by permitting direct allocation of funds, can alone permit unimpeded progress in the advance of teaching and research in the teaching hospitals. When one looks at the composition of interlocking and overlapping areas of influence in the London scene it seems as if no satisfactory solution can be found. The Government seem eager to maintain a correlation with the local authorities, because of the control of social services that are to he in the hands of the local authorities. But the social services comprise less than 10 per cent. of health activities. Over 90 per cent. are unconnected with social service. It would therefore appear illogical to finalise a situation so that such a small percentage of endeavour controlled such a large percentage. A very small tail will wag a very large dog.
My Lords, a solution is difficult to visualise, but a strong case can be made out, indeed has been made out, for a continuance of some substantial degree of autonomy on the part of the London teaching hospitals with direct access to the central Department and with no intervening administration. How can this be done, especially when one recognises the confusion that exists between the make-up and disposition of the present four metropolitan regions? It has been suggested, and I put it forward as a sound suggestion that offers a good solution to the problem, 107 that as the outer boundary of the four London regions is definite, these should form a single London region. This single large region could be controlled by a united London authority, or perhaps a teaching hospitals committee, which would be responsible for its administration. The teaching hospitals could then have access to the central Department direct and not through a number of other controlling authorities. They would do this as members of a group and not as 12 separate hospitals. I must emphasise that the teaching hospitals committee should have direct access to the central Department and not with the regional authority intervening. Such a plan would seem to carry the bones of success and acceptability, and I hope that the Secretary of State will give it the consideration that it deserves as offering a solution to the present problem that has not been fully answered by the Consultative Document. This plan may have its own difficulties and drawbacks, but it provides an answer to the present plan which, in its present form, is unacceptable to many. I understand that finality has not been reached. that new decisions can be made, and I hope that the Secretary of State will give long and deep thought before he imperils the future success of our 12 London teaching hospitals.
§ 7.42 p.m.
§ LORD ANNAN
My Lords, may I say something in general terms and then follow up the details with which the noble Lord, Lord Brock, has been dealing? It seems to me that we have been having an interesting discussion this evening about something that is very often concealed, though it is at the heart of politics; and that is power. And the question the Consultative Document deals with is where power resides. Why did we have four documents before we ever had a National Health Service? We had four plans. Why did we have two Green Papers, and why are we still feeling our way towards a White Paper in our own time? It is, of course, because we are trying to reconcile the power bids by different interests, and the first of these interests could be in itself a composite set of interest groups, the medical profession. The important groups are the Harley Street consultants, the general practitioners the teaching hospitals, the medical 108 schools (which, incidentally, can be pressurised by the Royal Colleges) and the nurses, the largest single group of workers in the Health Service. There are also the hospital administrators, and the local authorities; and, lastly, comes the patient, for whose benefit the Health Service exists and who needs most protection. because the patients are less well organised.
The question I want to ask is this. Does the Consultative Document get the power structure right? The second Green Paper tried to redress the balance between these different interest groups by devolution, and the Consultative Document also goes in for devolution. But it introduces this strong regional tier about which we have heard so much this evening, and it is the region which is going to allocate funds to the area health authorities and which will probably appoint the majority of their members. I believe that the Secretary of State will find himself under very strong pressure to appoint consultants to the majority of the medical members of these authorities. What I fear, therefore, is that these regional advisory committees, which is where so much of the power will lie, will come to be dominated by consultants, and I should expect the consultants to tend to resist changes in the hospital service which upset their empires. They will be well placed to bring pressure to bear on the hoards, and to stop particular area authorities from doing anything or operating any health centre with very wide functions. The consultants will also have a strong voice when it comes to deciding where particular specialities are to be located, or what goods and manpower are to be provided.
I think we ought to be clear about what the change from the Green Paper to the Consultative Document means. It means that the general practitioner is going to have far less influence. It means that local authorities will also lose influence. The majority of the members of the area authorities are now to be appointed from above, and that means, I believe, that they will not be so responsive to local interests and local opinions. Even the consumer councils are now to be appointed by the area health authorities, and this means that the sort of people who sometimes have the guts or the impudence—whichever way you like 109 to put it—to raise a fuss in the Press, or to probe about into what goes on behind the scenes, will tend to be kept out of the Service. I think that all this will diminish the power of the weakest of the interest groups; that is to say, the patients.
But while, as your Lordships see, I am anxious on behalf of the patients, and am anxious on behalf of general practitioners, I am also, despite the fears of the noble Baroness, Lady Serota, anxious on behalf of the hospital administrators. To-night we have heard much about management, as if it were a dirty word, and I was pleased that the noble Viscount, Lord Davidson, and indeed other speakers, said that management need not necessarily be something which is hostile to the interests of everything that we arc trying to achieve in the Service. One of the worries I have about the management structure as described in the Consultative Document is that there is so little provision for paid members. I ask whether this might be reconsidered. There should be at least a chairman and vice-chairman, and some members of these boards, who would be paid, because the quality of the people who serve matters very greatly. I would also suggest that we shall not get what we want in management unless behind management—and indeed embedded (if I may use such a word) in management—is the local vocal criticism of the community; which could give management just the lever it needs to keep the medical profession from becoming a little too set in its ways.
So much for the general points. May I now pass to the special situation of London, and the special needs of London University—and here I can keep my remarks much briefer than they would have been but for the most powerful speech which has just been made by the noble Lord, Lord Brock. My Lords, I think everyone agrees that a wide range of clinical facilities needs to be available for medical education. Some people think that the best way of ensuring it would be to arrange sectors extending out into Greater London. I wonder whether the noble Lord, Lord Aberdare, could give us some hope that the Department would consider altering the concept of teaching districts as set out in the Consultative Document and accept the 110 notion that these health areas in which there are medical schools should be designated as teaching health areas. I very much hope, also, that the Secretary of State will agree that if we accept that the two existing medical schools, paired according to the Todd Report recommendations, are to count as one general medical school, not more than one general medical school should he in a teaching health area.
