HL Deb 04 December 1972 vol 337 cc8-136

2.49 p.m.


My Lords, in moving the Second Reading of this Bill, I should like first, rather unusually perhaps, to pay a tribute to my own Secretary of State and to those who manage the Business in another place for the fact that this major piece of Government legislation is starting its passage in this House. Your Lordships have made it very plain, during the course of the last Session, and indeed in this one, that you found it intolerable to have to sit until very late hours and also late into August and again for two weeks in September, principally because of the imbalance in the legislational programme between the two Houses. My noble friend the Leader of the House made it plain that he was going to do his utmost to see that in future this was not repeated. However, I think that the noble Lord the Leader of the Opposition, who also tried very hard to achieve this object, will admit that one of the difficulties has often been that for very natural reasons the responsible Minister has been anxious to introduce his own Bill in his own House. I am sure that your Lordships would like me to acknowledge the unselfishness shown by my right honourable friend the Secretary of State for Social Services in allowing this Bill to be introduced into your Lordships' House.


Hear, hear!


My Lords, one rather sad fact I should perhaps mention before introducing the Bill is the death of the noble Lord, Lord Rosenheim, over the weekend. The noble Lord was universally esteemed, both in his own profession and by the outside world, not least by a host of very grateful patients from all over the world. He would have brought his great wisdom and unrivalled experience to a discussion on this Bill. We shall sadly miss his advice. We shall miss him not only for his professional skill but also for the immense contribution he made to our national affairs. He was President of the Royal College of Physicians; he was the previous President of the Royal College; he was currently chairman of the Medicines Commission; chairman of the Cancer Coordinating Committee; chairman of the Medical Council on Alcoholism, and a leading figure in the campaign against smoking. His record speaks for itself. He was also, I believe, the most deeply respected doctor of our time.

My Lords, proposals for the unification of the three branches of the Health Service—hospitals, general practitioners and local personal health services—date back to the Porritt Report of 1962. Successive Green Papers and Consultative Documents have developed the idea and con tributed to the overall aims of unification and integration. These aims are generally accepted by all political Parties and by most of those working in the Service, although there are differences of opinion about how and when. Following the Seebohm Report, the personal social services have already been reorganised within local government. Now with the Local Government Act on the Statute Book we proceed to the reorganisation of the National Health Service in order that it may take effect on the same date, April 1, 1974.

I think it appropriate to pay a very sincere tribute to all those who have served the National Health Service in its present form from the year 1948 until the present. While it is certainly not unknown for there to be criticism of the Service, on the whole throughout the country there is a deep respect and great gratitude to those individuals who give so willingly of their time and energy to serve the needs of the sick and the suffering. We owe our thanks to the voluntary members of the management bodies, to those who have made their careers in the Service and to the voluntary workers who have supported it.

For most of those working in the Service, reorganisation will have no direct impact on their work, but among the minority whose jobs may change it is understandable that there should be some apprehension about their individual futures and this is bound to remain until reorganisation is complete. We shall do all we can to reduce uncertainty as soon as we can and I hope that the provisions in the Bill will reassure the staff of our anxiety to see justice done to each of them, and will enable them to raise their eyes beyond the immediate horizon and to see the very real benefits that we expect from reorganisation.

The Bill is not intended just to create a more logical administrative set-up. It is designed to restructure the Health Service to enable it to meet the needs of the people it serves. The pattern of the past—and I am certainly not in any way wishing to belittle what has been achieved—has been the establishment of a very fine Service for the acutely ill. This exists and will continue to develop as new hospital building is completed and new equipment installed. But at the same time we have neglected—or if not neglected at least done too little for—those who in terms of scale of suffering probably deserve more of our attention: the old, the mentally ill, the mentally handicapped and the physically handicapped and those who suffer from arthritis or epilepsy.

The Bill seeks to create authorities charged with the total health care of a community. It integrates medical and nursing services provided in hospital with medical and nursing services provided in health centres, practice premises, the community and the home. The accent of the integrated service will be on prevention and on treatment in the home or, failing the home, in the community close to relatives and friends. The Bill looks beyond the health services and seeks to establish the closest possible links with other essential services provided by the local authority—the social services, education, housing and environmental health. This is the fundamental reason for establishing authorities for areas which match in boundaries the equivalent non-metropolitan county, metropolitan district, London borough or group of boroughs. The emphasis we have laid on this matching of health and local authorities has created some overlap problems but these are by no means insuperable and will be much less injurious to the whole system than a failure of cooperation between the health and social services. To ensure that this collaboration is as close as possible, a working party drawn from local government and the health services has been studying the problems and has already produced useful recommendations.

The proposed organisation of the new Service is based on three pillars. The first of these is the needs of the patient. Integration of services within each community will of itself bring benefit to the patient. Vast sums of money are already being spent on the provision of health services but we shall never have enough, and if we are to do the most that we can for each person using the Service we must make the best use of available resources. This means good management attuned to the needs of the Health Service and sensitive to public reaction. We believe that we shall achieve this more effectively by the creation of two types of body: one to manage the Service and the other to represent the public. We therefore intend, under the Bill, to establish reasonably small area management boards complemented by community health councils which will provide a new and more effective channel of public reaction. And as an additional safeguard against failure of service or maladministration, the Bill establishes a Health Service Commissioner for England and a Health Commissioner for Wales.

The second pillar on which the organisation is constructed is the involvement of the professions in the management of the Service, coupled with arrangements for expert professional advice at all levels. The health care professions will, we hope, play a full part in the district management and health care planning teams which will between them organise the health care of the local community. There will also he members from the medical and nursing professions on area and regional authorities, and at both area and all-Wales or regional level there will be advisory committees, medical, nursing, dental, pharmaceutical, ophthalmic and perhaps others.

The third pillar is collaboration with local government which I have already mentioned. This should be especially effective in a metropolitan district where the local authority is responsible for social services, education. housing and environmental health—in many cases it is in these districts that the most difficult problems arise. But it is equally important to make the best possible arrangements in the non-metropolitan counties for collaboration with the county authority and the district authority.

The administrative framework proposed in the Bill follows closely on the proposals in the White Papers on National Health Service Reorganisation in England and Wales. The order-making power in Clause 5 will be used to establish 14 Regional Health Authorities in England following approximately the same boundaries as the present Regional Hospital Boards (although they will be completely new and completely different authorities). The region will be responsible for major planning decisions and for co-ordination between areas, for the allocation of resources and general supervision of their use, and for the provision of certain services too specialised to be provided by individual areas.

In Wales, because of its smaller size, there is no need for a regional tier. The Area Health Authorities will be directly accountable to the Secretary of State who will determine national priorities, allocate resources and co-ordinate area plans. Specialised executive services which can only be efficiently provided on an all-Wales basis will be the responsibility of a special health authority—the Welsh Health Technical Services Organisation.

There will be some 90 Area Health Authorities in England and eight in Wales. They will be the main executive bodies for the provision of health care within their boundaries. Where an Area Health Authority contains a medical school it will be known as an Area Health Authority (Teaching) and will have a slightly different composition. An Area Health Authority will consist of about 15 people. In England the chairman will be selected by the Secretary of State, and most of the other members will be appointed by the Regional Health Authority. So important do we consider the link with local authority services that four members of the Area Health Authority will be appointed by the corresponding local authority. Each Area Health Authority will include at least one person representing university teaching interests, and will also have doctors and a nurse or midwife as members. In Wales the Area Health Authorities will have the same composition, but the Secretary of State will appoint the Chairman and members apart from the four appointed by the corresponding local authority.

The Bill does not lay down how the new authorities should discharge their functions, or how areas should be subdivided for management purposes. But the intention is that normally within the area, health care to the community will be organised in districts, the smallest unit that can provide the full range of health services including those of a district general hospital. Steering groups widely representative of the Health Service in England and in Wales have now put forward proposals based on studies of the future management of the Service carried out by smaller groups. These proposals are now under consideration in consultation with the interests concerned, and no decisions have yet been taken on them but I should like to mention just three aspects of them: first, the organisation begins from the smallest unit upwards—the district upwards; secondly, the fact that it seeks to involve doctors, nurses and other professional workers in the management structure; and thirdly, the fact that it proposes to lay first emphasis on the patient by the organisation of health care groups made up of a team representing all the necessary professional skills from both the Health and Social Services.

The main contents of the Bill are set out clearly in the Explanatory Memorandum and I do not think I need do more than mention one or two clauses in particular to which I would especially draw the attention of your Lordships. Clause 3 brings within the National Health Service the local education authorities' present responsibilities for the medical and dental inspection and treatment of schoolchildren. A close working relationship with the education services must be maintained, and the Collaboration Working Party has concluded that satisfactory arrangements can be made. We intend that they shall be.

Clause 4 imposes a duty on the Secretary of State to make arrangements for family planning services to the extent that he considers necessary to meet all reasonable requirements. The Bill will not itself result in any change in the scale of services, but will provide a framework for flexible development unfettered by administrative barriers. I have already referred to the establishment of Regional and Area Health Authorities, and the only matter in Clause 5 to which I need draw your Lordships' attention is the establishment of Family Practitioner Committees. Each Area Health Authority is required to establish a family practitioner committee, the constitution of which is provided for in Part II of Schedule 1, and is similar to that of the present Executive Councils. Their work will be defined by regulation under Clause 7(3), and will consist of entering into contract with individual practitioners and administering their terms of service, including remuneration and statutory disciplinary arrangements. On other matters affecting family practitioner services the Area Health Authority will be responsible including planning of health centres and approval, where necessary, of practitioners' own proposals for providing premises and the important arrangements for attaching nursing and other staff to general practices.

Clause 8 provides for the statutory recognition of local professional advisory committees in each English region, in Wales, and in each area. Clause 9 imposes a duty on Area Health Authorities to set up community health councils. Their basic function will be to represent the interests of the public in each health district, and in so doing, to make the Service sensitive to people's needs.

The councils will have power to secure information about health services in their districts, will have reasonable visiting rights to National Health Service premises, and will have access to the Area Authority and to its management team in the districts. The councils will be expected to publish reports, and the Area Authorities to publish replies to them. We hope for a continuing and constructive relationship between Health Service management and the community health councils, in which advice is sought and given and views are conveyed and considered in mutually helpful interaction. Half the council's members will be appointed by the local government district councils. The other half will be appointed by the area health authority, mainly on the nomination of voluntary bodies involved locally in the National Health Service, but some after consultation with other locally-based organisations. The councils themselves will appoint their own chairmen from among their own members.

Clauses 10 to 12 are all concerned with collaboration between the Health Service and the complementary local authority services. Clause 10 imposes on health and local authorities a general duty to co-operate and goes on to require Area Health Authorities and the relevant local authorities to establish the joint consultative machinery in which they can get down to the business of making collaboration work—ensuring that plans match, and that the arrangements at ground level for operational co-ordination of the services work satisfactorily. One of the foundations of collaboration will be mutual dependence of local and health authority services. This will apply in many fields and it is expressly recognised in relation to staff in Clauses 11 and 12. The Secretary of State through the health authorities will have a duty to make doctors and nurses and dentists available to local authorities, while social service authorities will have a corresponding duty under Clause 12 to make their specialist staff available to the health authorities.

Clause 13 makes clear the Secretary of State's power to use voluntary organisations to secure provision of any N.H.S. service. There is already power to give financial assistance to voluntary organisations, and this will be delegated to the new health authorities to enable them to make grants to voluntary bodies which provide services within the general scope of the authorities' responsibilities. I know your Lordships are well aware of the great importance that we attach to the voluntary services and will welcome the fact that they are to be incorporated in this way in the future. Clauses 14 and 15 abolish all existing authorities with the exception of certain boards of governors of post-graduate hospitals which are listed in Schedule 2. Among the authorities that will disappear under the Bill are the boards of governors of teaching hospitals of worldwide renown. I know that many of your Lordships have served these great teaching hospitals with great devotion, and it is appropriate that we should recognise that there are many Members of this House who have served as chairmen and members and that it is in no sense a criticism of that management if the time has come for a change in the system.

We value as much as anyone the importance of teaching and research in the National Health Service. We are determined to secure the right conditions for both after 1974 and we have proposed a number of safeguards both at regional and at area level. We have also proposed an advisory co-ordinating working group for London, where the problem is particularly difficult. I am afraid it proved impossible to reconcile all the interests concerned with the future of health services in London. We have put forward proposals that in our view go as near as possible to combining the principles of reorganisation with the preservation of the existing framework of services. The London post-graduate hospitals are difficult to fit into an area pattern. Many serve as national reference centres for hospitals in the whole of the United Kingdom and they tend to draw many, if not most, of their patients from outside their surrounding districts. The power is therefore being taken to preserve the boards of these hospitals, which are listed in Schedule 2, in the first instance for a maximum of five years.

No part of the Bill is more important than that dealing with the staff and Clause 19 contains important provisions for protection of salary and terms and conditions of service of staff who are transferred from the old authorities to to the new. Clause 20 provides for the appointment of Staff Commissions for England and for Wales, to advise the Secretary of State on arrangements to ensure that staff interests are safeguarded during the reorganisation period. As your Lordships will know, staff advisory committees have already been appointed in both countries to do the necessary preparatory work.

The provisions in Clauses 31 to 39 are concerned with the appointment of Health Service Commissioners in England and Wales. These, like the provisions for community health councils, are designed to strengthen the rights of users of health services. There will be separate posts in each country, although the first holder, Sir Alan Marre, will combine them with the posts of Health Service Commissioner in Scotland and with his existing responsibilities as Parliamentary Commissioner for Administration. The Health Service Commissioner will follow the Parliamentary Commissioner precedent in that his appointment, tenure of office and salary will not be dependent on a Minister of the Crown. He will be appointed by Her Majesty by Letters Patent and may be removed from office only in consequence of Addresses of both Houses of Parliament. This will ensure his independence of Ministers. I am sure that noble Lords who know Sir Alan Marre will agree with me that his experience and his wisdom which he has shown as Parliamentary Commissioner will guarantee that this function of Health Service Commissioner will be discharged with the utmost impartiality and care. For the Health Service the Bill brings an improved—


My Lords, will the noble Lord forgive me for intervening for one moment in regard to the Commissioner? Is he to operate as the Parliamentary Commissioner has operated previously, in that a constituent has had to contact his Member of Parliament and the Member of Parliament, if he so wills it, passes the communication or the subject matter of it to the Parliamentary Commissioner; or will the Commissioner appointed in this particular case operate so that any individual member of society within this country shall have the door open to him so that he can go direct to the Commissioner, as opposed to the procedure operated by the Parliamentary Commissioner at present?


My Lords, if the noble Lord would care to look at the Appendix to the White Paper he will see the full proposals for the Health Service Commissioner. I think that will cover his point, but we will return to it again at Committee stage if he wishes to.

My Lords, for the Health Service the Bill brings an improved and integrated organisation. For the health professions it offers more effective participation in the the day-to-day running of the Service and its future planning. For the patient it promises safeguards for his interests and, above all, better care through better use of resources and better co-ordination of services. For the nation as a whole it builds on the foundations of a National Health Service that is already internationally admired, a new structure that holds promise of even higher standards of health. I beg to move.

Moved, That the Bill be now read 2a.—(Lord Aberdare.)

3.19 p.m.


My Lords, may I first, in all sincerity, associate my noble friends and myself with the remarks of the noble Lord, Lord Aberdare, at the outset of his speech about the tragic death of the noble Lord, Lord Rosenheim. It leaves a great gap not only in the medical profession but also in our ranks. We all found his quiet, sympathetic, gentle nature most supportive and attractive and he was not only a very great doctor but also a great human being.

I must also thank the noble Lord, Lord Aberdare, for his customary courtesy in explaining so patiently and carefully the purposes and provisions of this long awaited measure which the Government have at last brought forward after a protracted period of gestation. A careful examination of its 57 clauses and 5 Schedules reveals that the Bill is little more than an enabling Bill, vague to a degree in many crucial areas and perhaps more important for what it does not say than for what it actually does say. The main result is to give wide discretionary powers to the Secretary of State over almost every sector of the proposed new Health Service.

We also welcome this opportunity to consider the Bill before it goes to another place and I can assure noble Lords opposite that we on this side will assist with its passage: we will scrutinise, we will criticise, we may even oppose certain of its provisions: but we will, together with Peers in all parts of the House, seek to fulfil the traditional role of this House in considering this major measure before the other place. We will certainly seek to put some flesh on these bare bones as it proceeds through its various stages in this House. The light that the noble Lord shed on some of its more shadowy areas this afternoon was particularly helpful at the beginning of our deliberations.

Many of us will recall that this is the third occasion in some two years that we have debated detailed proposals for this impending major upheaval of the Health Service which will affect the health and wellbeing of every single citizen in this country. Now, at last, and in my view a year too late, the noble Lord has introduced a major Bill which is due to give effect in only 15 months' time to the complex organisation proposals which were set out in the two White Papers on the reorganisation of the National Health Service in England and Wales which were published last August. The bare outline that the Bill sketches does not, however, differ appreciably from the basic principles in the earlier Consultative Document and the subsequent White Papers so, as the noble Lord has reminded us, we have already considered much of the ground which the Bill covers.

Nevertheless this is still an historic day for those of us with a deep commitment to the progressive development of one of the greatest of our universal social services after more than a decade of public debate, and even longer if we look back, as the noble Lord did, to the Porritt Report, and perhaps indeed to the Dawson Report of 1921. Such is the lengthy process of engineering complex change in a democratic society. Although, as the noble Lord reminded us, this Bill is primarily concerned with organisation and structure, the bare bones of the new legislative framework that he has outlined will undoubtedly determine the future quality as well as the pattern of health care in this country. At this moment it is perhaps salutary to recall the opening words of Aneurin Bevan when he moved the Second Reading of the first great National Health Service Bill in 1946: In the last two years there has been such a clamour from sectional interests in the field of national health that we are in danger of forgetting why these proposals are brought forward at all."—[OFFICIAL REPORT, Commons, 30/4/46; col. 43.] Following in all humility in the footsteps of so courageous and determined an architect of our National Health Service may I suggest to the House that there is a similar danger to-day, particularly for those who have struggled these last two years to master Green Papers, consultative documents, the "preliminary first tentative hypothesis", Collaborative Working Party reports, White Papers and, finally, this—I nearly said "ghastly" Grey Paper on Management Arrangements in the Reorganised National Health Service. This sets out the rigid and hierarchical McKinsey-type management structure now proposed for an integrated service in such a welter of "management" language and initials that the reader has to be warned in the Foreword that the particular words are used in such a precise management sense that they have to be defined in a special appendix of role specifications. While the Report admits at the outset that success in achieving the stated objective of better health care depends primarily on the people in the health care professions, an appendix then proceeds to mould them into rigid externally designed bureaucratic "occupants of roles" to achieve a completely mechanistic and hierarchical system borrowed from industrial and commercial bodies, but totally unsuited to a social service like the Health Service.

This major reorganisation must surely be designed above all to assist those in the Service to develop truly integrated, complementary and community-based health and social care systems, focused first and foremost on meeting the changing needs of individual patients and consumers, flexibly and sensitively, as the frontiers of medical science and our knowledge and understanding of the relationships between the environment and the pattern of health and disease advance. Unless it does, one must most seriously question whether such an upheaval, involving over a million staff and millions of patients and potential patients, is really worth undertaking, especially when many of the opportunities and very real benefits that such a long-awaited and long-discussed change could bring are now being missed. The Government have completely failed to take account of rising public concern. particularly among the younger generation, about the loss of human values and human contact in large sophisticated, impersonal and remote organisations and of the growing movement towards smaller, mere organic and flexible organisational structures which can respond more rapidly and more sensitively to professional and consumer needs. I believe there is a very real danger that in the new management structure there will be more and more people doing less and less directly for patients. I think this was the point that the noble Lord, Lord Reigate, was seeking to underline in his Question this afternoon.

Thinking now of the Service as a whole, I believe it would be fair to say—and the noble Lord, Lord Aberdare, endorsed this in his opening speech—that in spite of the bitter controversies that surrounded the birth of the National Health Service, no major political Party or professional group now seriously questions the need for such a service. One has, after all, only to cross the Atlantic to the United States, where the cost of health care is escalating beyond the means even of the well-to-do, to appreciate to the full the immense benefits it has brought to millions of people and a whole new generation that has now been nurtured in it. The revolutionary principles which Aneurin Bevan enunciated in the great debate of 1946 have stood the test of time and are still valid almost thirty years later. As we have just been reminded, it is primarily the evolutionary tripartite structure which evolved from those prolonged battles that two successive Governments have now agreed must be changed in order to unite the three separate streams of health care.

We on this side of the House therefore still firmly believe that it is only by providing universal health care services free at the point of need and financed through taxation and contributions paid when people are well, that we can remove the fear of ill-health and spread the costly burden of acute or chronic sickness. The doctor must be completely free to prescribe and to give the treatment the patient requires, regardless of its cost, if we are not only to encourage early diagnosis and treatment but also to have a truly preventive service, which I am sure is an objective we seek in all parts of this House to-day.

We were concerned when the present Government introduced cost-related charges for dental and ophthalmic services up to a given ceiling because we regarded it as a serious breach of this principle. Fortunately, their comparable proposal to relate prescription charges to the cost of the drugs supplied had to be dropped because of practical difficulties and because of the opposition of the medical profession. I was, therefore, glad that the much-canvassed suggestion of "hotel charges" which was in the air when the Government first came into office has not seen the light of day in this Bill. I am equally glad that the next Labour Government are now committed to removing the existing financial disincentives to the proper care of eyes and teeth and to phasing out as quickly as possible fiat-rate prescription charges which have been introduced over a period of time by successive Governments of both Parties.

We therefore regard the proposal in Clause 4 as highly retrograde, since it gives the Secretary of State power to recover charges for the family planning services, which the Bill transfers from local government to the new integrated Health Service, especially as it comes at a time when so many local authorities are already providing a free service. I know that my noble friend Lady Gaitskell, who is closely concerned with these matters, will be speaking later in the debate about the need to provide a universal, free and comprehensive family planning service. We are also concerned at the potential implications of Clause 43 because we are strongly opposed to any further erosion of the universal nature of the Service through the extention of private practice, if that is what is intended.

My Lords, I turn now to considering the purposes of the Bill as a whole, particularly as they affect England. My noble friend Lady White, who is so experienced in these matters, will be speaking towards the end of this long debate and will be dealing particularly with the Welsh aspects of the Bill, as well as with the provisions for setting up community health councils, and the important proposals which the noble Lord mentioned to appoint Health Service commissioners including the new procedures for investigating complaints.

The House will already know from our previous discussion of the various sets of proposals that we are in full agreement with the major purpose as defined in paragraph 1(a) of the Explanatory Memorandum to the Bill. We are concerned only that the unification on which we are embarking should result in a fully integrated Service and not in a partial one, and that it should be achieved through an organic, open and more democratic structure which will encourage and develop the opportunities for the health professions, Health Service staff and consumers, either as individuals or in groups, to participate and be involved in the various stages and levels of the policy-making process.

We are therefore completely opposed in principle and in practice to the proposals in Part I of the Bill and its corresponding Schedules which set out the composition and membership of the new health authorities which the noble Lord outlined. They create what virtually amounts to a five-tier Service, with the Secretary of State and a reorganised McKinsey-type Department at the top, defining national objectives and standards and once again allocating resources to some 14 Regional Health Authorities appointed entirely and directly by the Secretary of State, albeit after consultation with the range of interests specified in Schedule 1.

Under these proposals the Area Health Authorities will clearly be the creatures of the Regional Health authorities, from whom they will receive their resources. The chairman will be appointed by the Secretary of State, after consultation with the chairman of the Regional Authority, and all other members, except for the sprinkling of four local authority members and one directly nominated by the university, will again be appointed by the Region. At least the former representative concept of one-third local authority, one-third health care professions and one-third Ministerial appointees would have increased the potential for active participation in policy-making within the resource allocations coming directly from central Government, from the Secretary of State, as has been the very successful experience of the teaching hospitals in the past. This proposal has been completely abandoned—no doubt a sacrifice to the managerial model which distinguishes sharply and quite unrealistically between the mysterious qualities of "management ability" and the representative role, quite unlike the much more free-flowing democratic structure which the Baines Report commends to the new local authorities that are shortly to come into being and are to be established at the same time as the new health authorities in 1974.

Apparently there is not even to be any provision for at least the chairman of the family practitioner committee to serve on the Area Health Authority as of right, although, as the noble Lord rightly told us, one of the major purposes of this reorganisation is to strengthen the community base of the Service. Let us not forget that it is the 24,000 general pracitioners in this country who provide the essential continuity of health care to each individual patient and each family through some 80 million consultations a year. Surely their close involvement in the development of health centres, of group practices and of the attachment schemes, which the noble Lord also mentioned is an essential part of the overall policy planning of a comprehensive, unified service.


My Lords. I did say that these would be the affairs of the Area Health Authority; the family practitioner committee will be dealing with matters of contract.


I understand that, my Lords. I was pointing out that I want to see a member link between them; I want to see the chairman or, say, one other member of the family practitioner committee serving on the Area Health Authority to ensure the crucial policy link.

At the fourth tier—the health district, the one below the Area but above the service delivery level—there is to be no member involvement whatever, although the proposed health districts will range in size from populations of 200,000 up to 500,000—larger than many of the new metropolitan districts in local government. Thus, my Lords, to fulfil purposes (b) and (c) of this Bill and provide the means in each area of representing the interest of the community and ensuring that the views of the health professions are given full weight in the planning and management of the Service, we shall have about four local authority members on each Area Health Authority, a few doctors and perhaps a nurse or midwife indirectly elected into managerial roles. For the rest, the professions will be insulated into the proposed regional and area advisory machinery which the noble Lord, Lord Aberdare, described to us.

Nor, in my view, should this concept of democracy apply only to professional staff. The Bill is singularly silent on the role of the trade unions in all the proposed consultations that are to take place about membership under Schedule 1. There is no mention whatever of joint consultative machinery in an organisation which is, after all, the largest of our nationalised industries. The major means of representing the community and consumer interests is through the creation of what have variously been called "toothless watchdogs" or, by my honourable friend Mrs. Williams in another place, "administrative eunuchs". These fears have been strengthened by the total absence of any specific provisions in Clause 9 of this primary piece of legislation which leaves the membership, powers, staffing and finances of the community health councils entirely to be prescribed by regulation. I have little doubt that many of your Lordships with long experience of the health and social services, in both the statutory and voluntary fields, will share the widespread concern that has been expresed publicly about this gap in the Bill.

We shall be seeking to strengthen considerably both local authority and staff participation in the areas and the regions if the Government insist on maintaining this fifth wheel on the coach. We shall also try to persuade the House to provide for member involvement at district level through district sub-committees of the areas, as envisaged in the Green Paper of which the noble Baroness, Lady Brooke of Ystradfelite, was so strongly in favour when she led for the then Opposition when we debated the second Green Paper of the former Administration in March, 1970.

I have little doubt that many noble Lords who will be speaking to-day will be specially concerned with the admittedly very real problems that are posed by the geographical location and concentration of undergraduate and past-graduate teaching hospitals in Inner London. They are far more expert than I am on this subject. The real problem here is how to achieve what the White Paper rightly points out is needed by Londoners, no less than by people living in other parts of the country—namely, an integrated Service. I really cannot see why there is a need to make confusion even worse confounded by perpetuating the four existing Regional Boards, as they are now proposing to do. One Greater London region, or perhaps two—one North of the river and one South of the river, which is the natural boundary—would surely be preferable. The proposals to group all but three of the 32 London Boroughs into Area Health Authorities will undoubtedly lessen even the tiny amount of democratic involvement now envisaged in other parts of the country, unless the size of the Area Health Authorities in London is appreciably increased. The grouping of as many as three together, as is suggested in some instances, produces such complexities in developing the essential direct working relationship between the Area Health Authorities and the London Boroughs, particularly in the fields of geriatrics, psychiatrics and pediatrics (including the School Health Service, where the I.L.E.A. is also involved) is such that the mind literally boggles.

I had intended to refer to some of the crucial and complex inter-organisational issues which have been the subject of close consideration by the Department's Collaboration Working Party, but I shall merely confine myself at this stage to welcoming the principle embodied in Clause 9 to create the statutory interface, although I have some doubts and reservations about the powers and the purely advisory nature of the new joint consultative committees which we are to have. It would, however, be helpful if the Minister could tell us to-day when he comes to reply at the end of the debate, whether the Government have finally come to a decision about the future of social work in hospitals, which has been the subject of some controversy. I personally failed to find a clear answer in the Bill.

Finally, my Lords, the noble Lord, Lord Aberdare, rightly paid tribute early in his speech to the staff of this great Service, a tribute with which every single one of us would wish to be associated. When we think of the proposals in this Bill our first thoughts, as were his, must be for the staff, after this long-drawn-out period of anxiety and insecurity, and especially for the medical officers of health and their staffs who have been in limbo for so long and who have contributed so much over this last century or more in local government to the development of preventive health services, particularly for mothers and young children. It is on their shoulders that the main burden of preparing for and implementing change will fall while they still need to maintain the existing levels of service to the community. I very much hope that the Minister, when he replies to the debate to-night, will be able to give them all a firm assurance that there will be no redundancies as the result of this reorganisation in a service which is always short of staff and which needs every man and woman prepared to serve in it.

3.43 p.m.


My Lords, I should like to join in what the noble Lord, Lord Aberdare, and the noble Baroness, Lady Serota, have just said about the loss we have suffered by the untimely death of Lord Rosenheim. I had known Max Rosenheim for over forty years, since the time he was a medical student and I was a junior member of the staff of the hospital to which he came. I shall certainly very much miss his friendship and wise counsel. His is a sad death at such a young age and with such a great deal to accomplish.

My Lords, as has been said, we have debated this subject three times (almost four times, if we include one Unstarred Question on the matter) in the past 2½ years, and therefore I do not propose to go into great detail about the Bill. But there are one or two points which I should like to raise. I am sure that from a great many points of view it is a very good thing to join up the tripartite shape of the National Health Service at the present time. I personally feel that it has worked remarkably well for being a tripartite Service, and as someone who was a worker in the Service I never found any great difficulty arising from its tripartite character. But there is one place where I feel it may do a great deal of good for the patients and for the people the Health Service is designed for, and that is in the provision of community care, because I believe that one of the real shortages in the Service has been the varying amount of community care which the various local authorities have been able to provide. It has appeared almost as though some local authorities were unwilling to spend money from the ratepayers to assist a Service that was funded by the State. One found, particularly in cases where one was dealing with elderly or disabled patients, that it was very difficult to find places in the community where they could be taken care of if they were not fit enough to go back to their own homes and yet there was no need any longer to detain them in hospital. I hope that possibly that will be one of the things that may change when we get the Service unified.

One can see what I mean if one takes as an example the case of an unfortunate Nigerian about whom there was a programme on the wireless—not on television—two Sundays ago. I believe that he was called Mr. David Oluwale. I forget the exact number, but he had been in prison about four times for short periods on some curious charge of "wandering"—whatever that may be—and he had been discharged from prison. He had been in a psychiatric hospital about four times also, and had been discharged from there. On each discharge it was recorded that he had no fixed abode and no employment to go to. There were various other factors involved which I do not want to go into now, but finally Mr. Oluwale was found in the river. It does seem peculiar that a mental hospital, or even a prison—and the noble Lord, Lord Donaldson of Kingsbridge, I know is very interested in this sort of thing—should be able to discharge somebody when he has absolutely nowhere to go. That was something which could not have occurred forty years ago because of the Poor Law, and although I do not want to put forward any claim for the Poor Law it was an all-embracing organisation in which nobody who required assistance did not get it. I admit that the assistance was rough, harsh, and uncomfortable and that no one would wish to see it repeated now. But it seems sad that an organisation like that is taken away and nothing is put in its place.

In these days one is told that there are reception centres. That is indeed true. There is one in Camberwell, in South London, and I believe there is one in North London, too. But what is the use of Camberwell for somebody who is in Fulham upon a cold, wet December night? No good at all! I trust therefore that under the current plans it will be possible to provide far more community care for the people who require it. I know that l may be told—I hope that I shall not be told so to-day, although I have been told so in the past—that local authorities have provided a large number of extra beds in the last twenty years. My answer to that is, quite simply: they may have provided a large number of extra beds but they have not provided enough extra beds and people are still suffering and, in some cases, dying because of that.

Secondly I want to mention the curious position of the community health councils, which appear 'to me to be in a very difficult state because they have no money. I do not think that they have any staff and they have no premises. One is not quite sure what they are going to do. I can see that to have a council which has some power, which is going to represent a consumer and which is going to have members of the voluntary organisations on it—bodies like the disabled income group and that type of organisation—would be extremely valuable, but they must, surely, have some power. It has been said that they can make representations to the Secretary of State. Well, I think if we have got a good Secretary of State, as I am pleased to say we have at the present time, those representations will be a very good thing. But there must be a little more in order to insist that a bad Secretary of State accepts the recommendations at the present time.

There is another thing about which I am not quite sure. Their function is purely advisory. Is it, therefore, a good thing that they have power of inspection of hospitals, power to question officials of the authorities and so forth? Surely to have power like that, with no responsibility at all, tends to make people behave in a slightly irresponsible fashion, which I am certain is the last thing to be intended. Then I think, too, as indeed the noble Baroness has just said, the hierarchical structure of four or five tiers will be very stifling and bureaucratic; I am not at all happy about the way that is going to work. if you have an enormous amount of goodwill on everybody's part and friendly feelings everywhere, it might work quite well. If you have not, there is nothing you can do to make it work if the people involved do not want it to.

The last point I want to make before I come to one or two questions concerns this extraordinary document produced by Messrs. McKinsey and the staff of Brunel University. I am not quite sure what the purpose of this document is. Does it have legal backing? Is it enforceable? Can we amend it? It goes into an immense amount of detail about things which would be much better left to general principles with the details to be worked out locally by the local people. I was thinking of one or two things as I tried to read it. It is almost impossible to read because it is written in such a strange kind of jargon. In Section 4, Nos. 7, 8 and 10, there is reference to the clinicians on the staff of the hospital taking part in the management. Put generally like that, I am not quite sure whether if you are a clinician in charge of patients you are going to have time to do much on the management side. Then in the third section, at No. 9, there are great details about the way to elect and appoint staff. Surely it is unnecessary to go into that kind of detail in a document of that sort.

Those are the real points I want to make. I saw in the medical Press the other day that although most of the emphasis appears to be on management and not on patients the patients have a curious way of hitting back. I read that it was found in the United States that if you want to build an intensive care unit if you did not put any windows in it it was far cheaper than one with windows. That is a bit of building technique. They built quite a lot without windows, and they found that in the ones without windows 70 per cent. of the patients suffered from delirium, whereas in the ones with windows the proportion was only 25 per cent. So it did not pay to build them without windows. Those are matters you have to think about occasionally.

There are one or two questions I should like to ask the Minister. Am I right in thinking that the whole work of the medical officer of health, with the health inspectors, will be taken over by the community physicians? Will the health inspectors be on his staff? The medical officer of health plus the health inspectors—they were called sanitary inspectors—have security of tenure and cannot be dismissed without the agreement of the Minister of Health, now presumably the Secretary of State. Will that continue for these people? Because it is a great safeguard against the actions of vindictive councillors and persons of that type.

The other question I was going to ask is what is going to be the position of the Social Services Department. I have really got the reply to that now, because I found the document, which apparently was issued last July, in the Printed Paper Office; it appears to have taken from July to December to come across from the Elephant and Castle to the Printed Paper Office. It seems that it is recommended that the medical social workers and the psychiatric social workers should become part of the local authority establishment. I know that is going to cause a great deal of upset among many medical social workers and psychiatric social workers, and I wonder whether the noble Lord could tell me, when he comes to reply, whether that arrangement is really fixed or whether it is capable of amendment in the Bill as it goes through this House. It may not be possible to amend it in this House because there is nothing in the Bill itself about those workers.

I agree with what the noble Baroness, Ludy Serota, said about Clause 4 and the suggestion that charges should be made for some of the family planning advice. That seems to me entirely wrong. I thought we had settled that matter when the Vasectomy Bill became law and the Department of Health and Social Security said that they were going to issue a circular saying that that advice could be given free of charge. I am interested to see from a certain amount of correspondence in the medical Press that many medical students in the country share my apprehension about the functions and duties of the community health councils. I always think it is not a bad idea to take some notice of what the young, coming members of the profession have to say. I do not say that one should be wagged by them entirely; but if they express some strong opinion it is quite a good thing to take some notice, because, after all, they are going to be the future doctors for whom the Service is partly intended as well as for the patients.

Finally, I am very pleased indeed that it is intended to appoint a Health Commissioner. Sir Alan Marre is an old friend of mine, and I am quite certain that he will be a very good Commissioner. My Lords, although I have been somewhat critical of parts of this Bill, I have every intention of encouraging its passage through this House as quickly as possible, though noble Lords on these Benches will probably have various matters to put down when we come to Committee stage.

3.59 p.m.


My Lords, may I first associate these Benches with the tributes paid to Lord Rosenheim, whose death will be lamented by all connected with the Health Service. I lay no claim to knowledge of other aspects of the Health Service, but as Chairman of the Board of Governors of Middlesex Hospitals for the past ten years I claim some experience of practical health administration, and as Chairman of the London Undergraduate Teaching Hospitals Committee I have been closely involved in discussions with the Secretary of State, with the noble Lord, the Minister of State, and the noble Baroness, his predecessor, and their Department.

Your Lordships will appreciate—and the noble Lord has indicated that this will probably be the case—that as successors to generations of boards of governors, who have built up these great hospitals over the centuries, we feel no joy in proposals to dismantle these boards, together with the hospital management committees throughout the country, and to dismiss their members. This is by no means only a question of sentiment or of nostalgia for the "good old days". On the contrary, in my judgment the maintenance of individual boards of governors with direct responsibility to the Secretary of State has played a full part in preserving, during the initial period of the National Health Service, the particular aura of the various teaching hospitals. It is an aura which, as the noble Lord was good enough to indicate in his speech, has given good service to the public and good service to medicine both nationally and internationally.

In the long months of discussion with the Department we have made it clear that the teaching hospitals fully support the objective of integration of the Health Service. Their reservations and criticisms have been directed not at all to the objective but solely to the proposed methods and the timing. The undergraduate teaching hospitals have urged that, especially in the admittedly complex situation in London, an interim period like that arranged for the postgraduate hospitals, or at least a more empirical approach, would give better results; for example by developing existing arrangements for joint consultative committees and district responsibilities, increasing local representation on boards of governors, and intensifying the already close relations between teaching hospitals and other health services. In particular they have stressed the importance to the Health Service in general, and to medical education in particular, of maintaining the intimate relationships which exist be tween teaching hospitals and their associated medical schools.

I do not wish to weary your Lordships by repeating all the arguments which I put forward in these matters in the debates in March, 1970, and in November last year, nor do I wish to go again at this stage into all the complications of London, with its difficult location of teaching hospitals. But if I may recall one phrase which I have used in both my previous speeches on this subject, it is a good general administrative rule not to destroy something that works fairly well without being sure that you have something better to put in its place. I think it is proper to put it on the Record to-day that the Teaching Hospitals Association and the great majority of members of boards of governors are not satisfied that, so far as the services which the undergraduate teaching hospitals can give to the community, this condition is fulfilled in the present proposals. They maintain their view that a more empirical and less uniform approach would have led to better service and more efficiency. Having said this much, the teaching hospitals recognise that in the end it is the responsibility of Government, having heard arguments from all sides, to take decisions and to put legislation before Parliament. Whatever is finally decided, the teaching hospitals will do their utmost to make the new arrangements work as efficiently as possible, and to give the best service they can to the public and to medical science.

I should like to put on record our thanks—and my personal thanks—to the Secretary of State, to the noble Lord, Lord Aberdare, and the officials for the courtesy with which they have listened to our arguments. We could wish that they had sometimes found our arguments rather more persuasive. Nevertheless, we are grateful for the special provisions made in the Bill for teaching areas, and for assurances given with the object—to use their own phrase—of "the Department escorting the teaching hospitals into the new structure". In particular we welcome the promise in the White Paper of additional safeguards for the teaching hospitals during the early years, and we look forward to further discussion of this matter in detail.

We also welcome the arrangement for endowment funds. In general, there seems now to be considerably more recognition, at least in principle, of the importance of teaching and of adequate university and medical school representation at various levels. The detailed application of this principle still needs to be spelled out, and I hope that the noble Lord replying will be able to assure the House that every practical step will be taken to maintain the present position where teaching hospital and medical school generally work as two parts of a single organisation. As I have said before, unless we maintain standards and facilities for teaching doctors for future generations, it is a great waste of time to plan a better health organisation.

My Lords, this brings me to the arrangements for future administration of the Service as it affects the actual management of the hospitals themselves. These matters are under discussion between the Department and various bodies concerned, including representatives of the Teaching Hospitals Association. I will therefore mention only one or two points. As a general point there seems to me to be some contradiction between the White Paper and the recently published Paper on Management in the allocation of responsibilities to regional authorities and area authorities. As I read the White Paper, the regional authority was to be mainly a planning body acting, so to speak, as intermediary between the area and the Department, while the area was to be the effective operating unit. This is certainly the impression we have derived in our discussions with Ministers. The Management Paper, on the other hand, appears to leave with the region much more responsibility for operational control and for monitoring the work of individual officers. This suggests to me, at least in London, a very heavy and expensive duplication of work between the regional authority and the area authority. I assume that the Department have made full costing estimates of this superstructure of area and regional authorities. I hope that the noble Lord, when he replies, can give the House some figures. In any event, it is a subject which will need close examination at later stages.

My other point concerns the actual mangement of hospitals under the proposed arrangements. Little is said about this in the Bill, in the White Paper, or in the Management document, though the Secretary of State has been good enough to give us some further information about the intentions. The boards of governors are naturally most concerned that, in being required to hand over their responsibilities for management, they should, so far as possible, ensure that they are handing over to something viable. In particular—and here especially I know that I speak for the chairmen of all London undergraduate teaching hospitals—we are concerned to ensure appropriate status, salary and authority for the person actually managing the hospital, both absolutely and relatively to officers at area and regional level. This at least is a subject on which I can speak with some confidence, having watched for ten years, day in and day out, the load which falls on the chief administrator of a large hospital, and the need for occasional quick and authoritative backing for his decisions. This job can certainly not be done effectively by an administrator not located in the hospital itself, nor can it be done by a junior officer subject to tiers of senior and more highly paid officials. This is a subject which we are discussing further with the Secretary of State and to which we attach the highest importance.

I do not, I am afraid, take very seriously the suggestion in the Management Paper that immediate decisions, often of great difficulty and importance, can effectively he taken by consensus of a team. I may perhaps quote one or two phrases from that Paper, if your Lordships will bear with me. At paragraph 2.42 it is said that the D.M.T.—that is, the district management team— will be a group of equals, no member being the managerial superior of another. The team thus brings together, to make decisions and to share in joint responsibility, both clinicians and officers accountable to the AHA for hierarchically-organised services". Paragraph 2.44 says: 'Joint responsibility', means that the AHA will expect the members of the DMT to co-operate in order to reach a consensus view and to be bound by team decisions. The officers of the ATO will monitor their counterpart officers in order to ensure that they contribute effectively to the work of the DMT. If the work of the DMT is found unacceptable by the AHA, the DMT will not be held corporately accountable, but the AHA, with the assistance of the Area officers, will assess the performance of each team member to determine the source of the difficulty. I will not labour the point.

There is another phrase in the Management Paper, indicative perhaps of a state of mind, of which I am suspicious. I quote from paragraph 2.11: The AHA should avoid establishing standing committees of Members, with or without delegated powers, to deal with particular functions (such as finance) or professions (such as nursing) or with geographic areas (such as Districts). The AHA will be a small body selected for its capability. Its Chairman will act for the Authority between meetings, consulting with the officers. Freely translated, I take this to mean, "Keep the members out of the way, leave it to the officials, and we can probably 'square' the chairman."

The main purpose of the Bill is to bring about a very desirable integration of the Health Service. I therefore support the Motion for the Second Reading. But Parliament should recognise that, in its present form, the Bill means a thorough disinvolvement of lay participation in direct hospital administration throughout the country. It removes the administration of undergraduate teaching hospitals from boards of governors with their mixture of medical, academic and lay membership, involved in every aspect of the hospitals' life, and with direct responsibility to the Secretary of State. It entrusts it instead to layers of officials and administrators, reporting to statutory bodies too far away to know what is really happening in the hospitals. It may prove over the years to be a more efficient system. I doubt it.

4.11 p.m.


My Lords, I wish to identify myself with the tributes that have been paid to the late Lord Rosenheim. I think nothing finer can be said of him than that he was a great doctor—humane, kindly, knowledgeable, understanding—and I feel that his premature death diminishes us all, particularly the medical group in this House. I shall not follow the noble Lord, Lord Cobbold, in detail, but I must admit that his enthusiasm was infectious; and although I cannot agree with him in everything he said about the governors of the teaching hospitals I shall nevertheless speak rather strongly about what I consider the undemocratic method of setting up this particular machine.

I suppose there is one point on which we all agree: that the Title of the Bill, the National Health Service Reorganisation Bill, is deceptive. Of course it does not directly affect the health, the wellbeing, the cure or the treatment of any individual in the country, and it is in great part concerned simply with the reconstitution of committees. Whether from this very expensive exercise—expensive in terms of money and manpower—there will emerge the comprehensive Service that we desire still remains to be seen. But I agree with the noble Lord, Lord Cobbold, that the Government have undertaken a great exercise and that if it fails, or even if it is not very successful, it will be a tremendous disappointment to all of us who have waited for many years for this reunification of the Health Service.

The Secretary of State stated in the White Paper that, the purpose behind the changes … is a better, more sensitive, service to the public. The word "sensitive" particularly appealed to me, because I feel that it sums up a service which should be administered by compassionate men and women whose expertise and record of service to the community is beyond doubt. In examining this Bill, I think that every one of us should have that in mind. Nevertheless, the word "sensitive"—which I presume was deliberately picked by the Secretary of State—is hardly descriptive of to method adopted to establish the administrative committees. I am sure that your Lordships have all read the Bill and you have heard my noble friend Lady Scrota, but I want to emphasise what is being done.

It seems to me that the Government are prepared deliberately to sow the seeds of discord by adopting a method of choosing the personnel which savours of nepotism. That is a very strong word, but if one considers what is being done I think it is not overstrong. While it is of course important to promote efficiency, it is more important to keep in mind that human suffering is what the Health Service is all about, and I feel that in their desire to present a neat network of committees those who drafted this Bill were apt to forget the end in arriving at what they considered to be the correct means.

Undoubtedly the Area Health Authority boards represent the administrative focus. The chairmen of these will be appointed by the Secretary of State and the members will be predominantly appointed by the Regional Health Authorities, who are themselves also to be appointed by the Secretary of State. It would appear to me that the master's voice will echo along the complete administrative chain, from the Elephant and Castle to the North, South, East and West of the country. The question is, therefore: can these proposals be regarded as democratic? Also, am I right in thinking that they may cause some trouble before we arrive at an acceptable arrangement?

I served my political apprenticeship in local government, and I am alarmed by the criticism of the scheme in London by Alderman Shearman. Alderman Shearman is the Chairman of the London Boroughs Association, and everybody here will agree that he devotes his life to matters of this kind, is steeped in local authority work, is a man who really must know what he is talking about, and is also a man who would not, because of his work, frivolously condemn any measure which the Government produced. But he has condemned the Bill as illogical and irrational. That is very strong language coming from a man in his position.

Should we leave officialdom to choose the representatives for what we hope will be a more responsive Service? A recent Answer in this House provided me, at least, with evidence that the official mind is not always attuned to making the right decisions regarding the choice of the appropriate person for a particular function. There were many noble Lords present in the House when I asked that Question, and it will be recalled that a working committtee was, quite recently, established by the Home Office to examine the whole question of bail. With the thought of Holloway Prison and those unfortunate wives and mothers—women who I knew would be longing for bail at Christmas—I listened incredulously to the long list of committee names consisting solely of men. When I asked why not one woman had been chosen to help consider a woman's problem, I was told that the members were chosen only on grounds of merit and use fulness. I do not know whether the wives of noble Lords in this House have any merit or usefulness, but the fact is that never before has the whole female population been condemned as lacking a modicum of merit and usefulness for considering women's problems. I quote that as an example of what happens when officials are left to choose a committee. That was not in the last century, my Lords, but only two weeks ago. When I think of the composition of these administrative committees of the Health Service being nominated by like-minded, prejudiced officials I do, if it is possible for me, tremble.

Over the years, as we all know (and many noble Lords here were with me in the other place), we have had frequent debates on different aspects of the Health Service which make depressing reading if one takes into account the repetitive nature of the contributions. Time after time, either noble Lords here or Members in another place have raised similar questions; but the years have passed, there have been yet more debates, and one still feels that no notice has been taken and no action proposed. For my own part, I have asked successive Ministers to provide a comprehensive domiciliary service on the grounds of providing care and treatment for those, particularly the elderly and the disabled, who are anxious to remain in their own homes. This seems to me the very essence of common sense; and having myself been in practice for so many years, I know that one should regard this as a priority in considering the reorganisation of the Health Service. Frankly, my Lords, it has never ceased to astonish me that the Treasury have always failed to recognise that a comprehensive domiciliary service, with its proper quota of home helps and home nurses, not only is a humane concept but would save large sums spent on hospital accommodation. One has only to think of the queues of people waiting to get a hospital bed, and of the people at home whose lives would be more ordered if the sick man or sick woman who was still compos mentis was still in the home, where they longed for them to be. The first thing I should like to learn—because not only am I concerned with the means, but I am thinking of the end—is, will this new form of administration provide this full, comprehensive service? That is the one test I shall apply in assessing its value.