I hope that the Department are not wedded irrevocably to the principle that borough boundaries and health areas must be coterminous. I know that this point has been raised before, but I wonder whether it would he possible to arrange for more than one contiguous borough to be included in a teaching health area. In the University of London we tend to get the impression that the Department rather dislike the King's/St. Thomas/Westminster project, and are not at all happy about the marriage of Middlesex and St. Mary's. But, after all, the Department have accepted the first of these marriages front an educational point of view, and we had therefore hoped that they would accept the administrative consequences. I recognise that here I am discussing a highly technical and controversial matter, but many of us in the University of London believe that eventually there must be a joining together of the pairs of teaching hospitals once their twinned medical schools are working as a unit. I realise that this will not he popular with the Teaching Hospitals' Association, and I do not know whether I can carry the noble Lord, Lord Cobbold, with me on this point (I was extremely sorry that I missed his speech this afternoon, but I had to attend a statutory meeting), because he may well hold the view that the maximum size of the unit for administrative purposes might be about the size of the Middlesex Hospital, which has prospered so much under his good chairmanship. But can London hospitals still continue in their splendid isolation, which is often a spur to even more ferocious encounters in the Hospitals' Rugger Cup? My hope is that we can look forward in future to more co-operation between hospitals.
May I end by emphasising that the plans for the development of postgraduate hospitals are made at the same 111 time as we are planning for the teaching hospitals, and unless this is done we shall never get the proper distribution of hospital beds in specialisation or specialties such as ophthalmology, ear, nose and throat, and orthopaedics. I will not detain your Lordships longer with special pleading, but I hope that these points may be borne in mind.
§ LORD COBBOLD
My Lords, may I intervene, as the noble Lord mentioned my name. I do see tremendous difficulty in going quickly to such a large unit as the twin hospitals would comprise in administrative terms, but I would assure your Lordships that a great deal of cooperation is already going on between Middlesex and St. Mary's, as I happen to know, in matters of arranging where specialties are undertaken.
§ 7.52 p.m.
§ BARONESS YOUNG
My Lords, no one who has served in local government can come to this debate to-day without a feeling of deep regret that this Government, like the previous Government, are proposing in their reorganisation of the National Health Service to remove the personal health services from local government entirely. The principal reasons given in the Green Paper, published earlier in 1970, are the desire of the professional medical service for clinical freedom and finance—this despite the suggestion contained in the Report of the Royal Commission on Local Government, under the chairmanship of the noble Lord, Lord Redcliffe-Maud, of the possibility of unifying responsibility under local government. It does, however, seem ironic that, at the very moment when the Local Government Bill, one of the principal aims of which is to strengthen local government, is being discussed in another place, the Consultative Document proposes to take away one of the oldest and most important of local government services.
Lest it be thought that all local government health services are either inadequate or unco-ordinated, I should like to say, in the spirit of an obituary notice, what has happened in my own authority. There is no evidence from the hospitals of lack of co-operation, and as a health authority we were the first to introduce a scheme for the attachment of health 112 visitors to the general practitioner service. This scheme was started in 1956, fifteen years ago, and was completed in 1963. A further scheme of attachment of midwives and district nurses to general practitioners was started in 1967 and is now nearly complete. Two-thirds of general practitioners now work either full-time or part-time in purpose-built local authority health centres or clinics, and there is close co-operation between the hospital service and the city social service department.
Over local government as a whole there are many examples that can be cited of pioneering schemes, particularly in the field of preventive medicine. I realise that this is past history, and I should therefore like to go on to make two general points on the Consultative Document, which at present concern the local government system. Everyone in local government must welcome, I am sure, the proposal that area health boards are to be coterminous with the new county boundaries. What does cause concern is the proposed membership. Paragraph 17 indicates that there may be fifteen members on an area board or sixteen for an area with a teaching hospital. These boards will be responsible for very large areas. For example, the new Oxfordshire has a population of 500,000, and out of the fourteen representatives perhaps seven would come from local government—that is, one to every 70,000 of the population. In the new Hampshire, with a population of 1,466,000, seven or fewer of the representatives would mean one local government representative to every 200,000 people.
As the Association of Municipal Corporations has pointed out in its evidence, no one wants the new boards not to pay due regard to the needs of efficiency, but this must be coupled with knowledge of the needs of the locality, let alone the needs of the patient. It seems that with so small a membership, members will not be able to know at first hand the conditions they are considering or the service for which they are responsible. There is no suggestion that the members, with the exception of the chairman, will be other than part-time volunteers. Indeed, the Consultative Document does not define very clearly the role either of members or of members in relation to the professionals.
113 It may well be argued that it is the job of the community health councils to take up more detailed problems. I welcome the opening remark of the noble Lord, Lord Aberdare, which (if I understood him correctly) meant that the areas of the community health councils will be coterminous with the areas of the new districts. I hope that this may be so, because if they are based on the hospitals, this may create confusion in the minds of the public. But here again we find that the nomination of members of the new community health councils will be by area. Will these people be prepared to speak out against the system, if necessary? And how will the public really know who they are, if they wish to make a complaint? I myself did not quite understand the statement in the Consultative Document that there may be difficulties and confusion between management, on the one hand, and the community's reaction to management, on the other, because if the community health council has power, it surely should have power with responsibility. If it does not have responsibility, then it is dangerous to give it power. But perhaps it is not intended to have power at all, and, if that is so, what really is its purpose?