In the Health Service, as in other services, key workers are of paramount importance, and I should like to think that more attention is given to the appointment of key workers throughout the country. I have in mind my own borough, the Borough of Camden, where—and I think I have said this before—some of the key workers, including the Medical Officer of Health, possess a high sense of duty and vocation which is reflected in the medical and social services of the borough. As I read this long Bill about these complicated committees I know full well that in certain boroughs, where there is an administration similar to any other, we can get a first-class service with the present administration; yet in another borough one can find similar officials and similar committees but a third-rate service for the people.

Most of the points I had it in mind to refer to have been mentioned, and in the time at one's disposal one must be very limited. It is intended to establish community health councils for the purpose of channelling complaints. Again, these bodies should reflect the public interest; yet they are to be mainly nominated, and consequently will deny the community genuine participation. If we are told that we are to have an organisation set up to protect the community, then surely it is the community that should be represented on these committees. While the Health Service Commissioner will be welcome, I still find it difficult, although I have read the relative parts of the Schedule and the Bill, to define where his powers begin and end.

I am assuming, I hope correctly, that the Commissioner will act as the watchdog of the administration, carefully guarding the quality of the service by exercising vigilance; and I should like to think that this includes the appointment of key officials. He or she—and, my Lords, I am a realist and an optimist—should not wait to receive complaints, for this Bill empowers the Commissioner to initiate complaints concerning those departments which fail to administer in the spirit as well as according to the letter of the law. Now we all know that individuals or committees can be identified with some kind of action that should take place, but unfortunately so many of them fail to act with promptitude. I hope that the Commissioner will take prompt action when necessary, and there will be no undue delay. For the success of the reorganisation will depend on the quality of management and on the co-operation of the component parts.

I want to say just one word about Wales, if my noble friend Lady White will allow me, because I know that she is going to speak particularly about Wales; but being married to a Welshman makes me very Wales-conscious. I observe that in the Welsh Grand Committee Mr. George Thomas, a former Secretary of State for Wales, said that one of the curses of Wales was the nominated body. He then referred to what he described as a most disturbing deterioration of the general practitioner service. Undoubtedly the valleys of Wales are not alone in needing more general practitioners, but this does not call for the carrot and the stick to make the existing doctors work: it calls for a policy to augment their numbers. When I said to the noble Lord, Lord Cobbold, who has just spoken about the teaching hospitals, that I could not agree with everything he said, I had in mind, of course, the failure of the teaching hospitals to use the brilliant girls who wish to be educated in this country. I have already referred to this point, but I entered Parliament in 1938 and I have probably mentioned it in every Health debate since that year—and still nothing has been done. I am hoping that perhaps, at last, now that the governors, whom I have regarded as the guilty men—


My Lords, we have several brilliant girls in extremely senior positions.


Several: but we want more than several. We do not want a tiny proportion of the medical student population. I would go so far as to say this to the noble Lord, Lord Cobbold. I believe it may also have been in the Minister's mind that he felt the time had come to take this important power—the power which I believe they have exercised against the brilliant young women of Britain—out of the hands of the governors. I am prepared to sit down if the noble Lord wants to interrupt again. I have longed for this moment. I have waited for it for decades; and I am hoping that, as a result of this Bill, there will be a magnificent change.

My Lords, I just wanted to say that the Welsh Grand Committee overlooked the supply of wasted potential in the brilliant Welsh girls who failed to find a place in the medical schools—those Welsh-speaking girls for whom Wales is longing to-day, I understand—simply because a quota system dictated by prejudice has operated against women. May I finally say that if the number of doctors in the Welsh valleys fails to increase in the next few years, then this exercise in reorganisation, although it is armed with the necessary powers, will have failed in producing essential key workers. So the value of the provisions of this Bill will be judged not by the proliferation of committees but by the final bridging of the gaps in the National Health Service which have been emphasised again and again in debates in both Houses.

4.30 p.m.


My Lords, I should like to join with others who have spoken in saying how much I thought of Lord Rosenheim. I was rather a new acquaintance of his, but I fully appreciated his graciousness and his friendliness, even to someone he knew only slightly.

I welcome this long-awaited Bill and I want to speak on two different aspects of it. I have chosen two subjects about which I know a little. I found the greater part of the Bill almost beyond my comprehension as I do not understand Parliamentary language. But first, my Lords, as Chairman of the National Association of Leagues of Hospital Friends, may I assure your Lordships that the 920 Leagues of Friends affiliated to the National Association will continue to work for their hospitals, their patients and their staffs, whatever the shape of the organisation which administers hospitals. Our loyalty is to the individual hospitals and to the people who live and work in them and the people who come to them as patients; not to any particular administrative structure. Whatever the Bill does or does not do, there can be no question about the services of the Leagues of Hospital Friends.

My first point is a very important one. It has been mentioned before but I should like to add my words. I think the most important thing is that the Bill is designed to abolish the artificial administrative barriers between what are now three quite separate parts of the Health Service. In my talks with people in all walks of life I have found that this integration of the whole of the National Health Service into the one structure is welcome. It is not surprising that this is so, especially from the point of view of the general public who, after all, supply the Health Service with its patients, because a patient does not place his medical and nursing needs into watertight compartments and cannot understand why anyone else should want to do so.

Another important part of the Bill which I welcome is the clause which requires health and local authorities to work closely together on all matters concerned with the health and welfare of the people. The 1970 Local Authority Social Services Act did many good things, but one of its unfortunate results was the apparent divorce between the statutory provision of health and of social services. The joint consultative committees which Clause 10 requires the two types of authority to set up should, I hope, help to mitigate the effects of this divorce; particularly if, as I understand is to be the case, the two sets of authorities are to have the same boundaries. Of course, the setting up of the joint consultative committees will not by itself lead to the discharge of a single patient who is being kept in hospital simply because there is nowhere else suitable where he can go. There must also be a full acceptance by both authorities of their responsibilities. But at least the fact that the two sets of authorities have the same boundaries and are meeting together regularly to discuss common problems from, let us hope, the point of view of the patient, will help to eliminate some of the administrative confusion which now bedevils so much effort.

My main worry about the Bill is that the people who are to have the statutory duty to run the Health Service are to be so remote from the patient. The lowest level of health authority is to be the area, which may contain a population of many hundreds of thousands of people; at a lower level the administration will have to be done by professionals. I do not want to say a word against the professionals of the Health Service, many of whom are my friends, but I believe that the members of the Area Health Authorities, to whom the Bill gives such very wide responsibilities affecting the lives of so many millions of people, are going to find it very difficult to be other than impersonal in administering what should be a most personal service.

There are, of course, to be the community health councils and Clause 9 confers on them the duty: to represent the interests in the health service of the public in its district … But I cannot find anywhere in the Bill—and others, I have noticed, have had the same difficulty—that there is to be any duty on the part of the area or any other authority to take any notice of what the community health councils say. This I think is a great weakness in a Bill which otherwise has many good things in it. The statutory authority is to be much further away from the patient than is the case now, and I cannot say that the Bill gives me any great confidence that the community health council will be able to bridge this great gap effectively.

For the quarter century of its life the National Health Service has relied effectively on the principle of public participation. Many thousands of ordinary people have given freely of their time and their talents by serving on hospital management committees and other bodies and they have not made too bad a job of it. Now, apart from the comparative handful of members of the general public who will serve on the new region and area authorities, there is to be no place for the non-professional except on these community health councils. Are the powers of these councils to be effective enough to attract people of the calibre of those now serving on the hospital management committees? I hope so, but I doubt it, and so I am left with the conclusion that the interests of the patient are not going to be served by the new administration with the same intimate knowledge and concern as they are to-day.

My Lords, the Minister, I am sure, will be aware that there is much unhappiness throughout the country about this part of the Government's proposals. I have been sent reports from a number of organisations which have studied this question of consumer representation, and no doubt the Minister has seen many more. I do not pretend to agree with every recommendation in all the reports that I have heard, but there is no doubt that much hard and valuable thought has been given to this vexed problem. I hope that in making the regulations under Clause 9 he will remember how important it is that the community health councils should be independent and effective and that they should be seen to be independent and effective so that they will attract as members people of the calibre we need to represent the interests of the public.

My second point is a comment on the wording of Clause 4 relating to family planning which mentions the possibility of making charges for the service. I am concerned at recent reports that there is some disagreement about the benefits of a completely free family planning service. It is my view that a free service is the only way to make family planning really effective. Recent experience in the London Boroughs and elsewhere has proved this conclusively. It is necessary to remind ourselves of the objects of a family planning service. Recent reports by the Royal College of Obstetricians and Gynaecologists, by the Family Planning Association and by the Birth Control Campaign have all accepted that little more than half the women in Britain who could become pregnant are protected by reliable contraceptives. As a result there are a quarter of a million unplanned pregnancies in this country each year and a large number of abortions. The aim of a family planning service must be to cut down these unplanned pregnancies drastically.

Under Clause 4 of the Bill: .… regulations may provide for the making and recovery, in respect of treatment given and articles supplied … of charges prescribed.… There is a view that we must provide a full family planning service for everyone, but those who can afford should pay for it. I have much sympathy with that in theory, but unfortunately it has not worked out in practice. Experience has shown that the success of any family planning programme depends very largely on the publicity given to the service. It is obvious that a slogan such as "Family planning is free" is the type of thing that one could put across to the public. But, "Family planning is free if you are poor or ill" is not going to have any chance of success at all.

The case for free family planning is supported by the facts. Early in 1972 the Scottish Health Education Unit carried out a 20-week pilot study on family planning publicity, with national newspaper advertisements, and in one area alone, one that I know well, with television advertising as well. Sales of contraceptives rose by 10 per cent. in Scotland as a whole, but in the South-West, where television advertisements had been shown, the increase was nearly double the Scottish national average. Similarly, many of the Greater London Boroughs have started free family planning services this year, and those, such as Islington and Lambeth, which have advertised the service widely have found their attendances at clinics have risen by nearly twice as much as in the boroughs which have done little advertising.

So publicity for family planning is obviously essential. And we can show that we shall not be able to tackle the problem of the quarter-million unplanned pregnancies unless the family planning service is completely free. All the results available from Aberdeen and other local authorities show that family planning attendances soared when the service was free of charge. The London Borough of Lambeth has published some particularly interesting figures which show an increase in new attenders of nearly 70 per cent. Of these new attenders more than one-third had never received any professional family planning advice, and a great many were the mothers of large families. These are the sort of results that must be obtained throughout the country, but they cannot be obtained if the Secretary of State is going to make charges for the family planning service. Both contraceptive advice and supplies should be free of charge.

Finally I should like to say a word on the argument that the free availability of contraception will increase promiscuity. The evidence suggests that this argument is nonsense. The only reasonable indicator is a comparison of the number of illegitimate births with the number of women using contraception. There is no doubt that there has been an increase in extra-marital sex since 1960, but the figures show that the increase in the use of contraception has followed a year or two after this trend, rather than preceding it. In Aberdeen, for example, the biggest increase in unmarried pregnancies came in 1967. A free family planning service for the unmarried was introduced in 1968, and the illegitimate birth rate has since dropped from 9.5 per cent. to 7.7 per cent. In England and Wales the steep rise in the illegitimate birth rate started in 1965, while the equally steep rise in attendance in family planning clinics started after the 1967 National Health Service Family Planning Act. Obviously there is a social problem with promiscuity, but there is no evidence that free family planning services increase it.

My Lords, I hope that at a later stage of the Bill the Secretary of State may be persuaded to consider an Amendment to the wording of Clause 4 relating to charges for family planning, or at least to give his assurance that it is the Department's intention to provide the completely free family planning service that is needed.

4.43 p.m.


My Lords, I did not know the late Lord Rosenheim, so I cannot pay a personal tribute to him; but I know that the members of the Bench from which I speak would like to be associated with the tributes that have been paid to the memory of a very distinguished doctor.

I have presumed to put my name down as a speaker in this debate because I have had the privilege of serving, practically without break since the appointed day, either on a board of governors or on a Regional Hospital Board; so I have had close association with the subject. I should therefore like to say how glad I was to hear the noble Baroness, Lady Serota, plead that with this reorganisation there should be no redundancies among our staffs. This has been a worry to our staffs. It seems curious to ask a man to sit down and, as it were, reorganise himself out of a job. I think it would be grossly unfair if people who have served the country and the National Health Service well for years lost their jobs as a result of this reorganisation. Therefore I wish to be associated strongly with what the noble Baroness said.

With regard to the situation generally I should like to support the sentiments of this Bill and the aim behind it, because I think it is now generally realised that a closer integration of the various departments of the Health Service is needed. I hope that there will not be any misunderstanding in the country generally, because I too believe that with our National Health Service we have one of the finest examples of service to the community and of social welfare that you could have anywhere. The anxiety that has been removed from people's lives by the fact that they can get this skilled medical care free has undoubtedly been of great benefit to many thousands of our people. I wish therefore to pay a warm tribute to all those who have worked in this great Service up to the present time.

I hope that the closer integration that is to come will not be just on the administrative plane; it must be right through the Service. Presumably, the family doctor will practise the primary health care. He will promote health and prevent disease to the best of his ability; and when possible he will diagnose and treat. The doctor and the community health team will be based on the health centres. Those teams have to co-operate with the consultants and their teams, who are based on the district general hospital in each area, and various teaching hospitals. I hope that we shall have the closest possible co-operation between the family doctor and his team locally and the consultant and his team based on the hospital. The more interchange there can be between them, the better. Therefore I hope that it will not be just on the administrative plane that we shall have this greater interlocking.

My Lords, may I say a word or two, first, about the joint consultative councils, and then the community health councils. The joint consultative councils. I should have thought, would be very important indeed, because obviously there must be the closest possible co-operation between the Area Health Authorities and the local authorities, whose boundaries are going to be coterminous. It therefore appears to me that the joint consultative council will have to perform the vital role of ensuring this co-operation, and will have to resolve disagreements as and when they arise between those two bodies as of course they sometimes will. I hope therefore, as is suggested in the Bill, that they will be able so to advise the authorities that these disagreements are eliminated to the maximum extent, because otherwise it is difficult to see how those two authorities, the Area Health Authorities and the local authorities, will be able to achieve co-operation, in view of the fact that they are both responsible to different Ministries.

With regard to the community health councils, I should like to be associated with the remarks that have been made by the noble Lady, Lady Ruthven of Freeland, because I am bound to say that when we think of these similar bodies in other aspects of the national life—perhaps transport—can we say that they have always been as effective as has been hoped for? I do not know. And, as has been said, have the authorities which in the end have to make the decisions really taken much notice of what has been said? They probably have done so sometimes. But I am bound to say that the community health council is something to which the Government ought to give more attention before the Bill finally becomes an Act. I also wish to ask: is it wise that the councils should be staffed by people who are seconded from the Area Health Authority? I cannot help feeling that staff in that position may on occasions feel that they are serving two masters. I feel that the community health council would be in a much stronger position if, as the noble Lord, Lord Amulree, said, they had their own resources, their own staff, their own premises and were people who could stand on their own two legs. At the moment, I cannot help feeling that in the end they will not be able to stand up against the Area Health Authority should a disagreement arise.

Nevertheless, I strongly agree with the general idea of the community health council and I would plead with the Government to remember that in this regard the Churches might be given their reasonable representation. I use the word "reasonable"—we do not expect more than that—because, after all, there is an old-age connection between the work of healing and the Churches. During the 25 years of the existence of the National Health Service, a number of us have had the privilege that I mentioned just now of serving on boards of governors, Regional Authorities, hospital management committees, and so on, and sometimes executive councils. We welcome that. I should be very sorry indeed if all that seemed to disappear under the new set-up. I do not see that there is going to be much room for the likes of me in this new Area Health Authority, with all the emphasis on managerial expertise and the like; but it seems to me that it would be on the community health councils that we should like to serve and to help to the best of our ability.

In regard to the making of complaints and the proposal for Health Service Commissioners, that also I should like to welcome, because the fact that we now have Health Service Commissioners will give much public confidence in the Service. As I understand it, there is no need for the complainant in these instances to go through his Member of Parliament. I think that this is a wise provision and I am glad that the Government have taken this step. But again I hope there will not be misunderstanding. It should not be thought that up to the present time complaints have just been brushed aside as if they did not matter. I have served for years on a general purposes committee of a Regional Board, and that means that I have regularly seen the complaints that come along and the way in which the staff have dealt with them. I have seen the letters they have written and I have been amazed, time and again, at the patience they have shown and the courtesy with which the matters have been dealt with. I do not want that aspect of it to be forgotten as we think of the new arrangement whereby we shall have the new Health Service Commissioners.

There are only two other points I should like to make, and they concern voluntary work and the work of our chaplains. In regard to voluntary work in the National Health Service, how well I remember the speeches made in this House by, among others, the noble Baroness, the late Lady Reading, with her great record of service for the Women's Royal Voluntary Service, and the way she used to plead that voluntary work should never be forgotten! I believe that voluntary service for the community is something that is characteristic of the English way of life, and rightly so; and it is based on sound Christian principles. I therefore welcome the provision in the Bill that there should still be scope for voluntary work in our hospitals and in various aspects of the National Health Service. I believe there is still a considerable pool of people from whom we might get more voluntary service in various ways; and that that voluntary service should continue is what I am sure we all desire. Certainly the Churches would like to feel that they still have scope in a voluntary capacity for their moral welfare work and the like, by means of which they have been able to make a distinctive contribution over the years.

As to our chaplains, we have a bit of a worry here. In the past we have been urging that the chaplains should be invited by their hospital management committees to make regular reports so that the hospital management committees might appreciate and understand the work which the chaplains were doing and realise what was being done by people whom, after all, they had appointed. It is good, too, for the morale of the chaplains that they should have the opportunity of making these reports. I take it that under the new set-up the chaplains will be appointed by the Area Health Authorities. They will be very much more remote, as has already been pointed out in this debate, because not only will they have a bigger area to cover but also much greater responsibilities to assume. Therefore I hope that thought will be given to this matter. It may seem a small one, but it matters a great deal to some thousands of chaplains Church of England, Free Church and Roman Catholic. If thought could be given to the way in which they would be able to have direct personal contact with the people who employ them, I think that would be very beneficial to the work that is done. We, for our part, are trying to see that the work of the chaplains is improved, if it possibly can be. We have appointed a strong committee under the chairmanship of Professor Sir Ronald Tunbridge, which at the present time is surveying the whole of the chaplaincy work and will shortly be making a report. I hope that will help us very much in our thinking on this matter.

My Lords, in conclusion, I should like to wish this Service well and hope that the reconstruction will bring about what we all wish for. This Service, as I have said, is something which has done great things for the people of our country for many years, and I hope that with this reorganisation it will go forward still more strongly. Although I know that I shall be one of those who will be phasing out, inevitably—anno domini calls for that—I shall nevertheless watch the Service with great interest and, as I say, wish it very well.

4.57 p.m.


My Lords, I should like to say how very much I appreciate the opportunity of following in this debate the right reverend Prelate who has just spoken. For many years he was one of my constituents and I had many opportunities for discussion with him and of hearing during the later stages of my Commons career about his work in the Birmingham region. When he talks about being "phased out because of anno domini", I trust that that is only the kind of little joke that is sometimes made when one is talking like this, and that he will continue for many years to give his valuable services. I say that with strong feeling, my Lords, because he has information and experience at first hand of what the National Health Service means to the rural areas. And, of course, there are many facilities, including communications and transport, which are available in urban areas but do not exist in rural areas. We ought to think more and more of what it means to a man, his wife and family who live in these more remote parts where access to hospital facilities is not so easy.

It has taken 25 years for a revisionary Bill to come before Parliament after the original Act, which started its life in 1946. In parenthesis, may I say that I think I am one of only two members of the original Committee which in 1946 gave its attention to the original Bill then before the House of Commons that eventually led to the establishment of the National Health Service. What the position will be like in another 25 years, none of us here can tell, except that I suppose we shall be in the European Economic Community, or something larger; and no doubt we should think a little about the shape of things to come, because we may have to amend further our own National Health Service.

Going back in time to the first Green Paper, which was published in 1968, I should also like to pay a tribute to Mr. Kenneth Robinson, the then Minister of Health, because he did a magnificent job, and a very imaginative one, in seeking ways and means of bringing the Service up to date and rectifying old errors. Although there were criticisms at the time of that Green Paper—most of which were rectified in the second Green Paper of 1970—nevertheless, in the matter of the popular elected representation on the various committees to be established, this Bill is somewhat reactionary in tone. The yardstick of efficiency, as has been said by speaker after speaker, is that a man or woman shall be appointed according to their ability to produce their quota of managerial efficiency. I do not agree with this yardstick, especially in the rural areas. What should be the yardstick is the ability to comprehend the requirements of an area, and to know the needs of the humans involved. That may not always follow 100 per cent. the economic factor.

I believe—and here I want to be careful in what I am saying—that we are missing an opportunity to remove one of the great weaknesses of the position as it is at present; namely, the rather faceless image that we find in the higher echelons of the National Health Service. The people who are on the Regional Boards are largely the people whom the public does not know. The right reverend Prelate is well known in the Birmingham area, but there are many people who are not known. This is a pity because they should have accountability to the public, not merely to the people who appoint them. On the question of the appointment of people to regional boards, and sometimes to the lower levels, I know that this theory of efficiency was met with tremendous resistance by one's advisors on the grounds that you did not want people who would rock the boat too much; you did not want people who were going to be tactless in what they said in public. These things are all true, but in the past we have lost by not having people on these various bodies who would go back to a given area, meet the public and account for what they had been saying and doing.

We should pay a great deal of attention to the community health council, and to the equivalent bodies dealing with general practitioners, especially the family practitioner committees, dealing with the community health councils. This should be—in fact this is in the Bill—partly a critical role, but it is not in the nature of human beings to be very critical if they know that the patronage (if I may use that term) by which they have been put on to a board stems from the people who are to pay them. I should have thought that it would be far better that the community health council membership should come from a higher body altogether, from the Minister himself, and the critical role should be protected so far as possible. Nor do I think that the small membership appointed by the local authorities is adequate in this context. I am going to ask your Lordships to be patient with me if I somewhat broaden my horizon by asking this question: are we really getting our priorities right? Is there a need for a Commission to study such questions of whether we are casting our finances in such a way as to give people the optimum scientific benefit which we know is possible if our finances were not prejudicial to the whole set-up as it is now. We still appear to spend far less in this country per capita on social services than is being spent in countries in Europe.

In a Parliamentary Question in another place in February this year, the Under-Secretary of State gave the expenditure per capita on social services in 1968 for the United Kingdom as £91; for France, £146; for Germany, £141 and for Holland, £114. If you translate those figures into the percentage of the gross national product for certain countries—and I must confess that these figures are slightly old because no newer figures are available—we find that as a proportion of the gross national product spent on social services, including all health expenditure, the United Kingdom was 12.6 per cent. in 1966; France, 15.6 per cent. and Belgium, 16.3 per cent. I quote these figures to demonstrate that we are ham strung by a political atmosphere in this country; namely, the prejudice engendered in the early days of the establishment of the National Health Service, whereby ever since this country has felt and has been led to believe that it spends far too much on the National Health Service. The fact is that we spend far too little. Although the position is rectifying itself whereby the expenditure on defence is reducing a little proportionately, nevertheless much has to be done to bring ourselves up to date comparable with these other countries. May I ask the Minister of State whether he will pay some attention to the availability of statistics in this matter? It is very difficult to extract strictly comparable figures so that we can judge where we are going.

I ask your Lordships to permit me to put one or two questions to the Minister of State. Clauses 16 and 17 of the Bill deal with the disposal of property. I am not a lawyer, but from the clauses I read that this is property in the possession of hospitals as a result of endowments. I am not certain whether the remarks I have to make are covered by these clauses, and I do not expect the Minister to give me an answer now. But I think it is worth noting that up and down the country there are hospitals with vast acreages of land which is not usefully used. It may well be that things have changed from the time when I had a hand in looking at the figures. I know of a case in East Suffolk, and one in Surrey where hundreds of acres are used as parkland which have great value, and which might well be used for helping in the finances of the National Health Service, and would certainly alleviate the land shortage. We know that all hospitals and all authorities responsible for hospital development must plan for future expansion. Having said that, I think it is a matter that ought to be looked at.

Another question which is implicit in the family practitioner committees' responsibilities is: has anything more been done about assisting general practitioners in a specialist role? I believe that work has been done on this. I am referring again to the deep rural areas where there is a shortage of medical practitioners and a long waiting list of people who want to see consultants. Sometimes it is quite possible for medical people who have a knowledge superior to that of the ordinary practitioner, and who have the qualifications which could be useful, to deal with such cases.

Another matter I would raise is this. Under the powers vested in the Regional Health Authority in the matter of available capital there will be the continuing problem of the small local hospital. We all know that there is great sentiment to retain small local hospitals. We all know they are largely uneconomic. We also know that many cases can perfectly satisfactorily be handled by small local hospitals leaving free beds in the big district hospitals for which there are long queues, especially in certain specialties. What is going to be the policy in this matter? During the past two years I have detected a slight change in policy whereby it is said—one hopes it is said seriously—that, so far as possible, small local hospitals will be retained, with all the medical dangers that that involves. There is a case for it, of course, provided that there can be an adequate medical filtering service.

In talking of the wider horizon just now I mentioned the role other countries were playing in the provision of social services, including those for health. But we ought to be most careful not to emulate what has been going on on the Continent recently, where a social insurance reimbursement system has resulted in a thoroughly weak service in most countries concerned. Whereas years ago these insurance reimbursement systems were being lauded to us as examples of careful housekeeping, as opposed to the freedom of expenditure by the National Health Service, this is no longer true, and other countries in Europe are now looking to us as providing 100 per cent. coverage for the population, with efficiency, which is not met with in these other countries in Europe. Indeed, the huge number of prescriptions in Europe in most countries is strictly at variance with the relatively modest number of prescriptions issued in this country.

I have always been someone who thinks that the whole basis of the National Health Service, as the noble Baroness, Lady Serota, said a little while ago, must fundamentally be the general practitioner. He is the basis of the Service. I should have thought that when the Minister comes to issue regulations on the duties which the family practitioners' committees will carry out, in collaboration with the associated bodies of a given area, a good deal more attention must be paid to the right of access for general practitioners to hospitals. I do not mean in taking their cases to hospitals; what I mean is what applies, for instance, in certain teaching hospitals in London: general practitioners have a right to go into these hospitals and be briefed and brought up to date on almost what might be called a month-to-month basis. They can spend a day there once a month. It does a lot of good and much can be achieved in this way. Of course, it is always possible that one can gain wrong impressions front short briefing such as this. Nevertheless, I know that certain general practitioners have secured great benefits from the access they have been given in certain, but not all, teaching hospitals in London.

The sciences change so rapidly that one hesitates to call on one's experience of two or three years ago, but I well remember the right reverend Prelate the Bishop of Lichfield firing a shot across my bows some years ago in connection with the Abortion Act 1967. At that time I was a junior Minister playing an active role in the passing of that Bill. I remember that at the time I thought his fire was misdirected. It is a matter of opinion. The fact of the matter is that one cannot do without public opinion, lay or otherwise, when medical matters are being legislated for. I take the view most strongly, and hope your Lordships will agree with me when I say, that you can have opinions broadcast right, left and centre about various scientific matters; it is when the pendulum centres that you will get some element of efficiency, taking into account all the factors. My Lords, I wish this Bill success—much can be done in Committee—but it is a long time overdue.

5.14 p.m.


My Lords, at the risk of our tributes to Lord Rosenheim appearing almost too fulsome, I feel that I must add just a few words, for he certainly was a friend of mine for at least 35 years. Like me, the noble Lord, Lord Amulree, was extremely glad when we knew that Lord Rosenheim was to join us in this House and, further, we were glad and proud to be his Sponsors on the occasion of his Introduction. I feel that if Max could have known that this was going to happen, he would perhaps have wanted me to say how much he regretted not having spent more time in your Lordships' House since he was created a Peer. But it will be remembered that at that time he was both President of the Royal College of Physicians and Professor of Medicine in one of the greatest teaching hospitals in the world, and therefore was not able also to do his duty by this House as he would have wished. It was always his intention (he said so to me many times) to put in more time here as soon as he was freed from those duties. He was in fact freed from those duties quite recently; but since then he has been abroad, so that the time has never come when he joined us as a regular attender at this House.

Before I start on the few remarks that I intend to make on this subject this afternoon I would ask the noble Lord, Lord Burntwood, whether he is right in talking about a general practitioner's "right" to come into a hospital. I think that what he means is a general practitioner's "welcome" to come into a hospital. I myself believe that a general practitioner has a perfect right to come into a hospital. Needless to say, he must be a little careful that he does not interfere with work that is going on there, but he has a perfect right to come and visit his patients whenever he can. Many general practitioners do not make use of this facility; many of the best ones do. But many feel that they are not welcome; and it is really the welcome, rather than the right, which I believe the noble Lord, Lord Burntwood, would like to see given—as indeed I should.

In speaking on this subject I should perhaps say that I speak entirely for myself and not for any particular members of my profession. Indeed, it may be that some of the things I say will not be those that would be the most likely to be said by certain members of my profession. My remarks, of course, are entirely non-political, as is the subject, if only because the intention to reorganise the Service on the kind of lines now proposed has been expressed for many years, both by the previous Government and by the present Government.

My Lords, I am one of those who have been wholeheartedly in favour of the National Health Service from its initiation, and concerned to see that it shall be as good as possible, and not concerned in trying to make it not work. I myself believe that what Bevan fought for so hard—and he had to fight hard against certain sections of my profession—in getting his own way in this Service has largely proved right. We have a great deal to be grateful for, both to "Nye" Bevan and also to the noble Lord, Lord Moran, who was here earlier, but is not I think in his place at the moment, and who played an important part in getting the Health Service through at that time. He was able to see the wisdom of a great deal that Bevan was doing. I do not think that our clinical independence as doctors has ever been threatened, as was the fear at that time of many people in the medical profession. Indeed, it seems to me that our clinical independence has at times been treated with even too much respect. In any case, as the doctors say in the United States, the biggest threat to professional clinical independence in the prescription of treatment for a patient is the patient's ability to pay for it.

As a senior medical man nowadays I naturally get opinions from a number of people who, in one way or another, have had personal experience of the Health Service. They fall into two main categories. There are those who tell me (and these are the majority, although good news is never quite so interesting as bad news) of the wonderful treatment they have had, how grateful they are for free treatment, consultations, drugs, with freely available services of specialists and hospitals. So I want to emphasise them first; and of course they nearly always thank the nurses as well, if they have been in a hospital, and they praise their own doctors at home for their care.

On the other side there are, of course, the complaints. What form do they take? One man will say, "My wife has been in hospital for three weeks. They say she is going to have an operation, but nobody tells me when it is going to take place or even what it is all about. We do not even understand the nature of the illness and I cannot get to see the consultant"—and so on. I am sure your Lordships have all heard things of that kind. Another one will say, "I am told that I shall have to wait for a year and a half to get my hernia done if I have it done on the Health Service". Another one says, "My doctor is too busy to listen". Another one says, "I went to hospital four weeks ago and my doctor has not yet had a report".

The point I want to drive home this afternoon is that these complaints can be put right only by individuals: not by managers, not by reorganisation, not by administrators but very largely by the doctors themselves; and I think it is time the doctors started reorganising their work on these lines. Fortunately, this does not by any means apply to all doctors; but there are far too many doctors who are tremendously keen on their actual job but try to shrug off any kind of responsibility for making these little improvements in the Service which would make such a difference. It goes down from the doctor, whom I still regard as the head of the team, so far as medical care is concerned, right down in a chain—the doctor, the hospital sister, the nurse, the therapist, secretary, porter, and all kinds of people. As we all know, there are good and bad hospitals, and these are almost entirely matters for individuals to put right.

Perhaps I may give just one illustration to keep your Lordships entertained for a moment. My nephew and his wife were among those who telephoned me and said that their son was in hospital and they could not get to know exactly what was wrong with him. Somebody said he had pneumonia and somebody said he had not. So I telephoned someone I know at the hospital and I said, "By the way you have my great-nephew in hospital". He said, "Oh, have we?" I said, "Yes, a chap called Platt". He gave me an account of what was wrong and was very reassuring. But the sequel to the story is that the next day when my nephew and his wife visited the boy he said, "Mummy, am I very ill? I have had at least ten doctors to see me to-day". I am sure your Lordships will all agree that in an ideal Service this need not happen. It certainly should not happen.

One of the things that worries me most about the Service (and again this comes down to individuals) is the difference my influence could make—and it should not.

I believe that some of this spreads from the Porritt Committee—and here I am going to make some more remarks which may not be entirely popular with the profession. The noble Lord, Lord Aberdare, referred to the Porritt Committee, which was set up by the B.M.A. about ten years ago. Although I have no right to say this, it always seemed to me that the Committee was set up to indicate all the ways in which the National Health Service had failed. To the great surprise (I should not like to say "disappointment") of the members they found that most people, both doctors and the public, positively liked the Health Service. The members of the Committee could not say that the things that were wrong were the fault of the medical profession, so they said that they might be the fault of the tripartite system—and there I think it all started. That is not to say that I do not agree with them to a considerable extent. I believe that in some ways the tripartite system makes things difficult, and in some ways what is proposed in this Bill may be an improvement. But I go a long way with the noble Lord, Lord Cobbold, when he said—and I think he was quoting—that you should not dismantle a machine or an organisation which is working fairly well unless you are quite sure that you have something better to take its place.

For all these reasons, my Lords, I greet the Bill with what Gilbert might have called "modified rapture". What was wrong with the Regional Boards? I visited every senior administrative medical officer in England and Wales every year for four years when I was the chairman of the Distinction Awards Committee. I think that magnificent work was done by the Regional Boards, and I should like to ask the Minister to say what was wrong with them. Some of them, of course, had too big a responsibility—too remote a responsibility, unquestionably. For instance, the fact that the Sheffield Regional Board was answerable for Derby, Nottingham, Leicester and so on, involved too big a command, and a certain amount of reorganisation was necessary.

Will the general practitioner be any different if instead of by an executive council he is looked after by a family practitioner committee? Is there in fact any real difference between these two bodies? Is the tripartite division of the hospital service from the general practitioner service wrong because of the organisation, or is it because the consultants and the practitioners do not bother to pick up the telephone and talk to each other? Will the position be any different when the practitioner is answerable to the family practitioners service? The only difference is that they now will be under the same authority; but it never really mattered who paid whom. The fact that I was a hospital doctor paid by a university and that a general practitioner was paid by somebody else never prevented me from talking to the general practitioner, or his talking to me. So I have certain doubts as to whether this will create any fundamental difference in the Health Service.

There are certain things on which I feel I might express an opinion. I think the sacrifice of the boards of governors of the teaching hospitals is a difficult and controversial question. There is a good deal to be said on both sides. I see every point made by the noble Lord, Lord Cobbold; but I also hear the other side, concerned with the jealousy and frustration which exists in some of the non-teaching hospitals, which nowadays are doing a great deal of the teaching and who have got neither the status, the facilities nor the money that the teaching hospitals have. They want a little larger share of the cake, even though everyone agrees that the teaching hospital must have a liberal budget, for it is there that a good deal of the research and most of the teaching is done.

I agree in principle with the separation of functions. The boards of governors on which I have sat have been too large and have contained a large number of people who have not really taken any share whatever in the administration. Indeed, so far as I was concerned they need not have been there, except that they were there, for example, to represent Rochdale or something of the kind. It is important that Rochdale should have a representative, but not necessarily on the high-powered governing administrative body, and to that extent the community health council is a good idea. It is absolutely right that those at the receiving end—including the people in the localities who know what is going on and who are aware, for example, of the need for better maternity services in, say, Blackburn—should be represented and their point of view known. However, I do not think they should necessarily believe that they are also governing the Health Service at the same time. That is one of the most important matters which the Department will have to re-examine. The Bill is far too vague on this subject and I suggest that the Department reread the speech of the right reverend Prelate the Bishop of Lichfield about the importance of these community health councils.

On the whole I favour nomination after consultation to democratic election. I should have thought that democratic election was much more likely to lead to nepotism, although the noble Baroness, Lady Summerskill, seemed to think otherwise. Election often means the same old chaps being put in office and this frequently leads to cliques. On the whole, therefore, I am not greatly alarmed by appointments being made by Area Health Authorities or by the Secretary of State after consultation with the appropriate bodies. As for management, I hope that after the frantically interesting excerpts of the noble Lord, Lord Cobbold, from the Grey Document, it will be laughed out of phase before it takes root too deeply.

There are only a few other points about which I wish to comment at this stage. I still do not know what the Hospital Commissioner will do, though I agree that it is a good idea to have such an appointment. As I said in the debate on the Queen's Speech, I hope lie will have a preventive function and will, for example, make those who work in hospitals more careful lest they run into the kind of difficulties which will be brought before him. I should like the Minister to give an example of the sort of complaint which will come before him in view of the great many things appearing in Schedule 3 which it seems he will not be able to investigate. I hope that the noble Lord and the noble Baroness who will speak for Wales will tell us what they think about appointments made to senior medical posts in Wales, if it is not to have a Regional Health Authority but only Area Health Authorities, because in my view those senior appointments should be made by an authority bigger than an Area Health Authority.

If only to save my being struck off the register, which is quite popular nowadays. for unprofessional conduct for saying things about the faults of my profession, will anyone reporting my remarks—that is, in the newspapers rather than in Hansard—please mention that I also have the greatest admiration for all those in the Health Service who look after these details in addition to doing their proper professional jobs extremely well and that I still believe that British medicine is the best in the world.

5.36 p.m.


My Lords, I do not imagine that any members of a hospital management committee will be happy about their dissolution, any more than the monks were happy about the dissolution of the monastries, but the fact remains that the religion of those monks survived, and I feel sure that the Health Service will survive, though in a different form. I have little knowledge of the services other than the hospital services, but I believe that I can talk with some authority about the Bill and certainly as it affects hospitals and those who deal with children and the mentally handicapped. Before proceeding, may I say that although some of us, and I admit that I am one of them, do not feel particularly happy about the Bill, I feel strongly that we should examine its clauses in a most responsible manner, especially as it is the first major Bill to come before this House prior to its consideration in another place. We owe a great debt of gratitude to my right honourable friend Sir Keith Joseph for showing such confidence in my noble friend Lord Aberdare and this House by allowing so important a Bill to be introduced here for our consideration.

Two successive Government have agreed that the health services of the nation should be amalgamated, and I have no quarrel with that. However, I feel apprehensive lest by placing emphasis on management and disbanding so many voluntary bodies we may be taking the humanity out of the Hospital Service. May I illustrate this by quoting some figures, which I believe to be accurate as an average throughout the country? There are at present 300 hospital management committees with 20 members each, giving 6,000 persons; there are 34 boards of governors with 25 members each, 850 persons; 15 Regional Hospital Boards with 30 members, 375 persons; 119 executive councils with 30 members, 3,570 persons; 158 local health authorities with 15 members, 2,370 persons, making a total personnel of 13,165. In future there will be 90 Area Health Boards of 15 members each, giving a personnel of 1,340, and I think my noble friend said that there would be 14—in fact, I thought there would be 15—Regional Health Boards with 20 members each, making a total, according to my figures, of 300. This gives a total of 1,640 members. I have not tabulated the community health councils as they have no executive role and I shall be speaking about them later. These figures show that the Health Service of the future will be run almost entirely by professionals, and I am not alone, even among the professionals, in fearing that this will lead to a bureacracy and a loss of that humanitarian touch which, to my mind, has been the essence of the work done by volunteers in the Service.

My Lords, there can be little doubt that, like the proverbial curate's egg, hospital management committees are good in parts; but it is difficult to see how 15 members of an Area Board will be able to carry out the inspections, social functions and hospital visiting which is now carried out by hospital management committees and their house committees, especially in the area in which my group will be situated—Sutton, Merton and Wandsworth, which has a population of some 700,000 and 30 hospitals, apart from the other services which will be welding the Health Service into one entity.

There is little difference between the Green Paper of the previous Government and this Bill except that this Government have, I think wisely, introduced the Regional Health Board in between the Department of Health and the Area Board. The very fact of doing that should enable the Regional Health Boards to have more areas under them. Clearly, if Area Boards were reporting direct to the Department, the Department would wish to see as few Area Boards as possible; but with 15 Regional Health Boards being responsible to the Department it is logical to assume that a Regional Health Board should deal with more areas.

May I now say a few words about the district officers. The Grey Book, which we have heard so much about and which sets out the internal organisation, says that an Area Board will have a team of officers and that these officers will be paid more than the district officers. In each district there will be a team of officers similar to the professions represented at the top level, but it is emphasised that the district officers will not be under the Area Board officers but will report direct to the Board itself. Is not this as if in the present set-up the officers of a group hospital management committee did not report to the Regional Board officers but direct to the Board, which, to my mind, would cause great chaos? I hope that my noble friend will be able to explain to me the thinking behind that decision.

My Lords, may I now turn to the community health councils. I am disturbed that they will have no power whatsoever and no executive responsibilities apart from the power of their persuasion in reporting to the Area Board. Naturally, these councils will have more duties than just the hospitals, but I feel convinced that their main task will be to act as a vital link between the patient in the hospital and the Area Board. They will have to work in closely with the district officers and will need young, enthusiastic people on the council. I fear that without a budget or authority it may be difficult to get the best people to serve. The value of these councils will depend very much on the co-operation of the officers and I hope that they will have a great deal more than just free access to the hospitals. For this reason, I would ask my noble friend to do all he can to ensure that the councils have offices within the general hospital around which the district is to be planned, so that they can be part of the hospital set-up and not merely visitors who may, in some cases, be thought of as snoopers. In this way they can plan their visits and, above all, be known as real members of the team, and close to the officers with whom they will be working.

May I turn for one minute to the Leagues of Friends. Their role in the reorganisation will, if possible, be more important than it has been up to now. I trust and believe that they will have the full co-operation of and be able to work with the community health councils and the district officers, and will, where necessary, have access to the Area Board. The work they do is beyond praise. We must ensure that they do not feel left out and that they get the full co-operation of all. Without them, indeed, we shall be lost.

My Lords, I have been critical of the Bill, but I hope in a constructive way. The late Lord Norwich called his memoirs Old Men Forget, but it may also be said that "old men remember" and when we who are getting on in years start remembering we are apt to get set in our ways. That is the time to make way for the younger generation. 1974 will be the year of the professional administrator in the Health Service. I am deeply grateful to the officers in my group for their loyalty and sound advice which has enabled me and my hospital management committee to make some small contribution to the welfare of the many patients who have been under our care. I hope that this reorganisation will bring in many more young administrators, and if I could give them some advice I would say "Democracy as we know it in this country breeds humanity. Bureaucracy breeds dictatorship". The next year will not be an easy one, but I will do all I can to ensure a smooth takeover for the new regime in 1974.

5.46 p.m.


My Lords, having recently been at a meeting chaired by Lord Rosenheim, I should like to add my name to those who have paid tribute to a very great man. Also, having had the pleasure of taking part in the debate just over a year ago on the Consultative Document on the National Health Service Reorganisation, I feel a sense of great privilege at having the chance yet again to join your Lordships in a debate of such importance. I feel strongly that the National Health Service is of great value to everyone who is fortunate enough to live in Britain, but I hope with all my heart that this united Service will be greatly improved when it is reorganised. Since 1948 the Service has done a wonderful job. Of course there have been gaps, but looking back at the health facilities for the ordinary civilian in many countries, even nearer to us than the United States of America, I, for one, am pleased to be British. Having recently visited Germany and seen some of the wonderful new rehabilitation facilities they have, I think that the time is ripe for the reorganisation of our own National Health Service.

My Lords, I hope that everyone concerned will look closely at all aspects and facilities of our country's health and try to bring them up to date throughout the country, with one thing foremost in their minds: what is going to be best for the patient. For surely it is the patient around whom the whole of the National Health Service should revolve, with emphasis on how to avoid people becoming patients. I hope that this will not be left solely to the health care groups.

The voluntary organisations should be pleased that they are being welcomed into the reorganised Service. Unlike the attitude in 1948 when they were discouraged, the present Government know only too well what a mammoth task they have to provide a good health and after-care Service without gaps. In 1948 the Heath Service gave the attitude, "the State will provide". But statutory bodies ever seem to provide only the bare essentials. Many hospitals would be very sparse, uncomfortable places if it was not for the wonderful support and help given by such organisations as the League of Hospital Friends, the British Red Cross Society, the Women's Royal Voluntary Service—to mention just a few. Against adversity, such bodies have battled on, knowing the patient needed them. I hope that they will now feel a sense of satisfaction because they have proved their point that they are needed and will be an accepted part of this reorganised Service. Some hospitals have appointed organisers of voluntary help. If voluntary help in hospitals and the community is to be successfuly and efficiently carried out, surely all bodies using voluntary help ought to follow this example.

One of the biggest challenges of our modern society must surely be to try to combat the loneliness of multitudes of people. There are many very lonely, able-bodied people who lack confidence to help the many lonely elderly and disabled people who become immobile. Somehow these two sides of loneliness should be helped to come together and solve each other's problems. All too often people involved in organisation are so busy doing their own thing that they are too busy to widen their own circle and bring in others. I sometimes wonder whether each volunteer does not guard his own job too jealously. There are many various jobs that need to be done and that are vital to the happiness of some families living in the community. These jobs—for example, providing a baby-sitting service for families who have mentally or physically disabled children—might suit special small groups of people. Will the volunteers who are willing to undertake such jobs be able to get the training that they themselves feel they need? Who will finance and organise it?

Then the modern tendency for there to be more elderly and mentally and physically disabled people living in the community will surely mean that more paid people will be needed to look after them. This point was also made by the noble Baroness, Lady Summerskill. I think it would be wrong to depend on the volunteer to undertake this task. Does the Minister think it might be possible to have courses to train some of the many young people who are now leaving school with little prospects of obtaining a job? At the moment, the Government are running courses for the less able young person who would otherwise be unemployed. If at the end of the course he or she still cannot get a job, this must lead to frustration. If he or she were trained for the job of a community orderly or community nursing auxiliary, paid as a hospital orderly and able to work as an aid to the community nurse, this should solve two problems. When these young people had completed the courses they would at least have a job to go to, and the people needing care would be catered for.

As stated by many other noble Lords and Ladies, I feel that the duties of the community health councils as set out in the White Paper are too flimsy and vague. It says: It will be for each council to decide how best to go about… serving the interests of the public. Up to a point freedom and flexibility is excellent, but in this case I believe that more of their duties should be written in, so that they know the minimum expected of them. Is it not time that we had some standards set to aim for? Otherwise, the same old story of the good areas and the laggards will prevail. It will be interesting to hear where the community health councils will operate from and what facilities they will have, such as clerical support. So much vital communication which could pass through them may be lost if they are not given a loud voice which can and should be heard throughout the organisational structure. This council could be the vital link which has been missing for so long between the patient in hospital and the home. I am sure that it is beneficial for information to be passed to the patient about hospital life when entering hospital, and on discharge information should be given to him on what is available and who to contact if he needs help when he goes back into the community. When one looks at the vast new hospital palaces, one realises how remote the patient becomes from his usual environment, far away from all those he knows and all those he loves. Unless the social services are closely linked, the patient will suffer. Will social services which are working for one community with the health authorities have regional organisation such as the Regional Health Authorities will have? How will this be organised, if the new local government authorities are not directly linked to the proposed Area Health Authorities?

If to-day the noble Lord, Lord Aberdare, can do something to assure the family practitioner that he is a really very important part of the reorganised Health Service, the noble Lord will be doing more than this Bill has done. Also, if the noble Lord can convince this House that the Bill will be democratic in operation, with the consumer at heart, I for one will be more willing to accept it. Many general practitioners have a general feeling of distrust of the term "management", perhaps because of possible loss of medical freedom which might be implied in it—and this Bill seems to have more "management" than anything else. If the general practitioners could be more fully represented on the various committees, they might feel themselves to be a more integrated part of the Service.

Many doctors who feel general concern for the patient believe in the essential unit of medical practice as the occasion when in the intimacy of the consulting room or sick room the person who is ill, or believes himself to be ill, seeks the advice of a doctor whom he trusts. This is the consultation, and all else in the practice of medicine derives from it. With group practice some doctors fear they may lose this contact. Perhaps they should look at it rather from the angle of a group of practices. This will benefit the doctor and he will still have the crucial patient-doctor relationship. Some general practitioners feel that ancillary workers already have too much responsibility and access to patients without referral from the general practitioner. If they could be chairmen perhaps they would accept the team more readily. If the doctors build up resentment to this new approach to treatment, patients, as always, will be the ones who suffer. It is because of this that I feel so strongly that the general practitioner needs to be given a very big boost in the new National Health Service. They should be the first people patients contact; and their early correct diagnosis can be a matter of life and death. They will be better general practitioners with expert training, and will be happier and more contented if they have good working conditions. They will feel more part of this new Service if they feel that their voice is to be heard throughout the management. I was very pleased to hear the noble Baroness, Lady Serota, in her excellent speech, stress this point.