I make these points because surely it must be our belief that the needs of efficiency are served better when matched by the public accountability and discussion represented by local democracy. The whole procedure of election, of discussion in committee and of final discussion in a democratically elected organisation is surely something which has proved its worth in local government. And discussion is not simply for criticism. Discussion can frequently lead to public education. May I quote one example that has recently come to my notice in the field of preventive medicine? In the field of the preventing of cancer, our authority started a scheme for cervical cytology some six years ago. This depends not only on the administrative ability of identifying those women at risk; it also requires a very complicated follow up of domiciliary visiting service and demands an enormous amount of skill and patient work in overcoming the very real fears of people coming forward to take these tests. The fact that there can be an annual report of the medical officer of health, from which all these detailed 114 aspects of public health can be known and can be considered and discussed, can add up to a great deal of public education, and it seems to me that this very valuable aspect could well be lost.
The second general point that I should like to make is that of the co-ordination of the National Health Service with the social service departments of the new counties. Here it seems to me that very clear guide-lines must be laid down for co-ordination of administration. Otherwise the known present difficulties, when hospitals complain that too many beds are taken up by patients who could be discharged if only local authorities would provide the community care, will continue. "Co-ordination" sounds very splendid, but it must be clearly laid down what is meant by this, and there must be the will to make it work. It will not happen simply because administration says that it should happen.
Then there are two services which appear to people in local government to be left in a kind of limbo. These are the school health service and the child guidance service. Again I very much welcome the opening remarks of the noble Lord, Lord Aberdare, when he said that a special Committee is considering this question. This seems to me to be extremely important. Local government has just gone through the tremendous upheaval of establishing social services departments whose aim is the unification of social services under one roof in local government and to make clear to the public that there is, as it were, one door on which to knock if they want to find out anything about the social services. At least the present school health service is administered by the same authority as the social services. If it becomes part of the National Health Service it will be administered by a different authority. There are many occasions when the identification of children at risk must come through the school medical service, and the treatment of such children through the child guidance service. I hope that we shall know what the future links are to be between the school medical service and future education and social service departments which will be in the new county authorities.
My Lords, if I may add one more point, there is no mention of the whole 115 subject of health education, which is of great concern to education authorities. By this I do not mean quite simply a euphemism for sex education, although that is frequently part of it, but education in the much wider aspect of health, such as hygiene, diet, the problems of smoking and of drugs. Where will this fall in the new reorganised Health Service?
In conclusion, I would say that I have deliberately confined my remarks to the local authority health service. No one, certainly not myself, believes that in local government to-day all is for the best in the best of all possible worlds. But surely it is necessary to show, not only to the loyal and hard-working staff in local government services throughout the country as a whole, but also to the public at large, that the proposed changes really will mean an improved service for the public.
§ 8.3 p.m.
§ VISCOUNT WAVERLEY
My Lords, almost exactly 12 years ago your Lordships debated the hospital services on a Motion of my noble friend Lord Stonham, and it is about the hospital services that I wish to speak to-day. On that occasion I ventured to talk for the first time in this House. I said:I think it is generally conceded that one of the most important consequences of the National Health Service Act has been the progressive development of the non-teaching Regional Board hospitals.I declared my interest, being then, as now, a consultant physicial at such a hospital. I went on to say:Not only the welfare of patients, but our reputation in world medicine increasingly depends on the way our provincial hospitals can acquit themselves.They have acquitted themselves well, and I do not believe that any of your Lordships with medical, administrative, or, if it has happened, consumer experience would gainsay that. But this debate is about the future. I am fearful for the future of district hospitals. My anxieties are on two main grounds: administrative and financial. There are of course considerable areas of overlap between these. The Secretary of State has said in his Foreword to the Document: 116Doctors have played a large part in the planning and management of the existing service and will continue to do so in the future.No doubt they will. But will they be the right doctors to safeguard the present and, more importantly, the future of district hospitals?
Medical participation in hospital management has been recognised as of fundamental importance since the Health Service began. This recognition was strongly emphasised by the joint Working Party on the organisation of medical work in hospitals—the Cogwheel Report. In district hospitals where the Cogwheel system operates there is a continuous line of communication between all grades of medical staff, from the most junior to the most senior, and to the hospital management committee. In future there will be no hospital management committees. If the Cogwheel system is retained in any recognisable form, to whom will advice be tendered on behalf of any particular district hospital? This can only be to the area authority involved. In the rare event of there being only one district hospital in an area, this arrangement may be just administratively workable but where there are two or more such hospitals in an area, this surely must be a recipe for some sort of chaos.
Medical representation on an area authority is to consist of "at least" two doctors. In practice, it is probable that this will mean just two. It is also probable that one will be a general practitioner, detached from the problems of even one district hospital, let alone two or more. The other may or may not be a hospital consultant. If he is, only one district hospital from several will be personally represented. Surely, here are sown the seeds of discord. An area authority imperfectly seized of local problems will no doubt do its best to arbitrate between conflicting demands and interest, but will its best be good enough? I regard it as in the highest degree improbable. The area authority will be too remote from the district daily scene, too out of touch with realities for coherent administration.
The financial consequences to district hospitals are likely to be grievous, and this at a time when developments in medical investigation and treatment are advancing faster and more expensively than ever before. The area authority will 117 be required to finance the whole Health Service, save for general practitioners' salaries and certain, as yet, ill-defined areas which will continue to be the responsibility of the local authority. With almost no representation on the area authority, and, where there is more than one district hospital, no professional representation at all for the others, how can adequate district hospital funds be ensured? And even if they could be ensured, with so many competing and, beyond doubt, glamorous demands on available money, how could this remote authority hold the scales equitably between a number of district hospitals whose varying needs it could but opaquely understand? My Lords, at a time when expenditure on hospital services subserving similar functions to our district hospitals is rising all over the world, I fear it is inevitable that expenditure here will fall, and that it may fall very seriously.
Since the appointed day the status of district hospitals has been steadily rising. They have therefore been able to attract consultants of the highest calibre. This in turn has attracted correspondingly excellent junior medical staff. Success breeds success. Medical students have increasingly been seconded from their teaching schools to district hospitals for elective or longer periods. All in the present district hospital garden may not be lovely, but there is at least a garden. If, unhappily, my anxieties prove well-founded, and if, for administrative or financial reasons—or both—the status of district hospitals declines, the future will be grim indeed. In truth, my Lords, there will be no future, only a progressive slither of a vital part of this country's hospital service into mediocrity, and no chance then of recovery in any foreseeable future; for emigration of too many of our brightest young medical people will, I fear, have seen to that.
§ 8.10 p.m.
§ LORD CHAMPION
My Lords, I am very glad that it does not fall to me to wind up this debate in the generally accepted sense. There have been so many excellent speeches that I would fear to pass over a single one of them. They have been extraordinarily well informed; most of them have been brief and certainly to the point. It has been a debate that has been well worth while to listen 118 to. Speaking particularly on the Welsh aspect—and that is my job here to-night —of the reorganisation of the Health Service, I must put it on record that it is now 60 years since the first giant stride was taken in the direction of a National Health Service by the National Insurance Act 1911. Certainly when it came to framing the National Health Act 1946 the late Mr. Aneurin Bevan owed a tremendous debt to the pioneering effort of another great Welshman, David Lloyd-George. The country in turn owes both a tremendous debt of gratitude. For, despite any weaknesses that might have shown themselves, our Health Service has served the country well, and it behoves us in making changes to try to be reasonably certain that the new structure will give to the patient, and those engaged in it, a better Service than that which is to go. I agree with something that was said in the last debate on this general topic by the noble Lord, Lord Cottesloe: that we ought to be very careful when changing something that we are not destroying a system which has been built up in this country about which we can be proud and to which the world can look with some admiration.
In speaking here to-night I am not going to fight the long since lost battle of local government control of the Health Service, although Aneurin Bevan in his book, In Place of Fear, when discussing the Health Service some six years after the Act of 1946, admitted the difficulties of selection of the controlling bodies by the Minister of Health, and concluded:Election is better than selection …and that:…a solution might be found if the reorganisation of local government is sufficiently fundamental to allow the administration of hospitals to be entrusted to the revised units of local government.I have always understood (perhaps wrongly, but I do not think so) that the difficulty of putting the new Health Service under the local authorities lay in the fact that the professional bodies, whose good will was essential to the establishment and success of the Service, were strongly opposed to accepting service under the local authorities. In this matter the professions got their way. My late friend Aneurin Bevan was an idealist, but he was also realist enough to agree to the submissions of the professions 119 rather than risk losing the Service altogether. I do not think there is any doubt at all that the late Labour Government. when framing their proposals, faced the same problem and arrived at the same conclusion, but they would have given a much greater representation to the local authorities than is now proposed in this Consultative Document.
Labour would have had the health boards composed as to one-third from members of local authorities, one-third from the health professions and one-third, plus the Chairman, appointed by the Secretary of State. From that decision this Government have retreated, perhaps for the reason of professional opposition; of that I am not informed or aware. I am bound to say that the experience of the past 25 years points to the need for a greater element of democratic representation through elected local government representatives on the controlling bodies, even if full democratic control is not practicable.
I will not range over the whole Service covered by the two Documents. The main criticisms that we have in speaking from this Box have already been admirably put by my noble friend Lady Serota. She called attention to the fact that this debate is really about the patient, the person who will use the National Health Service. Although everything we talk about must be related to him, clearly management must enter into the matter, and I was glad that stress was laid on the fact that management counts, that we have to think in terms of good management, always provided that that management is directed at the patient and at the person who will, we hope, profit and be the better for the existence of the National Health Service. Speaking about the Document for Wales, I can say straightaway that I am in agreement with the decision to vary the structure for Wales from the pattern proposed for England. For once the decision had been taken to hand over the responsibility for the administration of the Health Service in Wales to the Secretary of State for Wales, separate consideration of some of the changes to the National Health Service became necessary and desirable.
The differences proposed are not very great, but they take into consideration the 120 relation of the responsible Minister to a smaller and more immediately manageable area. To cut out the regional tier is the right thing to do, for in Wales there will be only eight health authorities, and a direct relationship with the Welsh Office should present no practical difficulties at all. The area is small enough; the possibility of direct approach is there; the communication would be reasonably easy and, for that reason, I agree with the decision not to have anyone or any body between the Secretary of State for Wales and the area health authorities.
The first question that I might have had to put to the noble Lord, Lord Aberdare, was one relating to the fact that under the Bill now before the other House there are to be eight county councils instead of the seven mentioned in the Consultative Document. But, almost by accident, I have stumbled on the fact —it was in answer to a Question for Written Answer in the other place which appears on the last page of Hansard of the other place for last Friday—that the Secretary of State for Wales has announced that the South Glamorgan authority in Wales will itself have an area health authority, and that the teaching proposals contained in that particular paragraph of the Document will in fact pass to the authority that will be set up under the South Glamorgan County Council area; that is, the area health authority. This seems to me to be very sensible. The only point I would raise in this connection is this. It appears to me that there will be only one district committee—only one district—in South Glamorgan. I wonder whether this will be the case; whether it will be the one that will be based largely on the teaching hospital, the University of Wales Hospital, or whether there will be more than one for that particular area. If there is only one, then clearly there will be only a single community health council. I should like to ask the noble Lord to tell us, when he comes to reply, whether this is the case. Will there be just one district committee to be appointed by the area health authority, and will there be only one community health council to go with it?