My Lords, looking at the overall picture of the reorganisation of the National Health Service reminds me of a marriage. The partners must not sit back and lead their own individual lives. As the years go by, if it is to be a successful partnership, they must grow together in united co-operation. Otherwise, jealousy and frustrations arise and breakdown is inevitable. Those who are hurt are the children. If this were to happen with the National Health Service those to be hurt would be the patients.

5.58 p.m.


My Lords, the noble Baroness recently addressed a conference in Wales, and the Welsh voluntary workers applauded her. I am sure on behalf of your Lordships I can applaud what she has said to us this afternoon; and we are grateful. All I hope is that the noble Lord, Lord Aberdare, when replying, will not devote all his time to replying to the noble Baroness, because I too have a few points to raise, but hers was a well-constructed speech which deserves attention by the Minister of State. First of all, I want to declare my interest, as chairman of the Border Counties Wales Hospital Management Committee. I may say to the noble Baroness that I wonder how many hospitals in the country have a seat on the house committee for members of the League of Friends. We in our group have, and I am very glad they are doing such good work.

I am agreeable to the unification of the three branches of the Health Service. I should have preferred to see a review into each of the existing structures, to ascertain whether anything was lacking. The Wales White Paper and the Report on management arrangements give us a great deal of advice, but I should like to ask the Minister what is meant in paragraph 4 of the Foreword, when it says that not all members would subscribe to every idea in the Report. Does this mean that there is a Minority Report? If there is, can we be told what was in that Minority Report? Or is it that the American consultants would not agree? Generally, I agree with the majority of Welsh Members of Parliament that there should have been a separate Bill for the Principality. The Welsh Counties Committee and the County Councils Association would have preferred that the organisation of the Health Service be administered by local government, because we feel that the experience in respect of personal services like education and social services is valuable. I gave evidence to the Crowther Commission on behalf of the Welsh Counties Committee, and we came out in favour of an elected Council for Wales. I still think that that is the answer to the upper tier in Wales, and not the Regional Authorities that we see in England. The Bill asks for control to be vested in the Welsh Office. Why should we have to tolerate civil servants, different from the situation in England, on the question of management? There is now a nominated Welsh Council, and I should like to see the concept of receiving advice from that Council safeguarded. If the Commission favours an elected Council, maybe those powers will be laid down.

May I put some questions to the Minister of State about the Welsh position. First of all, we have been accustomed to getting reports from the Welsh Hospital Board on, for example, children in hospital and travelling to hospital. Shall we get such reports in the future? If so, will they be Command Papers, or will they be H.M.S.O. publications? It is a very important point for us in Wales. The recruitment of medical and administrative staff is also important because of the abolition of the Welsh Hospital Board. There are about 700 people in that Service. What is going to happen to them? Some of the senior medical officers, as the noble Lord, Lord Platt, has already mentioned, are disturbed about their future. Do they go to the Area Health Boards, or will they come directly under the control of the Welsh Office? I know that the fact that the Welsh Office would govern the Health Service means less scope for lay influence for Wales than under the English model.

I turn to the White Paper and management arrangements. The new model appears to be derived from industry, involving the concept of line management hierarchy. There are no changes as to the point of contact for the patient; little attention with regard to surgeries, clinics, wards or theatres. Even the nurses pass from one authority to another. The G.Ps. continue as individual contractors, managed and controlled by family practitioner committees. How is this new set-up to tackle the problems of recruitment of medical workers, physiotherapists, social workers, and trained nursing staff in rural areas, particularly in geriatric units? As chairman of a hospital management committee I am always worried when it comes to making appointments, even of consultants, when I am on an advisory committee, because sometimes there are no applicants at all. The strange thing in this society of 1972 is that, with another gentleman, I had to make a short list from 261 people who applied for the post of an assistant National Park warden. Is it not strange that the Health Service cannot get people to come into the Service?

My Lords, I come next to the Area Health Authority and the Management Report for Wales—and a reputable medical authority has given me this information. The authors of the Welsh document have done their best to press the facts of Welsh life into an English urban world. They have not given sufficient attention to the aspect of management in Wales, itself. As chairman of a management committee I am not only worried about the appointments, I am worried as to why insufficient attention has been given to Central Wales. There are to be eight Area Health Authorities, and they will be more remote from the public than at present. Let us look at the membership. There will be 120 lay people, compared with 230 on management committees. Powys, which is in central Wales, as your Lordships will know, has no district hospital; but I say that if it cannot have a district hospital there should be a sub-area hospital. Let us examine the case for three health districts. There are suggestions that there should be two in the Powys authority, but it is not certain. However, we must get that, because we have had three hospitals which care for mental health.

Now may I come to the community health councils, where the same situation arises. There should be in each county—Montgomery, Radnor and Brecon—a new district or a new community council, not one community council to cover the whole area. There are 15 hospitals in that area at the present time with 109 members, plus 28 H.M.C. members serving on house committees. In future, if this Bill goes through as it is, there will be only 30 members administering that vast territory. It means that there will be a distance of approximately 100 miles from Machynlleth hospital to the Adelina Patti hospital—and not very good territory to travel in the winter months. May I say about the health community council (I am not the only one who has criticised this) that it has no teeth. It is similar to the gas and electricity consultative councils; I am afraid that H.M.V.—"his master's voice"—will be talking all the time.

I welcome Clause 10, which provides for consultation between health and local authorities, and I hope that when the Ministers concerned have consultations with the association of local authorities they will remember that the Welsh Counties Committee is a separate organisation, although attached to the C.C.A. We want separate consultations, and we do have a Secretary of State for Wales. Coming to the Health Commissioner for Wales, I welcome this, in one sense, but I hope that what we hear these days, that the English Commissioner may be looking after Wales as well, is completely wrong. We want a separate Commissioner. I go further: why cannot we have one Commissioner for health, local government, and water services? Why not have one Commissioner doing the lot, provided that he is Welsh-speaking? It is important for us to have someone who understands Welsh, because if complaints are made it may be possible to listen to those personally, or to understand them, if they occur in letters. I know that staff are available to translate Welsh letters into English, but for me, as a Welsh-speaking Welshman. I prefer one who has a knowledge of the Welsh language.

I feel that in the documents we have had before us, there has been too much emphasis on management control, creating a rigid, bureaucratic regime as against democratic control. At the same time, I hope that full utilisation of medical knowledge to maintain the best possible standard of health among the community will be carried on as it has been for the last twenty or more years. May I end by saying that I am one of those unfortunate people who have to attend their G.P. practically once a month, a clinic once every two months—and that for the last 42 years. You may guess what I am suffering from. Let me say to the medical service that I should not be here now, speaking as I try to speak to your Lordships, had it not been for the great assistance and co-operation that I have always had all along the line in that regard. I want to express my appreciation to the staffs who are working in the Health Service, for the good work which they have done, to the members of the Welsh Hospital Board, and particularly to a friend of mine, Gwilym Prys Davies, the present Chairman, to the hospital management committees, to the executive councils on which I have served, to the health committees of county councils, on one of which I still serve, and, finally, to the voluntary workers who are continually helping us in the hospital service. I join with the noble Baroness who opened the debate from our side, and say, "Let us look to the day when there are no charges on health."

6.11 p.m.


My Lords, I think my noble friend Lord Watkins will understand if I am not able to follow him into the realms of Welsh nationalism. I listened with great pleasure to the concentrated and expert speech of my noble friend Lady Serota, who seemed to me to shoot the Bill down in flames. There appears to be a great divide on the Bill between the Government and the Opposition. I cannot pretend to understand the Bill and will limit my corn-meats to Clause 4—the family planning service clause. I agree with the noble Lady, Lady Ruthven of Freeland, who spoke on this subject. The noble Lord, Lord Platt, told me that he also intended to speak on this matter, but mixed up his notes and left it out. I should gladly have listened to him. On the other hand, I am rather pleased that he mixed up his notes, because there would then have been nothing left for me to say.

Clause 4 is a very short one, consisting of 89 words in 9 lines. First, let me examine the language, for if the words are scanty the language is distinctly circumspect. For example, it states: It shall be the duty of the Secretary of State to make arrangements, to such extent as he considers necessary to meet all reasonable requirements … for the giving of advice on contraception". How shall we interpret the word "reasonable" in a legal document? In a recent debate, we learned that what is reasonable for one man is an outrage for another. I am puzzled by the inadequacy of this clause, because until now the Government have shown an enlightened attitude to the problem of birth control. In 1971, Sir Keith Joseph, the Secretary of State, offered Government support for trebled national expenditure on local health authorities' family planning services in 1972. This encouraged certain local authorities to introduce a free family planning service under the National Health Service. Nine London boroughs, and as many in other parts of Britain, have a free family planning service because in their experience where no charges were made the numbers seeking contraception advice increased substantially. Clearly, the need was there. But this Bill includes regulations which provide for charges for treatment and for articles provided. Why is there this step backwards, and what is to be done about the local authorities who already have a free service? This is not the first example of the way the Government scorn the cooperation of local authorities, which is so necessary in this field.

This Government are very quick to claim that public opinion is on their side in the measures which they bring forward, and they can now rightly claim that there is public concern about the rate of population growth in this country. There has, indeed, been a tremendous change in the climate of opinion about birth control, but that has not been matched by the spread or take-up of information on contraception. It has taken over 50 years work by organisations such as the Family Planning Association and the Brook Advisory Centres, and the endeavours of voluntary workers, to achieve a more rational attitude to contraception. These organisations have been barred from publicity because of their charitable status, and advertisements were legally limited to the size of a large postage stamp in a quasi-medical paper. But a week ago there were full-page advertisements in several popular Sunday papers, sponsored by the Health Education Council, headed, "How to avoid an unwanted baby." The advertisements were completely unadorned, were full of information, and were directed towards men as well as women. Men have always been careless, irresponsible lovers.

If any noble Lords are under the illusion that publicity is not necessary, they should turn to the objective surveys which have recently been published. There is the one by P.E.P., which is a study of patients' attitudes after an abortion, which concluded that many married and unmarried women are woefully ignorant about contraception, and that modern techniques of communication are needed to get this information across. That survey also pointed out that, usually, it is not promiscuity but romantic love, coupled with ignorance about contraception, which leads to unwanted pregnancy. The study by the outstanding social scientist, Geoffrey Gorer, in his book Sex and Marriage in England To-day revealed the same alarming prevalence of ignorance, and carelessness in the taking of precautions against unwanted pregnancies.

I should like to mention the Birth Control Campaign, one of the organisations in this field which is free to campaign among the political Parties, because it does not have charitable status. It has drawn up the draft of a birth control service for Britain, setting out proposals for a full free comprehensive service within the National Health Service, and this draft deserves serious attention by the Government.

I am happy to say that in this debate there has been no loose talk about loose morals in connection with family planning, though I have heard that the Government are anxious not to appear as if they are condoning sexual laxity. I hope that this is only a rumour, and "gone with the wind". Finally, my Lords, the population bomb is ticking away in Britain to-day and the Government have an opportunity to defuse it by spreading a comprehensive free birth control service throughout the whole country.


My Lords, before the noble Baroness sits down, as she did me the honour of quoting me at my request, saying that I intended to say something about family planning and so on, may I say that I was going to do so but I should not have done it half so well?

6.20 p.m.


My Lords, I should first like to make an apology to the noble Lord, Lord Aberdare, and to your Lordships, in case I should have to leave before the end of this debate. I should not have put my name down to speak had I not thought that I could stay to the end, but we have not in fact been doing very well so far. I shall do my best therefore to join with the noble Baroness who has just spoken in being rather brief. In case I am not able to stay, perhaps I may say that I am not in fact asking the Minister any questions although I propose to serve notice that there are one or two points which I wish to probe at the Committee stage. My noble friend Lady Seear will be here and will also be able to tell me what happens; and of course I shall read what the Minister has to say in Hansard.

My Lords, I want to talk about consumer protection. A number of noble Lords have already done so, but consumer protection is a particularly difficult subject in this field because, on the whole, the consumers are extremely weak. When you are feeling ill you do not feel like making much of a row or a protest; and when you are well the first thing you want to forget is your illness, and you do not really have time to ally yourself with other people into consumer protection groups. Therefore, it is a good thing that nature appears to have looked after this aspect by making it also a field in which the people who are the opposite to the consumers—I suppose in this case the dispensers—are the kindest, and in which one can rely almost entirely on the doctors and nurses, hospital staffs and everybody, to give the very best help and care to everyone under their charge. Nevertheless, human nature being what it is, and in a big outfit like the National Health Service, I think it is very necessary that we get our consumer protection right.

The community health councils, I am sure, are going to be a very valuable innovation, and I certainly should like to welcome them. But I question whether we have gone far enough in, as the noble Lord, Lord Watkins, said, giving them teeth, because they certainly have not got any teeth. Now we know that in fact the Area Health Authorities and the community health councils will work together very much, whatever arrangements we make, but I think we also know from other consumer councils and consumer watchdogs like, say, transport consultative bodies, that what one needs to do is to give the councils some very real powers and some very real independence so that if, in the 999th case out of 1,000, it should become necessary for them really to stand up to the people with whom, for the rest of the time, they will be working extremely well and in an extremely friendly manner, they will do so. That is why I should like to see the community health councils less dependent on the Area Health Authorities for membership and less dependent upon them for money and facilities. I think I should like to see a National Community Health Council, if you can have such a thing, combining the various com munities and acting as a national body. I think I should like to see all these councils helped in the way of money and facilities direct from the Department of Health and Social Security, and not being dependent upon their Area Health Authorities. I also think that possibly the local community council should have a right to appear before and to be heard by the Regional Health Authority as well as its local health authority. I think there are probably many ways in which we could strengthen the position of these community health councils, and I do not believe that if we did so it would lead to added friction. I think that it would merely lead to just that much more attention being paid in some rather difficult cases to the local council.

I also welcome the appointment of a Health Commissioner. Again, in Committee I should like to probe his powers. As the noble Lord, Lord Platt, said, if you look at the Schedule which excludes all the things that he may not inquire into it looks as if in fact he will have nothing to inquire into at all; and I wonder whether we should definitely extend the powers of the Commissioner a little. For instance, the great majority of hospitals now have ethical committees, but one or two do not, and I think I am right in saying that only one in five of these ethical committees have any laymen or lay representation on them. I do not see any reason why we should not institutionalise into the law these ethical committees, and I do not see why we should not bring them into the purview of the Commissioner. I think the question of privacy, which as we all know is a perennial problem, not because it is a very widespread one (I hesitate to say that) but because where it crops up it tends to cause difficulty and trouble, is one which may well come under the aegis of the Commissioner. It may be that it does. If it does, I should be very glad to know it; but if it does not, I think we might consider bringing it in.

Those are the two areas—that of the Commissioner and that of the community health councils—where I think we ought to probe a little further; and may I say how much I agreed with the noble Lord, Lord Watkins, when he appealed for a Welsh Commissioner who should be Welsh-speaking. I think it is extremely important that, in any area where you are dealing with complaints by people, the person whose job it is to do that should be one who people feel is as sympathetic as possible, and certainly someone who can speak the language which, for some of them, may be their first language. I think this is a very real point, and I do not agree with the noble Baroness, Lady Gaitskell, that these are the reaches of Welsh nationalism. I think this is an essential point.

Perhaps I may close by saying that I know that the kind of thing I am saying and the kind of Amendment that I hope may be put down by myself and others at the Committee stage sometimes tend to put up the hackles of doctors, although not sensible doctors like the noble Lord, Lord Platt, and my noble friend Lord Amulree. But this is the fact, and it may indeed tend to put up the hackles of the advisers of the Government on this matter. May I just say that I cannot see how we do any harm whatsoever if we strengthen consumer representation; and we must remember that, good though our Health Service is—and it is very good—and good though our doctors are—and they are very good—when people are ill and when they and their relatives are really helpless, it is not that they need protection so much as that they need all the reassurance that they can get. The building up of consumer protection in this field is therefore a very important factor.

6.29 p.m.


My Lords, the purpose of this Bill, as we all know, is the integration—or, as it is now fashionable to call it, the unification—of the administration of the health services in the interests of efficiency. It is a purpose that we all support, and support wholeheartedly. To effect this purpose, it sweeps away ("abolition" is the word used in the Bill, in Clause 14) every existing authority in the Service: Regional Hospital Boards, hospital management committees, executive councils, joint pricing committees, boards of governors, local health authorities and all joint boards under Section 19 of the Act. All will cease to exist on the appointed day, April 1, 1974. The sole survivors in this holocaust are the boards of governors of the 12 specialist postgraduate teaching hospitals set out in Schedule 2. These are, for the most part, small hospitals with international reputations doing important specialised work; hospitals that do not conveniently fit into the new structure and whose place has still to be worked out in the light of experience. With this small though important exception, every existing authority in the health services will be swept away and replaced overnight by something different.

The Bill effects a major revolution, let us make no mistake about that. The new organisation will work. There will be a period—possibly quite a long period; perhaps even as much as five years or more—while the new system is settling into smooth working: a period of disorganisation, of muddle, severe at the outset but steadily decreasing. That is the inevitable consequence of an administrative revolution. But the new organisation will work because the devoted body of those who operate the Service, doctors, nurses and laymen alike, are determined to make it work for the benefit of the patient and the public in accordance with the peculiar pragmatic genius of the British people. It will work, but will it work better than the existing system which has, with all its faults—and they are not few—settled down over the years into a reasonable working organisation? Will it work better? That is the million-dollar question.

My Lords, in many fields I am without doubt that it will work better, and we must all hope that it will. In some other fields there must be grave misgivings. So far as integration is concerned, in the unification of the three branches of the existing Service, the hospitals, the general practitioners, the local authority services, it would, I think, be generally accepted that the weakest link is now the general practitioner. Between the hospitals and the local authorities there is in general happy co-operation, but general practitioners tend to be individualists and in many cases they are not close enough to the hospitals on the one hand or to the local authorities on the other. That is the greatest weakness of the present tripartite system.

In Clause 5, and in Schedule 1, paragraph 2, the Bill specifies the composition of family practitioner committees. But if we turn to the so-called White Paper—it is of course blue—in paragraph 186 we find that these committees are to replace the present Executive Councils on an area basis; and earlier in the Paper, in paragraphs 66 to 69 we are told that the general practitioners now provide a service as independent contractors and will continue to do so; and that the family practitioner committee will be made up in the same way as the Executive Council that at present administers the general practitioner services and on all matters of its work will deal direct with central Departments. In fact, though appointed by the Area Authority they will not be administered by the Authority but by the Department. They are the Executive Councils all over again, and far from being integrated into the area service the general practitioners will be administered, in matters of contract, terms of service and discipline, direct by the Department through the family practitioner committee. So much for unification; the least integrated Dart of the Service is not to be integrated with the rest of it at all.

What about efficiency? As to the effect of the new arrangements in the field of the local authorities' domiciliary services, I cannot speak. But in the field of the hospitals it seems very doubtful whether the new arrangements will promote efficiency. And in the field of the teaching hospitals, of which I have a particular knowledge and experience, it appears beyond doubt that so far from promoting efficiency they will have precisely the opposite effect. If there is one thing about this Bill that it is possible to predict with certainty it is that the efficiency of the teaching hospitals will suffer. I know that there are those who dislike the teaching hospitals, a dislike founded perhaps on jealousy; because it is thought that they get too big a share of the cake, as my noble friend Lord Platt said; or because they think the boards of governors are undemocratic and object to them on that ground as—I will call her my friend, although she sits on the other side of the Chamber—the noble Baroness, Lady Summerskill, considers. Those people could not be more misguided. The great teaching hospitals maintain exemplary standards and it is essential for the wellbeing of the whole Service that they should do so. If they do not, the doctors they train will be launched into the Service accustomed to lower standards and it is on the standards they grow up with that the standards and the morale of the whole Service ultimately depends. That, I take it, is sufficiently obvious.

It was therefore natural that many of us who are concerned with these hospitals should have been anxious to know who under the new arrangements will manage the hospitals. It was not until August, I think, that the Paper on management arrangements, the pale grey Paper—perhaps appropriately coloured—gave us the answer. We find it on page 99 of that almost unreadable document in paragraph 11(2). It appears that a creature elegantly called the "sector administrator" will replace the house governor of teaching hospitals or the hospital secretary elsewhere. At present the house governor of a teaching hospital manages the hospital, under the direction of a board of governors who deal direct with the Department. This, though perhaps it is inconvenient to the Department, is a short and simple train of command and a highly efficient system.

Under the new arrangements, the sector administrator who replaces the house governor is to manage the hospital under the direction of a district management team, a purely bureaucratic body, apparently—as was pointed out by my noble friend Lord Cobbold—of co-equals without a head but with a district administrator "as a general co-ordinator"—I am quoting the document. This amorphous body is responsible to the Area Health Authority (Teaching), which in its turn looks to the Regional Authority and incidentally, the management Paper extends the functions of the Regional Health Authority much beyond those envisaged in the White Paper. I shall return to that in a moment. The Regional Health Authority is responsible to the Department. And so, in place of the short and simple train of command—Department to board of governors to house governor—we have the multi-tier organisation, Department to Regional Health Authority; Regional Health Authority to Area Health Authority (Teaching); Area Health Authority (Teaching) to district management team; district management team to sector administrator. Can anyone in his senses really suppose that that cumbersome and bureaucratic multi-tier set-up will lead to greater efficiency in the hospital at the end of the chain? To use a phrase of the Duke of Wellington, people who will believe that will believe anything. Of course the efficiency of the teaching hospital will suffer; it is bound to suffer, and in the long run the whole of the hospital service will suffer, too.

There are some other features of the new arrangements in so far as they concern London to which I should like to draw attention. In the first place there are the Regional Health Authorities. These bodies were envisaged in the first instance as a new kind of animal, something entirely different from the present Regional Hospital Board. They were to be bodies with very little more than broad planning functions, as is made clear in paragraph 37 of the White Paper. But the Management Paper goes a good deal further in developing and extending the role of the Regional Health Authority, and the Minister has told us that the new regions will approximate closely in their boundaries to the old. It appears that in London (I do not know about the arrangements elsewhere), the Regional Health Authorities will occupy the same offices as the existing Regional Hospital Boards. No-one who has had much to do with public administration can really doubt that this is "asking for it". What will emerge at the end of the day is the same animal: the Regional Boards all over again, with the same powers, or nearly the same powers, but extended over the wider field of the Health Service. If my noble friend, when he comes to reply, tells me that that is not the intention, of course I shall believe him. But while it may not be the intention, everything conspires to ensure that it will be the result; that when it comes to the point the leopard will be found not to have changed his spots.

I now come to the delimitation of health areas in Greater London, which is not specified in the Bill, but has been notified at the same time to those concerned. This is a matter that presents peculiar difficulties, for various reasons that I need not go into now, and a number of attempts to resolve them have been made. The Department first put forward a proposal for 16 areas; the boroughs proposed 19 and so on: various ideas were put forward. After a long struggle, the Teaching Hospitals' Association persuaded the Secretary of State to agree to their employing a firm of outside consultants to make an independent and objective assessment, and they came up with a proposal for fewer and larger areas stretching outward on a sector principle. They proposed that there should be eight such areas. Their proposals were warmly welcomed by the London teaching hospitals, and warmly supported by the University, who are of course closely concerned that the facilities for teaching should be adequate and suitable. The Secretary of State has gone back to his original theme, with some minor variations, and, perhaps largely influenced by the boroughs (who are the people the least concerned), has decided on 16 areas, an inner ring of teaching areas and an outer ring of non-teaching areas.

I have no personal axe to grind over this matter. My own hospital, Hammersmith, will, with Charing Cross, be in a teaching area comprising Hammersmith, Ealing and Hounslow, an outward-looking sector that will provide an adequate population of about three-quarters of a million. This will suit us very well; indeed, I am not sure that the sugggestion did not first come from me. In any event, I am extremely grateful to my noble friend. In some of the other areas, however, the difficulties are left quite unresolved. I shall be interested to know the reaction of the University. Apart from the facilities for teaching, how on earth do the Department think they are going to staff the Area Authorities and the organisation in 16 areas in Greater London? I do not believe that individuals of the necessary ability and experience exist in sufficient numbers. It would be difficult to find enough even for eight areas.

There is one particular matter of detail that I would ask my noble friend to consider, and to consider most earnestly. In the area comprising Harrow and Brent there are two hospitals with rather special characteristics, different characteristics, which require, if they are to continue to do their special work effectively, particularly understanding and sympathetic governance. One is the Central Middlesex Hospital, a large district hospital of very high standards that has for many years been closely associated with the Middlesex Hospital in its teaching arrangements. The other is the very im portant district hospital at Northwick Park, as yet only two-thirds built, with a large and potentially most valuable unit of the Medical Research Council incorporated into it for purposes of clinical research.