The next point upon which I should appreciate some enlightenment is that of 121 a sentence in paragraph 6 of the document where, in relation to the area health authorities, it is said:They will be able to administer their integrated health services through a pattern of health districts where this is desirable for administration or other reasons.Does that mean that in some areas the whole of the services may be administered by the area health authorities; and, if so, what provision will there be in such areas for advice on the public's views of the service? I ask this because we are told that the community health councils are to be based on the health districts, and these very words that I have read out place some little doubt on whether or not there will in fact be in all areas health districts decided upon. I must admit that I find the references to health districts a little nebulous; and it is difficult to see (and the Document does not tell me) what will be their size, or whether within a given area health authority area there will be district committees for, say, the hospital service and others for the health services to be transferred from the local authority, and each with its community health council.
Then what of the separately financed committee for the family practitioner service which will deal directly with the Secretary of State but is also to have a direct approach to the area health authority? Which of the district community councils, if any, will cover that service and that committee? And how does the Minister visualise the closer working of the family practitioner service with hospitals and local authorities, as mentioned in paragraph 9? This is an aspect that was referred to by a number of noble Lords—certainly by my noble friend Lady Summerskill and the noble Lord, Lord Cottesloe, and others. How is this integration going to work out? How is it going to be possible to secure the co-operation between this particular committee and the family doctor as a member of that particular group and the area health authority which will have such an important part to play in this service.
As I see the service visualised in the Document, we are going to have at the top—and I agree that there is no need in Wales for the two-tier arrangement as projected for England—the Welsh Office taking decisions on overall planning and 122 the allocation of resources. Advising that Office there will be constituted a Welsh Health Council; and here I part company with the proposals. I can see no earthly reason why the task of advising the Welsh Office should not be given to the already existing Welsh Council. That is a body composed of a very wide range of interests, of which 10 of the 37 members are appointed by virtue of their membership of local authorities, and I gather that the Council has powers of co-option that could be used to strengthen the composition on the health side if that were deemed necessary.
That body, the existing Welsh Council, has itself admitted that at present it is not constituted in such a way as to undertake the executive work to be carried out by the Welsh Office. But, judging by what it says in its report for the years 1968 to 1971, not only would it be prepared to undertake the work of advising, but it also claims that it is in a unique position to offer advice on broad policy matters. It goes on to strengthen its claim by adding that it already reviews public expenditure forecasts on new capital works, including health expenditure. Clearly, such a body, with members drawn from a wide range of interests, ought to be given this task of advising the Secretary of State on health matters affecting Wales. To set up one more body of 20 to 30 members, and equip it with the necessary staff and offices, would be a waste of public money and of the time of people who ought to be otherwise occupied. I hope that the Secretary of State will give special consideration to this matter. This Welsh Council has been set up. It exists. It exists for the purpose of advising the Welsh Office and the Secretary of State, and this health side should certainly be a part of its functions.
On the composition of the area health authorities, it is obviously right for the matching local authority to appoint some of the members as mentioned in the Document; but no number is given, no proportion. I think that at least one-third of the membership of those authorities ought to be drawn from that source; that is, the local authority source. Such a figure as a minimum ought to be embodied in the Act which will govern the composition. In addition to the local 123 government matching authority members, there ought, too, to be at the area health authority level a strong, representation of the local government district councils, for they are very much at the grass roots of this whole matter and closely in touch with the public. That, surely, is what these area health authorities are going to have to try to do: to keep in touch with what is being said and what is being done in the localities.
My Lords, if there is to be the improvement in the relationship between the local authority and the general Health Service there must be real integration, as stressed by the right reverend Prelate the Bishop of Lichfield, and illustrated by my noble friend Lady Summerskill, between the county councils and the area health authorities. This integration is absolutely essential if we are to secure the sort of service we want to see—absolutely essential if we are going to get away from some of the other difficulties that have shown themselves in the past twenty-five years. I welcome the proposal for the setting up of the community health councils. I hope that they will fill the gap that exists in the Health Service; namely, to whom does a dissatisfied patient or relative turn to complain? The noble Baroness, Lady Masham of Ilton, brought out this point very strongly. I must say that I liked her speech very much. I was a little disturbed about one aspect of it, because she reminded me, when she was talking of the dying and those about to die, that I have passed my allotted span.
However, the community health councils must not only exist but also be seen to exist. The members of it must be known and they must not be tucked away in anonymous obscurity. How we are going to achieve this I do not know. When I was a member of an urban district authority, all the people in my area seemed to know that I represented them on that authority. They wore a groove in my doorstep when they came to see me about the difficult matters which they felt mattered enormously to them—housing, their children's education, and so on. I should like to see this community health council constructed in such a way and their membership advertised in such a way that people would be able 124 to turn to them immediately they had some problem about a patient in hospital, or somebody else needing the sort of care that can be given under the old local authority service, and so on. I should love to see a situation created in which some of the people who are appointed to these community councils would also have grooves worn in their doorsteps. It would be a good thing: good for the service, good for the feeling that they belong and that people belong to this country and this service of ours.