An Area Authority composed on the basis of a teaching authority would certainly have a better and more sympathetic understanding of these hospitals and of their special needs than an ordinary Area Authority; and as under Clause 5 of the Bill the Secretary of State can establish an Area Health Authority (Teaching) if, he is satisfied that the Authority is to provide substantial facilities for clinical teaching", I hope the Minister may be able to tell me that the desirability of establishing Harrow and Brent, in the exceptional circumstances, as an Area Health Authority (Teaching) will be considered. I am sure that if that could be done it would make all the difference to the development of the special and important work of those two hospitals. No doubt the University and the Medical Research Council will be asked for their views. If it cannot be done in that form, perhaps it would be possible for some special link with the adjoining area in which the Middlesex Hospital and St. Mary's are to be established.

In conclusion, my Lords, let me say again that, with all its faults, the new organisation will work, and will be made to work by those concerned. And let me beg my noble friend the Minister to reconsider, before it is too late, the arrangements for the metropolitan regions in the hope of producing Regional Authorities that are in fact the different animal that the Secretary of State encouraged us to expect them to be; areas that are outward-looking sectors which will enable the London teaching hospitals to help to fertilise the outer parts of Greater London.

6.47 p.m.


My Lords, in the 1970 Green Paper on the future structure of the National Health Service, with regard to the sharing of professional skills, the conclusion reached by the Government at that time was stated in paragraph 31 as follows: The Government has decided that the services should be organised according to the main skills required to provide them, rather than by any categorisation of primary user. Broadly speaking, the decision is that the health authorities will be responsible for services where the primary skill needed is that of the health professions, while the local authorities will be responsible for services where the primary skill is social care or support This brings me to Clause 18 of the Bill, dealing with transfers to employment by new authorities and social service authorities. There is a sharp division of opinion upon this within the social work profession. Many hospital social workers and medical authorities have expressed serious concern at any suggestion that social work in hospitals might cease to be provided by a separate group of social workers, with specific training in social work in a medical setting, employed direct by the National Health Service.

I do not share their concern. I personally feel that, taking the broad view, the transfer to local authority responsibility would, first, remove the barriers standing in the way to providing the best possible service for patients and clients over the whole range of their needs; secondly, benefit both the health and local authority services by providing for the best use of scarce resources of skilled professional manpower; thirdly, enable hospital social work to remain in the main stream of professional developments; and lastly, assist the development of inter-relationships between the authorities. This last point I think is most important. The importance of working together relates to the need to consider the person's social and medical needs together for help to be effective.

Local authorities seem to have been given a duty to provide a social work service. I do not see anywhere, but believe there should be, a duty on health authorities to ensure the provision and use of a social work service. Social work support is at present very unevenly spread in the hospital service, and it is understandable that those hospitals with well-staffed departments and satisfactory arrangements at present should be nervous that change might be for the worse, not for the better. But social work teaching is increasingly moving towards a more broadly based approach, fitting students to work in any social work setting. None the less, this trend does not deny the necessity and opportunity for those who wish to continue to specialise to be able to do so. Of course the over-riding con sideration must be: what pattern of employment will provide the best service for patients and clients? There must be continuity of patient care between the hospital and the community setting and an integrated organisation of the social work support which the patient needs. I should like to ask the Minister: will there be a statutory duty imposed on local authorities to provide social work support for hospitals and, more widely, for the health services generally? Also, will there be some flexibility from area to area, and guidance as to date of implementation? Will general guidance be made available to the new authorities who will be responsible for operating the new arrangements for 1974 onwards?

I think it would help if the Secretary of State were to arrange for a Working Party to prepare guidance on all aspects of the working of the new arrangements in the period of reorganisation. The Health and Social Services should rely on each other for the skills which each can best provide, and authorities should assume responsibility for social work in hospitals. The needs of the individual in the family cannot always be divided into compartments, and comprehensive care is therefore dependent upon both social and health services being available. I welcome this Bill, however, and feel in the long run it will be of great benefit to the patient. The patient is a person, and the area boards must be sensitive to his needs and feelings as an individual in the care of the Service.

I should like to urge on the Government that whatever area arrangements are made, the continuing need of the psychiatric hospitals and their patients requires a much larger proportion of available money than has been received in the past and that there should be some system of allocation which does not perpetuate the present disparity. I welcome the idea that community health councils might in future assist management in the task of overseeing and improving the wellbeing of patients and staff. In the long-stay wards, the need for patients and staff to feel that their problems are appreciated by management is of paramount importance. Since the mentally ill, the mentally frail and the mentally handicapped make up the larger part of this hospital population I feel the needs of this group must be constantly kept in mind. Finally, I should like to emphasise that the end product of the Health Service is the health of the patient, both physical and mental.

6.53 p.m.


My Lords, I agree entirely with the noble Countess, and I hope that I shall say something useful in as short a time as the noble Countess did when making her interesting contribution. May I say also how much I enjoyed the speech of the noble Lord, Lord Cottesloe, and how much I learned from that?

This has been a very fascinating debate. I have closely followed about 90 per cent. of it (unfortunately I had to miss two of the speeches) and a great many points have already been covered. It would be boring to repeat any of them, but I should like to pick up what the Minister said when he produced this White Paper with a blue back. On page vi we see these words: The National Health Service is one of the largest civilian organisations in the world. Its staff is growing rapidly. It contains an ever-growing multitude of skills that depend on and interact with each other. It serves an ever-growing range of health needs with ever more complex treatments and techniques. And though the Government has made substantial additions to a programme of expenditure which was already planned to grow at an above-average rate, there is never enough money—and never likely to be—for everything that ideally requires to be done. Nor, despite the great increases since 1948, are there ever enough skilled men and women. One of the things that particularly interests me, since I have an interest in laboratory work concerned with turning out pharmaceuticals, is that in the National Health Service there must be to-day one of the greatest avenues of employment. The Health Service directly employs probably a million people. But if you take the ancillary occupations and skills, from the electronic engineer who to-day helps in the operating theatre to the biochemist and the research people working on drugs you sometimes miss the importance of the panorama of work done for the Health Service. I should have liked (the Minister just touched on this) the whole gamut of the Health Service to be dealt with in depth.

For instance, without arguing it in depth this evening, I would say that an occupational health service is one of the things which some of us who have been connected with industry would like to see linked to the problems of industrial diseases. When I was for a short time a Minister one of my concerns was to study the problems of asbestosis and pneumoconiosis. I think the time has come when the nation should look directly at an occupational health service. There is little or nothing linking this with the place of work. I am talking in shorthand because of the time factor. I believe that millions could have been saved on the hospital service if we had insisted on beginning in reality health centres. The prejudice of the general practitioner—God bless him! he is overworked and has for a long time (though people will not believe it) been underpaid—against getting into a health service can be broken down.

One other factor I am rather afraid of here is that we are emphasising management. In the teaching profession, and in chemistry and other spheres, brilliant people too often move into a swivel chair, with the result that their real skills are lost. Nothing is sadder to me than to see a first-class general practitioner in the rough-and-tumble at the base of the pyramid of medicine going into a swivel chair in a local authority and no longer using his skills and know-how to heal the sick and the injured. I must not say that I am completely prejudiced against the idea of men with administrative and managerial ability moving out of the profession, but there is a possibility (and the noble Lord, Lord Cottesloe, spoke of this from his past experience) that because of the number of managerial committees we shall be looking for manpower. The tendency in the nursing profession, with the general practitioner and in some echelons of medicine, will be to take good men from their alembics and their scalpels and put them into swivel chairs. This demonstrates the point I am trying to make, although I am using a kind of shorthand. But I will not develop it further.

I should like now to mention the essential point of flexibility. In his introductory speech, for which I thank him, the Minister referred to 1974 being a deadline. One of the things about the British system of organised society is that we have a genius for—I will not say muddling through, but arriving at answers pragmatically. Why must everything be set down on sheets of paper? Give the medical profession, and those in local authorities who are skilled under this setup, time to arrive at their conclusions and let the organisation, like Topsy, "just grow", rather than say from above, "By April, 1974, this Bill must become an actual fact".


My Lords, would the noble Lord allow me to mention that under the Act that we have just passed for local government reorganisation the health departments of local government have to be fitted in somewhere? This is the reason for the deadline, in order that the health departments of local authorities can take part in a unified Health Service.


I thank the noble Lord. My Lords, I do not want to make Committee points (although there are many that we could make) and I do not want to make Party points. I was trying to say: do not let us overemphasise dates in this quarter centenary of the National Health Service. Maybe we can talk about that during the Committee stage.

I have here an article (I will paraphrase it) from the Sunday Times of August 6, 1972. The writer says: The consultant's seemingly divine right to establish both clinical and social priorities within the hospital is not challenged by even the politest whisper… Further on the article says: …G.P.s can no longer be supported indefinitely in sometimes resisting health centres. Clearly, the new regional authorities will be expected to deal with this kind of question. But, dominated by doctors, and lacking a bold lead from the centre, they scarcely promise radicalism. That is a bit hard from the dear old Sunday Times. Nevertheless, there is more than a grain of truth in that criticism of the situation.

I want to come to a point about the school health service and geriatrics. I should have liked to develop this point, but I will not do so other than to say that at the Committee stage we ought to do our best on both sides of the House to see that the maximum attention is paid to both ends of this scale of human life. I am glad to see that the Minister will now have more authority, not only with the schools service and the geriatric service but also in prison hospitals, and also in the areas to which the noble Countess referred, psychiatric areas.

Some 90 per cent. of the sickness we get is first seen by our hard-working general practitioners, and only about 10 per cent. by the specialists. Yet hospitals get 80 per cent. of the money. I believe that there could be a way of distributing this money more usefully. Less might be spent on furniture and more on rewarding the staff, making the nurses and the medical people happy. I know that this is true in particular in teaching and in lecturing. If the place is warm, good lecturers and students can work without having palatial buildings around them. Sometimes hospitals are built to last for ever. A hospital should not be built to last for more than 25 to 30 years, because of the rapidity of the changing society in which we live. Yet we are building hospitals as though they should last for a thousand years. These hospitals will become completely outdated, just as some of the old workhouses are now outdated. There should not be less money spent on hygiene—the operating theatre is where money should be spent—but maybe it is possible to save money in other directions. So far as the family practitioner committees are concerned, I endorse the criticisms made from both sides of the House. It is merely a change in name from the old executive council.

My Lords, I have been speaking for about eleven minutes; I am looking forward to the Committee stage, and I hope that the House will send to the other place a Bill worthy of the experiences that have been spoken about to-night.

7.5 p.m.


My Lords, we should all support attempts to improve further the magnificent achievements of the National Health Service which has contributed such benefits to life in this country. This is such a long and comprehensive Bill on which there has been much preliminary exploration and discussion in the form of Green Papers, a Consultative Document and a White Paper that further debate at this time is unlikely to be productive. Important alteration of the basic principles seems unlikely to be accepted and it is especially difficult to comment usefully on specific details in such a complex and somewhat technical plan concerned chiefly with administration.

One realises that when the National Health Service was first organised in 1946–48 great reliance had to be placed on the time-honoured medical set-up which inevitably supplied many general patterns of procedure and policy. It is also clear that with the passage of the years, and with increasing experience of this structure and organisation, based chiefly on time-honoured concepts, some readjustment was necessary and that in some; ways this would inevitably be radical, and directed at revision of the administrative structure. This was recognised a decade ago in the Porritt Report. One must welcome many of these changes, but not unreservedly.

It is necessary to consider that changes in the administration, beneficial though they may be, do not necessarily benefit the patient; nor do they lead to substantial improvements in the work, efforts and achievements of the doctors, both specialists and general practitioners, on whose efforts the success of the Health Service must ultimately depend. As the noble Lord, Lord Grenfell, commented, the humanitarian touch may be lost.

While accepting the need for the revision of the administrative structure, and the expectation that improvements must follow this, many members of the medical profession are concerned that administrative revision has become an end in itself and that the ability to practice good medicine is impaired. They are concerned that too much control, too much supervision, too much regimentation may not only be irksome and frustrating to those in the profession, but may adversely influence future recruitment. The Government are clearly determined to exercise more managerial control over the National Health Service, but we must hope that the urge to achieve this will not result in blunting professional achievements and promoting inefficiency in the clinical care of patients, as the noble Baroness, Lady Summerskill, emphasised. In other words, preoccupation with administration may not necessarily achieve better doctoring. The noble Lord, Lord Platt, has emphasised that there is much the doctors themselves alone can do to make improvements.

Unless one is to attempt to analyse and to discuss all the long, complicated and important documents that face one, and that seem to concentrate on the pattern of organisational or committee structure, it is only possible to make simple and incomplete general comments. I single out the fear that administrative reorganisation has exceeded itself. Furthermore, that this imposition of a unified bureaucratic heirarchy in the National Health Service will lead to an increasingly rigid and inflexible system of control that becomes more and more impersonal in dealing with patients and with doctors. Of special concern is the policy of control by members of boards and committees who are appointed for what are called their personal qualities or merits, and not elected as representatives. This may be an improvement but it may equally be harmful.

One change that we must regret is the disappearance of the boards of governors of the great teaching hospitals. In this matter the Government seem to be adamant. I support the comments of the noble Lord, Lord Cobbold, and others on this matter, and especially his emphasis on the need for retaining the importance and preserving the status of the chief administrative officer of the teaching hospitals. I must come to the rescue of the noble Lord, Lord Cobbold, in the attack made upon him by the noble Baroness. Lady Summerskill. The admission of women medical students is not in the hands of the boards of governors of teaching hospitals, but lies with the medical schools. It is especially important that the art and science of the practice of clinical medicine must be shielded from any harmful effects—


My Lords, might I. to Lady Summerskill's advantage, point out that I am chairman of the Medical School Council too, so she has me both ways.


Hear, hear! And we know. He does not.


My Lords, doctors must be fully and solely responsible for the ethical and medical control of how they treat their patients. In spite of assurances that this clinical freedom will be preserved, many doctors fear that impairment of their clinical and medical freedom will result from a too rigid bureaucratic control, however desirable this bureaucratic control may be in the non-medical affairs of the organisation and implementation of the National Health Service. I fully support what the noble Lord, Lord Cottesloe, has said in this matter.

From the many complex matters that might be specifically referred to, I select one which causes disquiet to the Welsh medical community and to the Welsh Council of the British Medical Association: that is the fear already mentioned that in Wales there is no Regional Health Authority and that consultants and equivalent doctors in other branches should be appointed by the new Area Health Authorities. It is hoped that some special arrangement may be devised for an appointing body at a higher level. I hope that the Minister will agree that some appointing body at a higher level than the Area Health Authority may in fact be arranged and thus allay the fears and reservations of our Welsh colleagues.

7.12 p. m.


My Lords, I also welcome the linking of the hospital and the community services, but P am frightened by the size of the Regional Health Authorities and in some cases the health areas in London, which may be convenient for administrative purposes but not necessarily for the day-to-day problems of the patients. If I may give your Lordships an example, before the 26 London boroughs were amalgamated into 12, it was possible for a voluntary worker taking round library books or meals or some such thing to an old person, and finding that old person not very well, to be able to report this fact to the town hall; then the borough old people's welfare officer would probably call round either that afternoon or, at the very latest, the next day. What happens now is that it takes at least at week before the message is received or before anything happens at all.

I also welcome that the help given by voluntary organisations is written into the Bill in Clause 13, but it is very sad to see that the Confederation of Health Service Employees are objecting to the use of volunteers in the Health Service for the following reasons. They object, first of all, because they say that volunteers are a threat to all staff. They say that volunteers should not talk to patients; they should not help patients with therapy—that is, making rugs or basket work or whatever it is a patient is doing; they should not write letters for patients in case there is something confidential in the letter; they should not do anything that a visitor would not be asked to do; they should not take patients on outings unless a nurse is with them. All this is in case the patient/staff relationship is upset. They also go on to say that volunteers are being used to plug the gaps instead of more staff being employed. They say that volunteers are being employed when really and truly the wards ought to be closed—that is, in some emergency one ought to close the ward instead of using volunteers. I might add that it so happened that in the 'flu epidemic two years ago one of the wards in a London teaching hospital was about to be closed because of the epidemic when the matron contacted the Red Cross and said, "Can you help?" It so happened that we had a trained sister and she volunteered and produced a whole team of Red Cross V.A.Ds. who staffed that ward by rota for a whole week until the nurses could return. I ask your Lordships to consider: what about the patients in cases like that? What happens if one just closes the ward, with all the patients in the ward and nobody to help?

The organisation I refer to also say that some volunteers are not used to working in any capacity at all and will not "muck in". Furthermore, they say that the inexperienced volunteer makes for staff discontent and insecurity. If a volunteer was trained to look after patients—it might be a retired trained nurse coming back into service or a volunteer who was trained or prepared for the job—then they say: Was that person a volunteer except in the financial sense? If a volunteer was not trained, just a pair of hands, they ask: Was she safe to be let loose in the wards?

I must confess that I was the target of this union's displeasure when I was nursing. I was a full-time Red Cross nurse on the duty rota. Because I was a volunteer I was able to volunteer for extra duties in times of crisis or at holiday times when there was generally a shortage of staff. The union's representative sent for me and said that I was working too hard and was in fact a bad example to the other nurses. I conferred with my nursing colleagues and they said: "For Heaven's sake, don't pay any attention!" So of course I did not and just went on with the job. This brings home to me that the Confederation of Health Service Employees seem to "have it in" for the volunteer. So I decided to see what the nurses of to-day thought of volunteers. A meeting was held quite recently where nurses in groups were discussing this problem of the use of volunteers, and one of the things they said was that volunteers could pioneer services that later on could be taken over by the State. I could instance district nursing which was pioneered by a voluntary body; then there is meals-on-wheels; there are rheumatism clinics and other clinics that were pioneered by volunteers and have now been taken over. They also said that volunteers had time to be good listeners to patients and to maintain contact with them at home after their discharge from hospital. They said that they were useful in the community services to fill the gaps between the official services and cover the hours when the official services did not work. I find it very interesting that a sister in charge of an intensive care unit found volunteers useful for reading to patients in the intensive care units, as they could concentrate on the job and help patients to relax amidst rather awesome equipment, notwithstanding that when relatives came to see patients they were rather upset by the equipment in those units, and their anxiety was transferred to the patients, which of course was not very helpful. So I hope your Lordships will agree that there is a place for volunteers.

There are two kinds of volunteers: those who want to give service and those who just want occupying. I beg the Government to recognise the difference and insist that those who just want to do something have some sort of preparational training before they are let loose on patients; as otherwise I believe the Confederation of Health Service Employees may be right when they say that an inexperienced volunteer can be a danger to patients and may make staff discontented and insecure, and would, I think, lay the Government open to the question as to whether the object is to find work for volunteers or to help the patient.

There are many opportunities for voluntary service in the community, and especially, I think, when the new directors of social services are getting their new departments organised. Some voluntary organisations already work both in hospitals and in the community, and they may be able to help to pioneer this gap-filling in the early stages of the reorganisation of the Health Service.

I hope your Lordships will agree that there is a service to be given by the voluntary organisations and by their volunteers, who do things for the joy of doing them and not for money, and I hope that when the Minister replies he will be able to make it clear that volunteers will be used to support the Health Service, to fill temporary gaps, and perhaps pioneer new services; and that they are there to assist the patients and staff and do not want anybody's job.

7.22 p.m.


My Lords, I propose to limit my remarks on the National Health Service Reorganisation Bill to its effect upon local government. This is not an attempt to sidetrack this debate, but I think it would be a pity if the debate ended without this House having put to it what a disastrous effect some of the present drafting of the Bill before us would have upon the principles and practice of local government in this country. The subject of National Health Service reorganisation covers so wide a field that a speech of tolerable brevity must inevitably be selective, and while making due allowance for the area over which progressive fluxity and constructive thinking must continue to operate one must also stress the points where a critical difference of opinion demands fundamental reconsideration.

Local authorities naturally welcome the devolution of effective responsibility to the lowest possible running level but nevertheless express concern that at district level decision-making will be entirely in the hands of teams of professional officers without any lay involvement. At district level in the National Health Service reorganisation there ought be close liaison with local authorities within that district, and it is the hope of local authorities that their own officers could in some measure be involved in the work of district management teams. For instance, the Association of Municipal Corporations, of which I am one of the Vice-Presidents, disagrees with the proposals in regard to membership of authorities. In many areas authorities of around 15 members will be too small and the members themselves will have too limited a background to discharge their responsibilities.

To mention another point before I go on to the main object of this speech, it is also a fallacy to suppose that the needs of the Service can best be met by choosing members (as has been stated in one of the papers) for their personal qualities after appropriate consultations. There is no reliable way in which personal qualities can be assessed, and there is no method of consultation which is effective for this purpose. Members of Area Health Authorities and of Regional Authorities should consist in the main of elected representatives of local authorities who would be in the best position to exercise an independent judgment. The suggestions made in the White Paper not only are unfortunate for the National Health Service but represent a perpetuation in British life of a principle of patronage and self-selection which is outdated and harmful to the fabric of democracy. It is also, incidentally, a process that will tend to place far too much power in the hands of permanent officials, at the expense of lay representatives.

There are four associations whose combined knowledge of every aspect of the practical working of local government is unrivalled and obviously merits serious consideration in discussing the effective success of any such reorganisation as that which is the subject of this debate. I have studied the views of these four associations and venture to recapitulate them for your Lordships' attention. They are, to name them—although they are very well known—the Association of Municipal Corporations, the County Councils Association, the Rural District Councils' Association, and the Urban District Councils' Association. These people, whose knowledge of the actual facts of local government administration is unrivalled, speak with one voice on the subject of the effect of this Bill.

The four associations I have mentioned feel compelled to reiterate their opinion that both patients and the public in general would benefit from administrative unification of the National Health Service with local government. Significantly, the English White Paper in paragraph 8 states: There are very strong arguments for bringing health and social services under a single administration. This could be accomplished by putting the N.H.S. within local government. But, for reasons accepted and fully explained by both the previous and the present Government, that is not attainable, at least in the foreseeable future. The decision not to integrate the N.H.S. within local government, coupled with the proposed transfer of water and sewerage to regional bodies, is seen as a major setback and a misfortune for democratic local government at a time when the paramount need is to provide a strong and comprehensive new structure and to reverse the established trend of local government services being lost to the centre or to ad hoc bodies. The weakness of this solution can be seen in the complicated arrangements for collaboration between the Health Service and local authorities. In particular, the associations are concerned to ensure that the satisfactory functioning and development of services, such as the school health service, will continue in spite of the proposed division of administration. It is noted, however, that the possible future integration of the N.H.S. within local government is not ruled out, and the associations believe that the obstacles which are said to lie in the way of this solution should be reviewed from time to time.

Having said that, let me say that in the event of the proposed reorganisation of the N.H.S. being acceptable to Parliament, the associations' objective is to make the proposed reorganisation of the Service as effective and democratic as possible. They are anxious to help in every way they can. Clearly, there must be good joint working relationships between the N.H.S. and local government and, because of this, the associations particularly welcomed the setting up by the Department of Health and Social Security of the Collaboration Working Party—to which reference is made in paragraph 56 of the English White Paper and in paragraph 6 of the Welsh one—and its various sub-committees. They strongly support the arrangements provided for in the Bill for linking Area Health Authorities and coterminous local authorities in particular by the setting up of joint consultative committees under Clause 10.

Following detailed studies of the Bill, the associations expect to be able to suggest for consideration in Committee a number of modifications aimed at reducing some of the problems inherent in the new system and generally increasing the effectiveness of the reorganisation. In the meantime the associations are particularly concerned about two issues of principle which they trust will be thought appropriate for discussion on Second Reading. Both of these are primarily concerned with the sensitivity of the proposed arrangements to local public opinion.

First, the question of local elected representation on health authorities. If, regrettably, unification of the N.H.S. is to take place outside local government, any element of local democratic control will depend primarily on the constitution and membership of the proposed Regional and Area Health Authorities. The associations have criticised the reorganisation proposals on the ground that they over-emphasize managerial efficiency. This desirable objective need not be impaired and in the associations' opinion would be positively enhanced if there were satisfactory lay representation to ensure that the health services are reasonably responsive to local needs and opinion.

The associations are especially concerned by the lack of adequate democratic safeguards either provided in the Bill itself or apparent in the Government's intentions as set out in the preceding White Papers. In the case of Regional Health Authorities, all the appointments are to be made by the Secretary of State and although there are provisions for consultation, there is no guarantee that the interests of the public will be represented by elected members who have a responsibility to the electorate through the accepted process of democratic local government. Moreover, while there is provision for direct local authority representation on Area Health Authorities— this is in Schedule 1, Part 1, paragraph (2)(d)—the function of the representatives is apparently to be confined to providing close decision-making links with the local authority services. Furthermore, their precise number is apparently left to subordinate legislation on which the Bill itself provides no guidance. This is particularly unsatisfactory when criticisms have already been expressed to the Government about the proposals in the White Papers.