Turning to the health districts, which we are told will administer the Hearth Service for the area health authorities, I should very much like to know more about these. Will they be based on a geographical district, or a hospital district, or a local government district council area, or how will they be based? Has a decision been taken on this matter, or is this one of the matters which will be considered by the Working Party which I gather will be looking into management structures and so on—a joint Working Party to be set up with English and Welsh members? This is going to be an extremely important subject. I think the noble Lord, Lord Aberdare, was right to stress its importance, but I wonder whether it will embrace in its consideration the sort of questions that I have been asking as to the geographical or some other form of district. It seems to me that for the sake of public understanding there is a strong case for the health district having boundaries coterminous with those of the local government district councils. I think this would help a lot. People would understand those boundaries and would understand the areas.
My Lords, I said at the outset that I was not going to fight over again the lost battle of local government control of the Health Service, but I do assert that there is an overwhelming case for a large degree of democratic participation in the community health councils, the area health authorities and the All-Wales Council. If the Government persist in their proposal not to use the Welsh Council I think it will be a big mistake. Certainly there is a great need for the projected community health councils to be closely in touch with the elected representatives in the area. My Lords, I conclude where other noble Lords have 125 concluded—and indeed many have mentioned it in other parts of their speech—that we cannot leave this matter to-night without thanking all those, at whatever level, who, despite its structural faults, have been responsible for the striking advances that have been made in our Health Service, which is, in many respects, an example to the world. I am sure we should all join in paying tribute to all those people who have done so much for us and for this Service of which we are rightly proud.
§ 8.35 p.m.
§ LORD ABERDARE
My Lords, I should like to start by thanking all of your Lordships who have contributed to this debate. It has been a most fascinating one to listen to, and that has made my task in winding up even more daunting. With 25 speakers I realised that if I only devote one minute to each speaker I shall keep your Lordships for 25 minutes. In fact I have wanted to leap to my feet at the end of each speech. I did actually interrupt on several occasions, for which I apologise. I was trying to clear up what I thought were one or two factual errors while they were fresh in my mind. I assure your Lordships that everything that has been said to-day will be most carefully studied. I will write to any of your Lordships who have requested answers from me and whom I am not able to answer at the moment. A number of questions were raised which really lie outside the field of National Health Service reorganisation, and I propose, if I may, not to go into them. But they will all be carefully studied. May I say, too, how grateful I was to the noble Baroness, Lady Summerskill. I did not agree with much of what she said, especially about tearing up the whole Paper; but she had the kindness to say that my right honourable friend had an open mind and was able to change it when he was convinced by the arguments. This indeed is true, and this has certainly been an interesting debate which I am sure he will read and find influential.
My Lords, may I pick out one or two main themes? One was the question of the teaching hospitals, which was raised by a number of your Lordships, particularly those with very deep personal knowledge of these hospitals. May I say to the noble Lord, Lord Cobbold, 126 how sorry we shall be when he gives up as Lord Chamberlain tomorrow. We have enjoyed his occasional appearances here in a tailcoat, and I know that he has been a very distinguished holder of that Office. But perhaps we shall see even more of him in the hospital service. to our great gratification and assistance. My noble friend Lord Cottesloe, my noble friend Lord Reigate, the noble Lord, Lord Annan, and the noble Lord, Lord Brock, all mentioned this matter of the hospital service. We fully recognise the contribution that these hospitals have made to medical education and to the practice of medicine, and we intend that they should maintain and develop this contribution in a reorganised Health Service. The hospitals will retain their individual identity and historic traditions, and their medical school associations and the special services they provide will be unaffected. The question at issue is their administration, and in particular the statutory committee structure and their relationship with the rest of the National Health Service. Within this limited field of administration our aim is to secure a properly balanced development of community and hospital facilities to meet the needs of teaching, research and services to the public. This can be achieved, we believe, by bringing the teaching hospitals within the general framework of a unified regional and area administration. But within this framework we are ready to make special arrangements to meet the special circumstances of the teaching hospitals, and the particular problems that arise in London from the location of hospitals in relation to the population they serve.
The issues are very difficult, and until we have completed the consultations and studies which we arc undertaking we cannot announce firm proposals. But it has become clear that the tentative proposal we made in the Consultative Document for teaching district committees has disadvantages, and certainly it has found little or no favour with those who commented on the Document. Our present thinking, therefore, has moved away from this concept to that of the teaching area of health authorities (I think the noble Lord, Lord Annan, made this point)with full operational responsibility for providing an integrated Health Service, including teaching hospitals, and as the noble Lord, Lord Champion, has seen from 127 the Written Answer in the Commons Hansard on Friday, it is proposed to do the same in the Glamorgan Area Health Authority. My Lords, the management structure within areas, both teaching and non-teaching, is being examined by the Management Study, and we envisage that decisions about the studies under new authorities will be left to be taken in the light of guidance from this Study.
My noble friend Lord Cottesloe mentioned the position of the postgraduate teaching hospitals, and said that it would not be practicable for the management of these hospitals to change by April, 1974;and certainly this is true. That will depend upon the development of convenient associations between them and other teaching hospitals. We therefore have in mind that for a transitional period from April, 1974, they will need to remain under their own boards of governors. I fully acknowledge the point he made: Hammersmith is a very special case to which we shall have to give very full consideration, no doubt in close consultation with him. We also undertake to consider the proposal put forward by the noble Lord, Lord Cobbold, about the five-year transitional period. I think that there are considerable difficulties in this idea, but we can discuss it.
Another major point raised during the debate concerned general practitioners. The noble Baroness, Lady Serota, the noble Lords, Lord Reigate and Lord Amulree, the noble Baroness, Lady Summerskill, the noble Lords, Lord Platt and Lord Champion, all referred to the general practitioners and the new proposed family practitioner committees. The Consultative Document proposal that each area health authority should be required to set up a committee with a composition similar to that of executive councils to administer the contracts of family practitioners follows the proposal on the same lines in the second Green Paper. It has been welcomed by family practitioner and executive council interests as it preserves the independent contractual status of the four professions.