The effective responsibility for running the Health Service at local level is properly that of the Area Health Authority, but if this responsibility is not to be bureaucratic and professional, then it will be essential to ensure that a substantial proportion of the membership of an Area Health Authority, preferably a majority, comprises people whose eligibility for service depends on their acceptance by the local electorate—in other words, people appointed by local government. This points to an A.H.A. membership of larger than 15 and certainly to a local government representation well in excess of four. Moreover, there seems to be no reason why the Area Health Authority, if properly constituted, should not appoint its own chairman. For democratic participation in the N.H.S. to be fully effective, however, it should be noted that the local government membership cannot be regarded as being solely for the purpose of representing the interest of specific local authorities and their services. Rather, they should be regarded as representatives responsible for the wellbeing of the people living in their area and of local government services generally. With these principles in mind, therefore, the associations urge that the Bill be amended and the Government's intentions made quite clear.

My Lords, let us consider the community health councils. The associations do not accept the suggestion in the White Papers in paragraph 106 of the English White Paper and in paragraph 19 of the Welsh one—that: The expression of local public opinion can be catered for in one of two ways. It can be done indirectly by including in the membership of the health authorities local people serving in a representative capacity. Or it can be done more directly, through bodies specially set up for this purpose, with direct links to the authorities. The Government prefer the second course. In their view, the membership of health authorities of local people serving in a representative capacity is a necessary and complementary safeguard. That is the view generally held by local government in order to ensure that the public has a full say in what is done in its name. In addition, the associations believe that the arrangements suggested for the proposed community health councils should be strengthened. The associations consider that the effectiveness of statutory consultative committees depends primarily on their independence from the nationalised service or industry concerned. They also believe that this view has general public acceptance.

My Lords, the associations welcome the Government's acknowledgement of criticisms of their earlier Consultative Document on proposals for community health councils. In particular, it is noted that the English and Welsh White Papers in paragraphs 108 and 20 respectively, envisage that half the members will be appointed by district councils. But as the Bill stands, Clause 9(4) membership of community health councils is to be prescribed by regulations. Surely there should be express provision in the primary legislation that district councils are to appoint members in the same way that it is stated in paragraph 2(1) (d) of Schedule 1 that the specified local authority or authorities are to appoint members to the Area Health Authorities. Furthermore, it should be clearly laid down that each and every district council within the area of a community health council is entitled to representation.

The essential weakness of the councils will remain, however, so long as they are still to be dependent on the Area Health Authorities for the appointment of half their members, for the provision of staff and accommodation and for all their expenses. In particular, the staff responsible for formulating and pursuing community health councils' criticisms of local health services will be National Health Service officials whose professional future will depend on maintaining the goodwill of their National Health Service colleagues and superiors. That is manifestly wrong. On that basis the councils will be insufficiently independent to have an effective and worthwhile role and cannot be expected to enjoy the confidence of the public as representative of their interests in the Health Service. The associations believe—


My Lords, may I interrupt the noble Lord for a moment? I am wondering whether he is speaking on behalf of himself or whether he is regaling us with the views of the associations because, of course, in our Companion to the Standing Orders it says on page 85: When speaking in the House, Peers may indicate that an outside body agrees with the substance of the views that they are expressing; but they speak for themselves and not on behalf of outside interests. I want to be quite sure that the noble Lord is speaking for himself.


My Lords, I am sorry if I have not made that clear. I am speaking for myself but I felt that as a person I should carry far more weight if I could say that the associations agreed with these views. I am, of course, as I stated at the beginning, an official of one of the associations in question. In my opinion—and the associations believe this also—these proposals are misconceived and should be reconsidered to serve the interests of patients and the public more effectively. Community health council independence from the National Health Service can be achieved in various ways, but in our view the most satisfactory would be to rely on existing local democratic processes. On that basis, local government could be made directly responsible for the councils' staff accommodation and expenses. Similarly, the appointment of representatives of local voluntary organisations should not be left to the National Health Service but should be settled by local agreement between the voluntary organisations or, in default of agreement, by the proposed joint consultative committees. Clause 9(4) of the Bill provides for the details of these arrangements to be settled by regulations. But the associations trust that the principles involved will be regarded as being of such importance to the future of the Health Service as to justify my stating these views in your Lordships' House.

My Lords, may I emphasise that the critical tone of some of my remarks is in no way meant to detract from appreciation of the hard work, skill and thought which has gone into the production of the Bill before this House and which reflects great credit on the authors. But perfect mechanical machine-like efficiency is surely not the be-all and end-all of successful administration in human affairs dealing with the health and happiness of millions of people. It is personal involvement that lends any such scheme as this the vitality that spells public interest and proud personal responsibility. May I then, in conclusion, have the temerity to quote to the Government Front Bench the old motto: When workmen strive to do better than well they do confound their skill with covetousness. And may I end with the suggestion that at the Committee stage of the Bill it can be improved on the lines indicated to-day to your Lordships.

7.47 p.m.


My Lords, the Minister of State will be glad to hear that I am not going to follow the last speaker's train of thought. I am going to speak for myself but I have to admit to the House, as it has heard before, that my thoughts are often coloured by what I hear and discuss in the King Edward's Fund. Like everybody else who has spoken, we support this idea of integration, but for my own part I am worried about the problems of part-time lay personnel. This Bill, in effect—and we do well to remind ourselves of this, as we have done about every hour—is about people. There are 600,000 staff, I understand, in the National Health Service; there are 350,000 patients in hospital tonight; and there are 45 million outpatient visits made a year. But the average man or woman in the street at this particular moment knows nothing of what is impending. I believe that it will come as a great shock to many of them.

May I make just two general points in relation to industrial consultants? I have had my spate of them in my own business, and I should have thought that in the National Health Service we have an example where it is quite impossible to measure the efficiency of the new as against the old in the way one might well be able to do in business. Are we going to get value for money? Who can tell? Only the patient; and even his reasoning is somewhat objective.

My second point is that since the patient is the end-product of the Health Service, to my mind he has a right to be involved. After all, it is a monopoly, and that is a nasty word these days. I was listening last night to somebody reading out the American Declaration of Rights. Did it not end up by saying that the Government can act only with the consent of the governed? All that, one would have thought, would have led to the involvement of more people, rather than fewer, in the National Health Service. But what has happened? Entirely the reverse, as the noble Lord, Lord Grenfell, has told us; and he gave the precise figures. There are going to be far fewer lay members of the public mixed up with the management of the hospital service. Indeed, I have heard an ugly rumour that letters are going out to the chairmen of big companies to see whether they have available people who can sit on Area or Regional Health Boards. That is nonsense when so many people are at this moment doing excellent work on a variety of these boards and management committees.

Then at the district headquarters, there is to be this management team. Here I would bring in the analogy with business. It would seem to me to be ridiculous in my group of companies to have what one might call "group 2 companies" without any board of directors at all, just a management team without any outside breadth of experience and knowledge on which they could call. In this district area, as many of us who are in the House to-night know, there are these disagreements that crop up in hospitals between medical, nursing and administration staff. These disagreements generally arise when people feel a sense of their own importance, of their own value and in the ordinary way at present they are referred first to the chairman, and it is only if he is worried and cannot settle it that it goes to the board. What is going to happen under the new set-up? Each member of this district management team has equal status—it says so quite clearly. Each member of this district management team is a representative for his subordinates. How can be give way on this minor issue that has cropped up? There are many enlightened people in the Health Service to-day who value the boards of management, who value the dispassionate chairman, with his tact, his ability to turn up at social functions, and to apply to so many matters in the hospitals a value of priorities.

How has all this—I was going to say gone wrong? How has it all happened? I have, and shall always have for the rest of my life, a very sore place in relation to the Civil Service since the British National Export Council, on which I played a part, was taken over by the Department of Trade and Industry and replaced with something which we had never heard of, called the British Overseas Trade Board. I am not for a moment implying anything sinister here. I think the Civil Service acts with the very best of intentions. But there is an opportunity here for strengthening the position of the professionals. I hope that one day somebody will write a book, rather like the Anatomy of Britain, and call it the Anatomy of Health and will find out what did happen over all these years with all the papers and reports to which reference has been made to-day.

What safeguards have we got? We have got the two that have been referred to so often this afternoon. First, we have the Health Service Commissioner, a good long stop. We were a little late in taking up this idea of the Ombudsman now it is a very popular thing. I have been wondering, as we have talked this evening, what he would say had he been listening to this debate. Your Lordships may refresh your memory, I think from Clause 34, of his ability to intervene when he feels the service is not providing what it should do for the patients. Would he not think it might be considered impertinent to flout the opinions of people like the noble Lord, Lord Cobbold, and the noble Lord, Lord Cottesloe, and others with their vast experience? It will be interesting to see how his services work out in the long run.

Then there is the community health council, which, of course, is exactly where the customer should come into his own. Some time ago the King Edward's Fund sponsored a report called The Integration of the Health Service in the Brighton and East Sussex Area. If it had not been for the fact that so much paper has been inflicted on you, I would willingly suggest that I let your Lordships have it, if you would like it. That report was the work of a multi-disciplinary advisory group on the whole subject of integration, but as a separate subject they dealt with the question of the community health councils. If you read their report, while they did not put it like that, they felt that it was one thing to have people sniping from the sidelines and quite another to have them sharing the responsibility.

The conclusions they came to were quite definite. I think the Minister has had a copy of this report, and I shall be interested to know to what extent, if at all, he shares that particular conclusion. They said that if they got no teeth or no money—we know they are going to get some money—it would be better for them not to exist at all. They said that this was an opportunity to have channels of communication with the executive of the National Health Service. If they did not have that, how could they start? They felt it was their duty to disseminate information in a general way about the Health Service to the community. They felt that these community health councils should be the recipients of all the complaints. They felt that they had a part to play in co-ordinating voluntary organisations with the Health Service. Above all, they felt they must have the right to visit all clinics and hospitals to oversee the welfare of patients. And then they added another point, that they felt that they should be consulted at the initial stage of any new project, including the siting of new hospitals. When you reflect on these requests or demands, that they felt should be included in the duties of the community health councils, they are almost exactly what a management committee had. So who can say that they are wrong? I am certain that unless they are given a status which the public can readily understand they cannot be effective, and indeed they will not get volunteers coming forward to serve. In effect they are going to assist the management in the task of improving the wellbeing of patients and staff. They said themselves in this report that they felt that the council members should undergo training, particularly for those involved with the psychiatrically ill and the mentally handicapped. If the King's Fund, as one part, is to undertake this work, it must know the answer to the question: Training for what?

I wondered what I should be thinking if I were the Minister of State, having listened to this long debate. I felt I had two conclusions. One was that I should be very certain of the many reservations of many people who have been speaking to-night who have been dedicated from the very beginning to the conception of the National Health Service. I think that those same people will be very watchful at the Committee stage, on whichever side of the House they sit, because our National Health Service is not, or should not be, a matter of Party politics, and we should all be voting according to our conscience. Secondly, I would be aware that the public values its National Health Service; we all know that. It will not be at the mercy of bureaucrats, and it will not forgive any Government that allows such a thing to happen.

To end on a friendly, constructive note, the King Edward's Fund has always held itself out to help the National Health Service in whatever form is agreed upon. It is going to help in the training of all those who are involved with the Service; this we shall continue to do with pleasure, because we know that however it is finally formulated it must be a success for the benefit of us all.

7.58 p.m.


My Lords, I must apologise to your Lordships for having had to miss a large part of the middle of the debate due Ito another engagement, and because it is now so late I will make my few points as briefly as I possibly can. The first is that I should like to hear the Minister in his reply say something about the quality of the service as well as the efficiency of the management, particularly because those of us who live in country districts find it difficult to see how sufficient numbers are to be found to man these area and other boards. These appointments cannot just be "Buggins's turn"; they are immensely demanding, not only of time but also of skill and experience, among other things financial experience. Unless really good members are appointed, they will not command the respect of the administrative and medical members with whom they serve. It is really on these voluntary members that the bulk of the responsibility falls at the end of the day. I am sure that it is going to be very difficult to find and to maintain the necessary level of talent and ability.

And at the other end of the scale, when it comes to making appointments to these community health councils, it will be hard to find good people who are prepared to give their time to something in regard to which very little responsibility, if any, is going to come their way. I hope the Minister can say something about that, too.

I should like to think, too, that he can tell us something about a shadowy figure who played a bigger part in one of the earlier debates on one of the many Papers—I am not sure which colour it was—produced by the Government. That somebody was called the community physician, of whom I find no mention in the present Bill. He could well be a figure of immense influence for good or for trouble, according not only to his appointment but also to the relations that come to be established between him and the authorities with whom he has to deal. It is a curious appointment. He would appear to be a principal figure not only on the hospital side of the Service but on the local authority side too. I should like to know—and here I am not alone; many people would like to know—to whom he is to be accountable; who is going to appoint him, and who, if necessary, is going to dismiss him? We do not warn shadowy figures of great power accountable to no one, emerging as a result of this Bill.

My next point concerns the question of Parliamentary time. Last year we had a local authority reorganisation Bill and a health Bill, this year we have the same. It would seem simpler to have had two local authority reorganisation Bills in one year, if we must have two; or two health Bills, and then we should not have had to try to master and keep au fait with two difficult subjects not only throughout the whole of last year but again throughout the whole of this year.

Is it really necessary to have two similar Bills for different parts of Great Britain? I know that it is traditional that we often do, but is Parliamentary time really sufficient to allow us to do this? Is it not possible more often to have one Bill, and for it to have separate chapters which would affect England only or Scotland only? I know that there are many occasions where it is not possible to have one Bill, but having read both this Bill, and the Scottish Bill, I really wonder whether it was necessary to have two, and for us and another place to go through all these stages twice.

My last point is this: those of us who live near to the Scottish Border can never understand why it is that in many an English or Scottish Bill there is no reference to the "neighbouring country". Instead of a land "frontier" there might well be a wide ocean space, between us. When a clause dealing with co-operation is found in a Bill of this sort it describes co-operating with the authorities North or South of the Border, but never seems to appreciate the importance of cooperation "across the Border". During the Committee stage of the Scottish Health Bill I moved certain Amendments to meet this point. I thought they were dismissed very peremptorily by the Minister, but I can promise my noble friend that I shall move the same Amendments again during the Committee stage of this Bill, to impose the duty of consultation not only between authorities in England but also, where they touch Scotland, with the neighbouring Scottish authorities too. Surely this is most important in the field of public health, because germs do not stop at county boundaries or at the border between England and Scotland.

I would commend to my noble friend the fact that in the field of agriculture, animal health is treated in Great Britain as one, and he has a good precedent. In this particular regard it seems that the veterinary surgeons and the Ministry of Agriculture are far in advance of the doctors and the health departments.

8.4 p.m.


My Lords, I must begin by apologising to your Lordships' House for the fact that it was, unfortunately, quite impossible for me to be here at the beginning of this debate, and that I have been absent from many of the subsequent speeches. My purpose in speaking, extremely briefly, is to draw your attention to one special limited but not unimportant point. I refer to the reorganisation of the social work which is at present undertaken in the hospitals but which in future, as I understand it, with safeguards, is to be the responsibility of the local authorities. Plainly there is a great deal of sense behind this proposal. It would seem somewhat ridiculous to have the great volume of social work undertaken by a local authority and to have one very small sector as still the responsibility of the National Health Service. I fully recognise that the proposed change is in line with the dogma—or doctrine, according to your point of view—of the general all-purpose social worker: the generic social worker, as he is called. While I fully accept that there are good reasons for doing this, and that the change must and should go forward, there are also certain disadvantages which should be given further consideration. I recognise that in the supporting document which has come out there are proposed safeguards, but these are not part of the Bill, and it is necessary that we should think a little more about them.

May I refer first to the idea of the all-purpose generic social worker? This concept was introduced and fostered, as the phrase is, by "some of my best friends", but that does not mean that I necessarily accept it totally and uncritically. I have always had some doubts as to whether it necessarily follows that a person who is very skilful in dealing with the sick is equally good with the old, the young and the naughty. It is possible that there are still very great advantages for the specialist, particularly if he can work (and I believe that this is now the practice in some places) in teams allowing for specialisation. But I suggest to your Lordships' House that the all-purpose team, as it is now to be called—and about which we are hearing a good deal because of stories, sometimes rather horrific stories, of the non-success of the all-purpose social worker—is not necessarily the most appropriate way of organising this kind of work all over the country. One can see that it can be extremely effective in a concentrated urban area, but it may well be a great deal more difficult to organise it effectively in a very scattered rural area. I think, too, that from the point of view of the patients—although I admit that most of the time patients are ordinary people in a community who happen to be sick for a short time—there is something to be said for having someone dealing with their problems who is specialising in them.

Then, of course, there is the fact that the social worker in hospital is, or ought to be, working in a team with the doctors and the nurses who are still part of the Health Service. I do not think it is esential that, because people are part of the team, they should necessarily be employed by the same organisation. But there are disadvantages—not overriding disadvantages, but disadvantages—in having two loyalties of the kind envisaged here. What this means is that there is still room for a great deal more experimentation in the way in which we organise services of this kind, and that we do not need to move swiftly in the direction of transferring the social work in hospital totally into the hands of the local authorities.

I want at this point to put the case (I recognise that it is a subordinate case, but it is not unimportant) of the people who have been doing this work in hospital for a very long period of time. I should be the last person to suggest that a service is run for the people who work in it and not for the people it serves. At the same time, we owe it to people who have been engaged in work of this kind over a long period of years that they should not be forced into a work situation, and a pattern of collaboration in work, to which they themselves are strongly hostile. I know that many of the people who will be affected by this change are very much in favour of it, but I also know that there are some who are greatly opposed to it. I gather it is suggested that safeguards should be given to people employed in medical social work that they will not be forced to change their pattern of working. I want to underline that this should be done, in fairness to them.

I underline this particularly because, as some of your Lordships will know, following the very proper and necessary reorganisation after the Seebohm Report there have been tragedies—and I choose my words carefully—arising from the way in which social work in this country has been reorganised. There have been tragedies experienced by women, in particular, who, overworked and underpaid, have done these tasks for many years yet now often find themselves working under people less experienced and less well trained than themselves. In consequence, they are extremely unhappy not only because of the loss of status which they have suffered, but also because of loss in the calibre of the work and in the professional skill which they have put into this work for so many years. In some cases—admittedly, a minority of cases—situations have arisen in which, if comparable situations had arisen on the factory floor, strike action would quite rightly have been taken. Situations have arisen in which changes in work content have been of a kind which would justifiably have demanded substantial redundancy payments. These are the kind of people who do not defend themselves in such situations, and who therefore need all the more to be defended in discussions in your Lordships' House.

8.11 p.m.


My Lords, we have been debating a Bill which affects the life—and, I suppose, the death—of almost every person in Britain and at the end of the day, and almost at the end of this debate, one is still left asking oneself: have we really answered the fundamental questions? Because when we have dealt with all the mechanics and bureaucracy, with the structures and the hierarchies, and with everything else which is embodied in the papers and in this Bill—including the doubtful wisdom emanating from McKinsey Limited Inc.—just how much difference will it make at the points where it really matters; at the patient's bedside, in the family doctor's surgery, in the maternity clinic, in the pathological laboratories and in the operating theatre? Will old people have greater hope of easier lives, not just poor lives prolonged beyond the allotted span by the wonders of intensive care? Will the families with children afflicted in mind, in body and, almost inevitably, in estate obtain more help and comfort from a community willing to share their burden? Will the adult disabled person feel that he or she is getting a fairer deal? Will the patients in the National Health Service, as a whole, and the staff at all levels—not only the doctors and, among the doctors, not only the senior medical men—feel that they have some voice and that that voice will be listened to?

If many aspects of community care are transferred from publicly controlled local authorities to the National Health Service, will community care and day-to-day treatment get more attention, as many people think they should, and as my noble friend Lady Summerskill, for example, emphasised in her wise and well-informed approach to the need for greater domiciliary care, or will the ethos of the hospital-dominated service prevail, in the sense that we get ever larger and more expensive institutions absorbing, possibly, a disproportionate share of limited resources? It is of course all a matter of balance, but it is against this background that we must consider a Bill which, for one which enshrines such a comprehensive reorganisation of such a vast service, is, as my noble friend Lady Serota pointed out, singularly vague. I believe that this is, in part at least, because Ministers themselves are not certain that they have found the right answers and hesitate to commit themselves in Statute. I am far from convinced myself, and I say this in the full knowledge that the preceding Government issued Green Papers which, while certainly not definitive, were in many particulars not very different from what we have before us to-night. But the fact that the two sets of Papers are in many respects similar does not in itself make them right.

My noble friend Lady Serota dealt most ably with the main points of structure in the Bill. She did not touch on Wales nor deal, in any detail, with the grass roots involvement at community health council level, with the patient as consumer, with his relationship with the proposed Health Commissioner and such matters. The noble Lord, Lord Inglewood, has already left us, but, contrary to his views, there are very strong sentiments in the Principality that we should have had two Bills rather than one. So strong in fact was this feeling that in another place some two weeks ago the Welsh Grand Committee, which includes all Members representing Welsh constituencies, had a full day's debate. Admittedly, they were not formally debating the Bill which is now before your Lordships' House, but they had a first bite. They did so, justifiably, because except for the first Green Paper of 1968, we in Wales have had issued papers which were separate from but parallel to those supplied for England. We have had a 1970 Green Paper, a 1971 Consultative Document and a White Paper this year. But in Wales our book on management is coloured red, not grey—no doubt a delicate compliment to the political complexion of the Principality. We, too, had a separate report from McKinsey Limited Inc., which was far from universally welcome.

There has been considerable disquiet in Wales about the kind of consultation which took place preceding our red book, and this disquiet arises partly because of the really rather astonishing admission on page 36 of the red book, that the Steering Committee, which was responsible for its production, did not take views from the Welsh Hospital Board. We in Wales have only one hospital board for the entire country. They were not formally consulted and this seems to me very remarkable indeed. But it is all the more disquieting because the Chairman of the Welsh Hospital Board, Mr. Gwylim Prys Davies, felt so strongly that the Steering Committee was going on the wrong lines that he resigned from membership of it. I have here the public statement which he made on that occasion, and it might be enlightening to your Lordships if I read some extracts from it. He said: At a time when people are feeling excluded from the process of decision-making—and as Chairman of the Welsh Hospital Board I have been very conscious of this sense of exclusion—it seems strange that we should be asked to support proposals which will reduce public participation in the planning and management of the Health Service. He went on: Management consultants' goals do not include certain fundamental concerns for democracy and the consumer to the same extent as they include management matters. Continued membership of the Steering Committee would, of necessity, imply agreement with all its basic recommendations. This agreement I simply could not give", and he accordingly resigned.

There has been a thread of concern underlying so many of the speeches in this debate. We in Wales are particularly concerned at the loss of a lay element in the administration of the Health Service. It is all the more acute in Wales than in England. The noble Lord, Lord Grenfell, gave some extremely striking and remarkable figures for England. In Wales, of course, we are on a very much smaller scale, but because we do not have a regional tier in the new dispensation we suffer even worse from the diminution of lay representation.

At the moment, we have some 258 members of hospital management committees, together with the members of the Welsh Hospital Board. Under the new arrangements, we shall have only 120 people in the whole Principality participating in the Area Health Authorities. We shall not have a regional authority. The family practitioners' committee will remain very much the same as the present Executive Council, so I leave them out of the argument. The members of the proposed community health councils are not, after all, to be engaged in the administration or running of the Health Service, so they do not count, either. Therefore, we have a very strong feeling that we are being deprived, more particularly when one considers that in this integrated Service one will be taking in the whole of the health work now done by local authorities; in other words, supervised by elected councils. We are taking up a very much larger sphere of administration which, as the management papers are at pains to emphasise, will require more sophisticated supervision, but we are being asked to do it with fewer than half the number of persons who are engaged upon it at the present time. So it seems to me that we have very considerable grounds for concern.

It is quite true that the main distinction between Wales and England in the new set-up is, as I have said, that there will be no regional tier: the eight Welsh Area Health Authorities and the Welsh Office will be in direct contact. This was the pattern proposed by the last Government, but, my Lords, with one very important proviso: throughout our Green Paper we stressed that the pattern was subject to Crowther. If the Commission on the Constitution recommend, as we believe they must, an all-Wales Council, preferably directly elected, then significant responsibilities in the Health Service seem to us to follow. The proposal that the Welsh Office should perform all the regional functions plus what one may call the Whitehall functions was intended by us to be a holding operation only; and I hope very much that in his reply to the debate the noble Lord, Lord Aberdare, will be able to say that this is the attitude of the present Government, too.

We did not want an advisory Health Services Council appointed ad hoc—a proposal which was made by the present Secretary of State but which has now been dropped—partly because one of the functions which we envisaged at the all-Wales level is strategic social planning, for which one needs far wider interests than the Health Service alone. It is true, as my noble friend Lord Watkins remarked, that we have in existence at the moment a nominated Welsh Council, serviced directly by the Welsh Office, which covers rather more than the English Economic Planning Councils and includes health in its remit. In the interim, its advice should certainly be sought. But having been its chairman for several years, I know quite well that this Council is neither sufficiently independent nor sufficiently well equipped to undertake continuous work in depth of the kind required. So consultation with it in its present form can be only faute de mieux. Any regional organisation which might evolve could, I would hope, meet the points made by the noble Lord, Lord Platt and the noble Lord, Lord Brock, about senior appointments. This is a matter of detail but an important one which, again, we shall no doubt wish to discuss at a later stage.