On the other hand, some of your Lordships have criticised it on the grounds that these family practitioner committees are unnecessary or even a hindrance to the integration of the health services. It 128 has been argued that to set up statutory committees dealing directly with the Department and separately financed may encourage continued isolation of the family practitioners from the rest of the health services. I think this fear, although understandable, is mistaken. Paragraphs 21 and 22 make clear that the job of these new committees will be to administer contracts—that is pay, terms of service, complaints machinery and so forth—which are concerned with the general practitioners; on these matters the committee will deal direct with the Department, as they are matters affecting the independent contractual status of the general practitioner. They will certainly be consulted on wider issues, such as provision and siting of health centres, location and layout of practice premises, attachment of community nursing and other skilled staff, facilities for general practitioners in hospitals and so forth, which involve other parts of the health services and their planning and development, but it will be the area health authority that will determine policy on such matters. I would remind your Lordships that these committees will have 50 per cent. professional membership, as at present. The plan is that the remaining 50 per cent. should be largely at any rate, appointed, by the area health authority so that the area health authority will have a considerable influence within these committees, and of course they will cover the same area as the area health authority.
Another major point mentioned by many of your Lordships was that of voluntary service. It was raised by the noble Lord, Lord Auckland. He has apologised for not being able to stay. As your Lordships know, he has recently suffered a bereavement and I know you would wish me to express our sympthy; we certainly understand why he could not stay. I can say that the change in administrative structure will certainly not mean that the strong links with many voluntary bodies of local services will disappear. On the contrary, we are very keen to encourage them all we can. The present arrangements for the provision of services by voluntary bodies will be continued and, where possible, extended by the area health authorities. Further encouragement will be given to individual volunteers who wish to give their services direct 129 to their local health service. The recent growth of paid organisers of voluntary work in hospitals will continue, and we hope that as a result of reorganisation it may be possible to extend this and to arrange for joint appointments to coordinate voluntary help both in the hospital and in the community. We are confident that the voluntary organisations and voluntary workers will respond fully and enthusiastically to these new opportunities, and my right honourable friend is already in very close touch with many of them.
My noble friend Lady Brooke mentioned in particular the W.R.V.S. She knows very well the respect in which I, too, held Lady Reading, and I can assure her that the wonderful service that we receive from the W.R.V.S.—just to mention one organisation because there are enormous numbers of others—is a source of great strength to the Health Service and one that we shall not easily let slip. We are very keen to develop all the voluntary services, not least the Hospital Friends. Here may I say how grateful I am to the noble Lady, Lady Ruthven, for her contribution. She leads the Hospital Friends and we are very grateful for all they do. She had some words to say about the community health councils. I think if she reads what I said in opening, she will find that most of the points she raised which have to do with the community health councils I tried to cover in that speech.
The noble Lord, Lord Garnsworthy, was kind enough to give me notice of his points, all of which concerned the staff of the Service. I agree so much with him and with the noble Lord, Lord Champion, whose last words were on this subject, that the staff of the Service are by far the most important people we have; without their co-operation and without the continuation of the sort of service they have given hitherto we shall not gain by reorganisation. He asked about a central training board. My right honourable friend is sympathetic to the idea of new arrangements for providing co-ordinated advice. That does not mean that we are looking for something like a new industrial training board, building up a, separate organisation of its own; we do not think that would be appropriate to the reorganised Service. What we are 130 considering is ways of providing more unified advice, and I can assure the noble Lord that we will be looking into that. He also asked about compensation in the case of staff possibly downgraded by reorganisation. We hope that will occur only in very exceptional circumstances. We mean to see that existing skills are used to the full, and any proposals on this matter will be worked out in full and detailed discussion with the staff themselves.
The noble Lord also asked about the amalgamation of hospital groups. My right honourable friend has discussed this matter with the staff side and has made it clear that he would sanction mergers of hospital groups after April 1 next only in exceptional cases where patients would otherwise suffer. Save in such cases, and in one other case in the Liverpool region where a merger now being planned cannot be implemented until after April, 1972, no mergers will be effected after that date. The noble Lord also asked about whether appointments to posts in the Service will be filled from within the present Service. It is important to ensure that the size and significance of the problem is not exaggerated, if indeed this proves to be a problem. We should certainly expect that the vast majority of posts will be filled from the existing staff in the different parts of the National Health Service, and of course those local government staff who are affected. This is in the context of a new Service which will be assuming additional and heavier responsibility, but until the whole structure of the Service has been more closely defined as a result of current studies it is not possible to be specific about the nature of top posts, or indeed about new or additional highly specialised posts which may be required. All these matters will be discussed at the appropriate time with the proposed staff commission.
My Lords, I am falling a little behind time with a mass of points still to answer. I hope some of your Lordships will forgive me if I write to you. Perhaps the noble Lord, Lord Hayter, will allow me to write to him about the research and development point he made. I hope I need not go back to the Whitley Council' debate we had recently, although I was 131 invited to do so by the noble Lord, Lord Garnsworthy and my noble friend Lord Reigate. I cannot say any more about that at the moment.
I was fascinated and interested by the speech made by the noble Baroness, Lady Serota, who knows so very much about this problem—probably a good deal more than I do. She has worked at it a good deal longer than I have. I should like to make one or two points about her interesting speech. First of all, she asked me about the Working Parties and whether their reports will be published. They will not be making reports in that sense. They are Working Parties, and they come up with recommendations as soon as they reach them. There will not be written reports, but their recommendations will certainly be made known.
The noble Baroness, and many other speakers, have made the point that we are over-emphasising management and not caring for the patient. I think her words were that this should be a Service for the patient and not for the administrators. This is entirely in accordance with our thoughts, but I believe that this is what good management means. The management that we arc after is the optimum use of resources, and it seems to me that optimum, in this sense, means bringing the best service possible to those who need it; that is to say, the patients, and indeed—to go even further than that, to follow up a point that the noble Lord, Lord Morris of Grasmere, made in his excellent speech—the healthy. It is just as important to prevent the healthy from falling ill as it is to treat them once they are ill. It is in this context that we see good management of resources.
I was challenged by one noble Lord to give a definition of what I meant by "management abilities". I have not had time to think of one of my own, but perhaps I could quote what my right honourable friend said on July 1 in another place:These tasks will call for high qualities of leadership, persuasion, energy and drive, so that the professional people responsible for providing services are encouraged and enabled to realise the authorities' objectives. These are the essential qualities of management, and without them—without leadership, persuasion, energy and drive, all geared to professional advice—we shall again have in the future, as we have now, very uneven services to the 132 public."—[OFFICIAL REPORT, Commons, 1/7/71; 605.]I see no reason whatever why a housewife should not provide "leadership, persuasion, energy and drive". The noble Baroness asked me, too, about the question of a Health Commissioner. We are still discussing this matter. We are in close touch with the professions over it, and I am afraid I cannot say anything further this evening. We also, as she does, highly value the contribution that is made by the hospital advisory service, and I hope that we shall go on receiving useful assistance from it.
The noble Lord, Lord Amulree, mentioned chronic and long-term illness. He, as I am, will be happy at the extra money that is going into those services. The contribution that can be made by small hospitals, about which I very much agree with him, is a subject in which we are interested and one which we are considering very carefully. The right reverend Prelate the Bishop of Lichfield also mentioned the matter of staff, about which I hope I have given some assurance in answering the noble Lord, Lord Garnsworthy. I assure him that the health centre programme is going ahead strongly. I think he felt that it was falling back a bit, but in fact it is going ahead well, and we are giving loan sanction in every case where we are asked for it. I also agree with him that the community health councils must indeed be a reality, and say how very much I welcomed his point about the part that the Churches can well play in these community health councils.
I am grateful to the noble Baroness, Lady Masham of Ilton, for her contribution. I should like to emphasise to her, as I did in an interruption of the noble Lord, Lord Wright of Ashton under Lyne, that there is no question of these boundaries interfering with patients. They can cross boundaries just as they do now. After all, there are 14 regions now, and maybe 14 or 15 regions to come. But it is quite clear that the regional boundaries are administrative boundaries, and so are the area health authority boundaries; and patients will go to the hospital where they can get the best treatment that there is. In fact we hope that there will be better cooperation in a reorganised National Health Service, and that is what the good 133 management that we want is there to provide.
Another point that I have not answered so far is one raised by my noble friend Lady Brooke, on the future of the public Health Service. I quite agree with her how important it is to keep up the morale of those serving in the local authority health services in this interim period. In fact, we are doing our best. My right honourable friend and I are going around attending regional conferences of local authorities for this purpose, to try to explain to them what is in our mind in these reorganisations, and to assure them that we are just as keen to incorporate the preventive health services in the new set-up as no doubt they are. The noble Lord, Lord Avebury, apologised for having to leave early, and I think it would be best if I answered in writing his two points. May I also thank the noble Viscount, Lord Davidson, for bringing up, very rightly, the question of those who suffer from mental handicap. He himself does a splendid job as chairman of one of our mental handicap groups, and I can assure him that we are not neglecting the need to train people for the new sort of residential homes that we want to find for the mentally handicapped. This is very much in hand, and we have plans for training courses for them.
The noble Lord, Lord Morris of Grasmere, referred to health visitors. This again is another very important aspect of the Service. We hope that the integration within the area health authority will help this sort of co-operation further; and, like him, we very much welcome their attachment to general practice or to health centres. The noble Baroness, Lady Young, mentioned, among other matters, the school health service. This is a matter that we are discussing in the Working Party with the local authorities, and, as I have said, there is a special subcommittee discussing the future of the school health service. The noble Baroness, and also, I think, the noble Lord, Lord Champion, asked about the community health councils and the districts with which they correspond. That 134 they will correspond with the health district is our idea. The area health authority will contain one or more district general hospital. Around each district general hospital there will be a district health administration. It would seem right to us, although we are still open to discussion on this matter, that the community health council should work to the area health management, because they will have to consider the integration of the services—not only the hospital service, but also all the other services within the district.
I thought the noble Viscount, Lord Waverley, was a little too gloomy about the future of the district general hospital. Certainly in our view it will form the centre for the development of the district services. As I have just been saying, it will be the lowest integrated health care provision tier, and there will be district management within the area. I very much hope that the Cogwheel organisation will never suffer, because we believe it to be a very valuable contribution to the administration of the National Health Service.
My Lords, I think I have answered all the questions that I can honestly answer, except for one that the noble Lord, Lord Champion, put to me, about an advisory Welsh Health Council. Our proposal was in response to suggestions made, following the Welsh Green Paper that there should be some national body in Wales, independent of the Welsh Office and the area health authorities, to act in the role of public watchdog. The proposal has had a mixed reception and some—not only the noble Lord, but also his noble friend Lady White—have questioned the need for this Welsh Health Council, and have suggested that the work could be effectively carried out by the existing Welsh Council. We have taken careful note of what has been said to us on this subject, and will take it into account before we come to any final decisions on the matter. I apologise to all those of your Lordships whose questions I have not answered, but I will communicate with you as soon as I can.
§ On Question, Motion agreed to.