Having said this about Wales, I cannot help thinking that possibly England, too, might find lessons at regional level in possible Commission on the Constitution recommendations, if only so that at that level, at least, we could get some measure of true integration of the health and social services, especially at the strategic planning level. So far, this has eluded us. I must admit that I myself have come to the conclusion that we should probably have done better to have had both services based on large local authorities, with possibly some special provision for the teaching hospitals. This would in no way have diminished the personal responsibilities of the individual physician, nor have interfered with his right in matters of clinical judgment. But I believe it might well have resulted in a better deal for the patient, and in doing away with the need for this complex apparatus of consultative, collaborative, advisory and other bodies now needed in order to make the dual system work. But I think it was the powerful and, some might think, ominous combination of the Treasury and the medical profession which prevented us from achieving this true integration of both the Health and Social Services. At regional level, at least, I would hope that in our lifetime we might see some improvement; but further than that, I think we shall probably all be dead first.

Now, my Lords, I turn to the other end of the scale, from the regions to the proposed community health councils. This is a subject which has been brought up in, I think, almost every speech which has been made in the course of this debate. I do not think anyone, except possibly the Minister, has been happy about the proposals in the Bill. Everyone recognises the importance of these community health councils; but one noble Lord after another, and one noble Baroness after another, has remarked that, as constituted, or as we suppose they will be constituted under the regulations suggested, they simply will not work. I do not think anyone has supported the proposal that these community health councils should be appointed, staffed or financed by the Area Health Authorities, whose activities it is their job to watch. The gamekeeper has been told to appoint his own poachers, and nobody believes it will work.

The noble Lord, Lord Milverton, in particular, referred to the proposal put forward by the local authority associations, which was that the local district council should take the responsibility for staff, accommodation and expenses. My Lords, I think this should at least be looked at very seriously, particularly as the White Paper (though not, I think, the Bill) suggests that one-half of the community health council members should be district council appointments. I feel very strongly that the community health councils should appoint their own staff. This might be on secondment from local authority services, by appropriate arrangement. This would safeguard career prospects without bringing in a career officer from the Health Service, who needs must be pre-occupied about his future and is unlikely to wish to endanger it by producing a report critical of those on whom his promotion may depend. But there should also be room, I feel, for young people who have served an apprenticeship in one of the voluntary organisations, whether old-established or a ginger group like Shelter, the Disablement Income Group, the Child Poverty Action Group and the like, because with such experience behind him or her and increasing maturity I believe that such a person could make a first-class officer serving a community health council.

The noble Lord, Lord Grenfell, suggested that the premises of such a council should be in the district general hospital. With the greatest respect to the noble Lord, I doubt that, because for one thing the community health councils will surely be concerned with a far wider range of health services than the hospital service, important as that is. I myself should have thought that the office might well be on council premises, but certainly not on the premises of the Area Health Authority. Because, my Lords, if on telephoning the watchdog you find that the telephone number is the same as that of the body being watched, you tend to lose faith in the dog's impartiality. And, as the local authorities point out, if there are several districts in a health district area they can agree which would be most accessible and convenient to the public.

I myself, however, would go a step further and query whether it is best that the community health councils should be coterminous with health districts rather than with local authority districts. After all, the functions are quite distinct. It is stated clearly that patients will move across boundary lines but that the health districts will largely be based on the pattern of hospital administration. But if expression of public concern is the object, as it is, for the community health councils, it seems to me that there is much to be said for keeping to the units designed to elicit public opinion in other fields. I hope very much that the Government, and noble Lords who are interested, will think hard about this. I believe it is a matter on which this Bill may be improved.

My Lords, I put forward this idea for another reason, too. There is much heart-searching, as our own debate and many publications outside have indicated, as to how an effective community health council should be composed; rejecting, as almost all of us do, appointment by the Area Health Authority, and accepting a strong element of local authority nomination, including, I should hope, someone from county level who is knowledgeable about social services, there is still a good deal of uncertainty about how the rest of the body of some 20 to 30 members should be chosen. The more closely one contemplates methods of voluntary organisational choice, the more dubious one becomes. I speak personally here, but I would favour Ministerial choice from names submitted by voluntary bodies, plus an element of direct popular election—say, three or four members. This could be done at the same time as local council elections. Admittedly it is in the American tradition, rather than in our own tradition, but I do not think that it is necessarily the worse for that. It simply means an extra ballot paper suitably coloured to distinguish it from the main election. If we really want the public to feel that they have a voice, it should be an identifiable voice; and there is no better way to achieve this, to my mind, than by direct election. Again, I hope very much that we shall seriously consider this at a later stage and at least make it possible by the provisions in the Bill for this to be brought about, if it is considered desirable.

If I may revert for a moment to the Principality, in Wales we have community councils under the Local Government Act on a much more comprehensive pattern than is proposed for England. It seems to me that they should have some place in the community health council set-up, especially in the sparsely populated districts of rural Wales. I am sure that the people at my end of Montgomeryshire, for example, have little appreciation of the position in Welshpool, at the other end of the county. Yet in the new local government structure they will all be part of the same district council. But there will be a number of community councils in the area, too, and I feel that in our circumstances, at least, they should be brought in. The essential thing in dealing with these community health councils, whatever the local circumstances, is to make them genuinely responsive to local opinion and local need. I believe that we should be willing, and should encourage the Government, to experiment and to innovate at this level and not stick to the bureaucrat's easy way out, as suggested in the White Paper. I hope that we shall all think about this between now and the Committee stage.

I want to refer in a moment to some of the community health council functions, as opposed to composition. But meanwhile I come to the matter of the Health Service Commissioner, this quadripartite being, Sir Alan Marre. Because, of course, as at present proposed, he is not only the Parliamentary Commissioner for Administration but is also to be the Health Service Commissioner for England, Scotland and Wales. Well, my Lords, of course in principle we welcome the acceptance by the Government of a proposal which was made by their predecessors; but we have very serious reservations about detail and, particularly so far as Wales is concerned, I would strongly support the proposal that we should have our own Health Service Commissioner. I hope that arrangements can be made to this end. Looking at the Bill it is not easy to amend it in this sense, because in the Bill it is not disclosed that all these people are in fact one person. But I hope that we shall have some assurance from the noble Lord, Lord Aberdare, that this matter will be reconsidered.

As several noble Lords have emphasised, as the channel for the investigation of complaints the Commissioner will be subject to a very large number of limitations as set out in Part III and Schedule 3 to the Bill. Will he, in practice, prove to be more than a "paper tiger"? This is what we must all be wondering. Will he be more effective as Health Commissioner than perhaps as Parliamentary Commissioner? I say this in no personal sense, but I refer to the limitations of the office, which in fact is very different from the Scandinavian conception of an Ombudsman. What really worries many of us—and this point, too, has been referred to in the debate—is the whole field of complaint procedure. I should like to call it improvement procedure, because in many instances this is what it should be; though, of course, one acknowledges that there are times when "complaint" is the operative word. But if one regards I every proposal made by a patient, or other consumer of the Health Service, as a complaint it puts all those in authority on the defensive. It leads to a black mark for both patient and members of the staff who try to draw attention to defects or deficiencies in the Service. It seems to me that the proposed structure outlined in the Bill and the Management Paper will not lessen this attitude but may well enhance it. We are, of course, at a considerable disadvantage in this field because we still are awaiting the report to Ministers of the Davies Committee. What we must do, I suggest, is to make certain that we put nothing in this Bill which would hinder—indeed, we must do whatever we can to help—a better attitude and procedure. There is a very wide range from what are basically attempts to improve the Service through administrative grievances to the much rarer complaints of clinical error, or even gross negligence by a clinician.

I think, my Lords, that we are all agreed that the majority of patients are unwilling to complain. There is often, and dightly, what is known as "the gratitude barrier". But I also believe that we cannot get the best possible service unless at each level of concern we find means of helping patients or relatives adequately to express what seems to them to be wrong. When it comes to formal matters many patients are inarticulate, a fact that middle-class members of committees sometimes find hard to understand. Furthermore they do not know how to set about launching any really serious complaint. Can we not look upon the community health councils as specialised citizens' advice bureaux in this field, with adequate staff to deal with this particular duty? This would give the community health councils, among other things, a direct responsibility in the Health Service at the very point where consumer protection is uppermost. I believe that this would be beneficial both to patients and also to the community health councils.

There is another field which seems to me difficult, but where again possibly the community health councils could help, and that is in the relatively few instances where a patient may have a case at law and is therefore outside the Ombusman's terms of reference. Few people have the courage, or the means, to set about establishing such a case; partly—let us be frank about it—because virtually no doctor will give evidence against another doctor; yet medical evidence is often essential. This is a very difficult field, but most of us know of at least one or two cases where gross error or neglect has resulted in damage for life for which in most other circumstances there would be some remedy, but the patient is usually helpless. These cases are few, but I believe that advice and help should be available and that we should make some provision for it in the Bill.

Finally, there is the position of staff who feel that there is ground for complaint. Their position is specifically mentioned in paragraph 180 of the English White Paper. Can they avoid victimisation if they do their duty? One of the very disquieting things in the hospitals which have been subject to formal inquiry under Section 70 is that it was staff who tried to draw attention to what was going on, and who were threatened, and even victimised, for their pains. In long-stay and mental hospitals, particularly, it is the staff who are in the best position to judge. Can we secure a real change in attitude and atmosphere so that reports of defects, if properly based, can be regarded as helpful and not as disloyal conduct to be stamped on hard? These are just some of the matters we must think about in preparing for later stages of the Bill. We cannot do work which properly falls to another place, but if such an important Bill as this undoubtedly is starts in your Lordships' House, our role is surely to bring out into the open topics on which further discussion must be focused if we are to have the quality of comprehensive health care which I know we all desire.

My Lords, I believe that we have had a very high standard of speeches in the debate to-day, and it is no derogation of the admirable contributions from other noble Lords if I say how much I was impressed by the speeches of the noble Lords, Lord Cottesloe and Lord Cobbold. The experience that we have in your Lordships' House, if used fully, not only to-day but through the remaining stages of the Bill, will, I hope and believe, make the other place grateful for our help, and not, as seemed at one time likely, slightly resentful of the fact that such an important Bill should be starting in this House rather than in their own. I would indeed echo the words of the noble Lord, Lord Aberdare, in which he expressed his appreciation to his right honourable friend Sir Keith Joseph, the Secretary of State, for giving us a chance of being of Parliamentary service on a Bill of this substance and significance. I am sure that we can look forward to a stimulating and, I hope, constructive Committee stage and later stages of the Bill.

8.41 p.m.


My Lords, the noble Lord, Lord Hayter, ventured to guess what my feelings were in the course of this debate. They are rather mixed: not altogether feelings of despair, but of some sorrow that I evidently failed in my opening speech to put sufficiently forcefully what I believe to be the imaginative proposals in this Bill. I longed on many occasions to be able to reply immediately to some of the speeches that were made, and I find myself at the end of a long debate with inadequate time to answer all the points that have been raised. I think therefore it would be best if I were to undertake to answer in writing any questions of a specific nature that have been asked, and to confine myself very briefly to the major topics that have been touched on in the course of the debate. I should like to say, however, with what great interest I have heard all the contributions that have been made, many of them with constructive criticism. With respect, I thought the speech of the noble Baroness, Lady White, was most constructive, especially on the subject of community health councils. Certainly all that the noble Baroness said will be taken into consideration—and I am sure she herself will make sure it is—on the Committee stage.

The first matter that was criticised was the whole management set-up that we envisage. The regional tier was first of all mentioned by the noble Baroness, Lady Scrota. We felt that a regional tier was essential. We did not think that it was possible to administer a service of some 90 Area Health Authorities without a regional tier. We felt that there were indeed great advantages in having regional authorities who could reflect the different approaches in different regions of the country. I think it was the noble Lords, Lord Cottesloe and Lord Cobbold, who said that we had changed in some way the concept of the region since the White Paper. I cannot agree that that is so. I can only quote the White Paper, paragraph 74, which says: The regional task will be in part strategic planning, in part co-ordination and supervision, in part executive. That is what I believe is reflected in the Bill.

So far as Area Health Authorities are concerned, the noble Lord, Lord Davies of Leek, put his finger on the point when he quoted from the White Paper, pointing out that there was never going to be enough money to go round, and how important it was that we should make the best use of what was available. I would couple that with what I tried to say (I think badly) in my opening speech about the need to change the emphasis a little in the Health Service from acute medicine, which is already excellent, to treating those who suffer much more pain over much longer periods of time from the diseases of old age, psychiatric troubles, mental illness and similar long-term, painful experiences. It was with that in view that we put forward proposals that the Area Health Authorities should be relatively small, effective bodies, made up of people who we believe will not take a hard-hearted businessman's view of the whole thing—nothing bureaucratic, which is the word that has been used throughout the debate, but people of breadth of experience, of wisdom, tact and diplomacy, and all, incidentally, potential patients, so that nobody can say that they are not representing the community; people who will be able to take a hard look within their area at the distribution of resources, to be able to take decisions to move resources from one part of the Service to another, if necessary, and to meet what we feel to be the demands of the future. This body of people will be made up of some representatives of the matching local authority—4 of them, which seems to me to be a pretty reasonable quota: it is 4 out of 15 who will be from the matching Area Health Authorities. There will be, as we have said, doctors, a nurse and a representative of the teaching interests. So there will be a fairly broad-based expertise, as well as those who are nominated by the Regional Health Authority on the Area Health Authority.


My Lords, if I may interrupt for one moment, can the noble Lord say a word about the nonmedical, non-nursing staff? What happens to them? Have they any chance of being represented?


Is this on the Area Health Authority?




Nobody will be represented. There is no representation on the area authority. But there will be doctors, and a nurse or midwife, and there will be other people who are selected for their abilities to take the sort of decisions that I have been trying to explain.

Then, from pretty well everybody who spoke I think we had some form of criticism of the community health councils. In the course of the Committee stage I hope that we may be able to improve on the community health councils. We believe that if you admit that the Area Health Authority is particularly a management body, the community health council is an essential counterpoise to it. I do not accept that they are not democratic bodies. We have sought to make them as democratic as possible by proposing that half their membership should come from the district council or councils, according to the area which they cover. I find it difficult to accept the suggestion of the noble Baroness, Lady White, that it should be coterminous with the local authority district service, although we did consider this, because one of their important fields of activity is to see that the people who need help get it from the right quarter. In this way they oversee in the district the proper liaison between the services of the hospital, general practitioner, nurse and local health centre. It is easier for them to operate within that health district, which is responsible for providing that kind of care, than it would be if they were available in a local authority district. But again we can discuss that when the time comes. I believe they will be useful.

I think it was the noble Lord, Lord Platt, who suggested that it would need to be the individual doctor who improved his ways if, for example, patients were to be given greater information about what was to happen to them and how long they would be in hospital. I should have thought that this was just the sort of matter which could be drawn to the attention of the community health councils. They would probably be well aware that at their local hospital various patients had made just this kind of complaint. Then it would be possible for the community health council to report that matter to the district management team, on which doctors would be represented—we hope there will be a consultant, a general practitioner and a community physician, as was mentioned during the debate. This would represent a channel through which this kind of worry could come to the attention of the district management team and it is a way, one would have hoped, by which some pressure would be brought to bear on the doctors and thereby improve the situation. In fact, we have to get a very positive role for the community health council, if it is going to be effective.

So far as the Grey Paper is concerned—the paper which the noble Baroness, Lady Scrota, called "ghastly"—I think that perhaps we have done this an injustice in the course of our debate this afternoon. It was, after all, approved by a Steering Committee. It is not only a product of management experts but was approved by a Steering Committee made up of representatives from all parts of the National Health Service. Although unfortunately there is a certain amount of jargon in it, it is almost impossible to write an administrative document of this sort without introducing a good many initials and a good deal of jargon. However, I did try to stress the fact that it has considerable merits in its approach to district management. It faces the problem of trying to integrate into one management system a structure of doctors who are independent and who owe no allegiance one to the other, and a structure in the nursing field and in general administration, where people are responsible to the man above them in a hierarchical pattern. It was with a view to trying to solve this fairly difficult problem, to bring the doctors into management while at the same time retaining the hierarchical structure of the other services, that they came forward with proposals which are certainly ingenious and which I believe will work and will bring together the professionals, the doctors, the nurses, the lay administrators and the treasurer.

The noble Baroness, Lady Masham, was anxious about the position of general practitioners in this set-up. I can assure her that they are very fully integrated into the team. Not only is it open for a general practitioner to be a member of one of the authorities in these areas, but he will also participate very fully in the district management arrangements. I do not think I ought to go into all the details now, because there are many of them; but they are fully integrated and in fact the doubts which I have heard expressed rather the opposite argument and concerned the question of whether the general practitioners would be able to find the time to make as big a contribution as we should like them to make in the district management set-up.

I naturally listened with the very greatest attention to what was said by the noble Lords, Lord Cobbold and Lord Cottesloe. I should like to say to the noble Lord, Lord Cobbold, how much the Secretary of State and I appreciate his immense patience in continuing to give us the benefit of his advice, together with that of the Teaching Hospitals Association, throughout a very long period in which we had discussed all these issues. As he well knows, and indeed as he has told the House, we have not been able to meet some of his major demands. The noble Lord made a persuasive case for leaving things as they are and having what I think he called "a long-term period". This is an attractive idea, but the difficulty is that when one is integrating this Service in the country as a whole, to exclude London is not easy, and it is particularly difficult when there are local authority health services involved which have to be found a home after April 1, 1974. But certainly, as I tried to say in my opening speech, we value the contribution that is made by the teaching hospitals—no one could fail to do that—and we are anxious that there should be the necessary safeguards which we have put forward in the White Paper to preserve the interests of teaching and research. We are also very anxious that within the management arrangements which we are proposing we should do all that we can to meet the difficulties that the noble Lord advanced. As he knows, we are still in discussion with him on that matter. On the Grey Paper as a whole, one noble Lord asked me—was it my noble friend Lord Grenfell?—whether this was a doctrine which had the force of law. Of course it does not have the force of law; it is a document which has been produced for discussion, and we are now in the middle of discussing it.

I do not want to go on too long at this late hour, but perhaps I may mention just one or two other points that have been made. My noble friend Lord Grenfell gave some very interesting figures of the numbers of people serving in the Health Service. Of course, his figures are quite correct if you exclude the community health councils, but I would prefer to include these councils. I see them very much as part of the new set-up and I also see serving on them some of the people who have been giving admirable service on hospital management committees.


My Lords, would the noble Lord give way for just one moment? Surely he would agree that there is a complete difference in role, if I may use the fashionable term, between serving on a management committee, where you are involved very much in the policy-making and decision-making process, and being an active, lively—aggressive, if you like—member of the community health council? These are two totally different things and surely it is wrong to compare them.


My Lords, I do not altogether agree with the noble Baroness. I think there are certain people who serve on hospital management committees who will find that they are doing very much the same work on the community health council. Our view has been that a lot of hospital management committees are made up of two sorts of people—those who are interested in the management of the Service and those who are primarily interested in the more local matters of the comfort of the patients, the painting of the wards, and so on: the more local details. These, I hope very much, will find a place for themselves on the community health councils where, in my opinion, they will be able to exercise very considerable powers of persuasion and influence.

My noble friend Lady Ruthven and the noble Baroness, Lady Gaitskell, referred to family planning, and I listened to what they said with great interest. Clause 4, the clause in question, provides charging powers equivalent to those which the present health authorities have; and this is in line with the general policy of the Bill on maintaining the status quo on charging powers. But how these charging powers should be used is one of the matters we are considering as part of the current review of family planning services. The charges themselves would require to be introduced by regulations which would be subject to Parliamentary control.


My Lords, may I interrupt for one moment? Are there not some local authorities who have a completely free service?


Yes, my Lords; I do not deny that. I am only saying that the Bill reproduces the arrangements that exist at present, and if we were to operate the charging side of it, it would have to be subject to regulations.

The noble Lord, Lord Platt, asked about the complaints that the Health Service Commissioner might deal with. The complaints that we should expect the Health Service Commissioner to deal with are points of the nature of excessive waiting times for hospital appointments, bad food (which was a particularly topical one), and various things like the failure of an ambulance to arrive at the right time when required. These complaints, having been referred to the authority, and having produced no satisfaction, or having produced an unsatisfactory reply from the authority, would then be referred to the Health Service Commissioner.

The noble Baroness, Lady Serota, asked about redundancy. We hope very much to keep redundancy, if there is any, to the absolute minimum. I cannot go so far as to say that there may not be any redundancy. We expect the total number of jobs that are to come in the new set-up will be equivalent to the total number of jobs there are at present. There may well be people who feel unable to move, or to take up a job in another area, who may become redundant. There are safeguards in the Bill for compensation, and just as we had discussions on the local government reorganisation I am sure we shall be able to discuss these provisions on this Bill.


My Lords, is the noble Lord able to give any assurance in regard to the matter he is talking about? Before any new people are brought in will every possible effort be made to absorb those already working in the Service?


My Lords, as the noble Lord knows, there is a staff commission in existence at the moment, under the title of a Staff Advisory Committee. They are very much seized of that point and will advise on what precautions should be taken to meet that point.


My Lords, is the noble Lord able to go further? I raised this when we were discussing local government reorganisation. He will appreciate that the attitude of the Government was not wholly acceptable. One would hope that the argument had been further considered. In regard to this reorganisation of the National Health Service the Government ought to be able to move a little further than they did on local government reorganisation.


My Lords, we have a staff commission and we shall take their advice. The noble Baronesses, Lady Scrota, and Lady Seear, referred to the transfer of social workers. I noted what they said. No decision has yet been reached on this matter; but I would draw attention to Clause 18(5) which provides that any staff who are transferred from hospital to a local authority shall not be required to work away from the hospital without their agreement. I do not know what the final decision may be, but I hope this will be some reassurance to social workers at present employed in the hospitals.

The noble Lord, Lord Amulree, asked about medical officers of health and public health inspectors. Public health inspectors have important environmental health responsibilities, and they will not be transferred to the Area Health Authorities; they will continue to work for the local authorities. The community physicians will work closely with them, and this is an example where the local authority will look to the area health authority for its medical advice.


My Lords, will these officials have the security of tenure which they have now?


My Lords, I think I am right in saying that they no longer have it because it went under the local government reorganisation Act. They will now be employed by the appropriate health authority, and will have the same safeguards as any other member of the staff. I listened with great interest to the noble Lord, Lord Burnt-wood. I had better answer most of his questions in writing, if I may. I have great sympathy with what he said about the small hospitals and the community hospitals. I have also great sympathy with what he said about the disposal of property. We are also looking into this.

May I end with a few quick words on Wales, as this aspect has been raised? So far as the Welsh Hospital Board and its not being consulted by the management study is concerned, the point I ought to make is that no formal consultations were undertaken in connection with the management study. The management study is now subject to consultation. It was a document produced by a steering committee through various Working Parties and is now open for consultation. But there were joint Working Parties of the Welsh Office and Welsh Hospital Board officials. Apart from the Chairman, Mr. Davis, one other Welsh Hospital Board member, the senior administrative medical officer and the Secretary of the Welsh Hospital Board were members of the management study. The noble Lord, Lord Watkins, mentioned the need for a separate Bill for Wales. We were trying to help my noble friend Lord Inglewood in this respect and to save Parliamentary time on a Bill which is essentially very similar. So far as the future of the Welsh Hospital Board staff are concerned, we take this very much to heart. Perhaps I could refer the noble Lord to the speech of the Secretary of State for Wales in another place on November 21 at column 18. I will not read it out. There is, I hope, some reassurance there for the staff of the Welsh Hospital Board.

My Lords, I realise that I have been—


My Lords, will the Minister say anything about the Welsh Health Service Commissioner?


I would rather leave that for the moment, my Lords. The intention is, as I said, to appoint Sir Alan Marre as the Health Service Commissioner for the three countries, and joining that with his present responsibility as Parliamentary Commissioner.

My Lords, I am grateful for all the advice that has been offered to the Government on this Bill. As I say, I hope I can leave you with some idea that we have a forward-looking and exciting possibility in the Bill: first, by joining together, so far as possible, the local authority social services and the health services; secondly, by integrating the three parts of the Health Service; and thirdly, by providing a machinery for consultation with local people through the community health council, with a fallback for complaints to the Health Service Commissioner. I am grateful to your Lordships, and I commend the Bill to the House.

On Question, Bill read 2a, and committed to a Committee of the Whole House.