§ 4.38 p.m.
§ House again in Committee.
§ THE DEPUTY CHAIRMAN or COMMITTEES (BARONESS EMMET OF AMBERLEY)
We were discussing Amendment No. 37, which was moved by the noble Baroness, Lady Llewelyn-Davies of Hastoe.
§ LADY RUTHVEN OF FREELAND
I should like to say a word before the noble Baroness replies to this Amendment. I put down my name to Amendments to Clause 4 because I consider this to be a non-political Bill and I know that there is a great deal of support on both sides of the House, in the outside world and also among local authorities, for free contraception. I am rather worried as to the future, because as the noble Baroness, Lady Llewelyn-Davies, said, in Aberdeen, for instance, they have had free contraception, and so on, for the last five years. When this change, this 988 reorganisation, takes place in 1974, are they to go backwards and will they have to make all their patients pay? This also affects Croydon, for instance, which will shortly become an Area Health Authority. Croydon has been giving free contraception over the last 16 months. It seems extraodinarily backward thinking to have to put these people on to another line of action. So I would urge that the Secretary of State and the noble Baroness think again about this question of free contraception. I am speaking from the Conservative Benches, but I feel just as strongly as do noble Lords who have spoken from the Opposition Benches. I hope that there will be second thoughts about the question of free contraception.
§ 4.40 p.m.
§ LORD GARDINER
I also have no intention of making a Second Reading speech, though in view of the importance of the question whether we ought to have a free and comprehensive service we might perhaps just remind ourselves that, according to the United Nations demographic plan, after Taiwan, England is the most densely populated country in the world. The United Kingdom is fourth England is second after Taiwan. We still have a large surplus of births over deaths, and the unwanted pregnancies are of the order of 300,000 a year which result in 150.000 live births, the difference of 150,000 being accounted for by legal and illegal abortions. Of course no one wishes to stop anybody who desires to from having a large family. For us the whole kernel really depends on what we can do about the 300,000 unwanted pregnancies each year.
I am not going to deal with any matters of principle but solely with the economic consequences of contraception. My noble friend Lady Llewelyn-Davies of Hastoe has already dealt with the moral reasons why so many of us feel—and I believe that the public generally feel—that this ought to be a free and comprehensive service. The reason why I wish to say something on the much duller subject of the economics of contraception is because, so far as I have yet heard, the only reason why the Government say, "No, we will not have a free and comprehensive service; we will have a partial service; we will have medical and social limits and means tests, and so 989 forth", is because they say, "Well, after all, in what we are doing we are increasing what is being spent on family planning from £4 million to what at the end of another three or four years will be £12 million. A free and comprehensive service will cost £30 million and we cannot expect the taxpayer to pay that." I believe this to be a wholly erroneous argument, mistaken economically and that in the end the cost to the taxpayer will be enormously greater. I beg the Government to think again about this.
A large survey has been made in this field by that reputable body Political and Economic Planning. What it comes to, put in a sentence, is that £1 spent on family planning saves the taxpayer and the ratepayer about £100. They have divided unwanted births into ordinary cases, into the third, fourth, fifth and sixth child in a family which has never made any provision for contraception at all, and illegitimate children. The clearest case is perhaps that of the illegitimate children. The question they have been considering is this. To what extent does an unwanted child use up much more than the average of the health and welfare facilities provided by the Government and by local authorities? In the case of an illegitimate child they quantified this increase at £4,365. How do they arrive at that figure? It is the extent to which more than the average is used up by unwanted children, in this case illegitimate children. Most of that sum, just over £4,000, is made up of supplementary benefits. This is simply because a majority of the mothers of illegitimate children live on supplementary benefits, and of course in many cases for many years.
Then they find that the chance of an illegitimate child being put into care is four and a half times as great as that of the legitimate child, and they quantify this excess cost to the local authority as £300. Then they find this much smaller figure—because this follows much less frequently—that the prospect of the illegitimate child at some time requiring accommodation for the homeless is greater, though not so much greater: they quantify it at £15. If one takes that class alone and the, alas! too numerous illegitimate children, the cost to the community is £4.365 during the years of dependancy—if one includes the mother 990 if she has to be put on supplementary benefit when otherwise should would not be. This may be contrasted with the figure which the Family Planning Association charges a local authority for a free and comprehensive service—£34 per individual.
One of the greatest difficulties that I think we all appreciate is that many authorities in and outside London are now providing a free and comprehensive service. It is not only that we are not going forward as fast as we should like; when 1974 comes, if the Bill remains as it is, we shall be going backwards. Lastly, may I come to the tests which I do not very well understand. When the Minister was asked about them in the other place he started by saying:The honourable Lady asks about means tests. We shall try to attach the exemption to exemption arrangements already made for other services and details will be available later."—[OFFICIAL REPORT, Commons, 12/12/72; col. 236.]I wonder whether the Minister could expand on that statement. Later Sir Keith Joseph said:Secondly, regarding social need, professional workers, such as health visitors and social workers, will be entitled to identify individuals who in their view need free provision of supplies on social need, which will often correspond to, but will not overlap and may be different from, financial need."—[cols. 237–238.]Can it be explained what is going to happen'? One of the things which has disappointed me a great deal, and I suppose it has disappointed us all, is the very great practical difficulty which I have realised in helping those in pockets of real poverty which still exist in the country. I thought, for example, that rate rebates which we provided were sensible and would reach the right people. But I am afraid that nothing has grown to be more clear than that that simply has not happened.
The Child Poverty Action Group has recently conducted a study of rate rebates in Islington. They found that only 15 per cent. of those who are entitled to rebates get them. They found that those in greatest need tend to be non-claimants, while those with rather higher resources were more likely to claim rebates. This appeared to hold true whether the criteria was income, housing costs or availability of housing space. They say that similar results were found to apply to the take-up of other means-tested benefits, and 991 the reasons why they were not taken up were, ignorance concerning entitlement; ignorance of benefits; the income limits for the claiming procedure; lack of articulateness in the face of complex claim requirements; pride and fear of stigma and fear of officials or the landlord.
In this field also it is the least literate section of the population and the poorest which most stands in need of advice and appliances, and I do not follow what is supposed to happen. Do social workers need to have training in means tests? What steps are to be taken to see that each social worker calling on a woman—and apparently having, as I understand it, the sole right to decide whether the woman is to be entitled to free contraceptive appliances or not—applies the same standard? I cannot believe that this matter has been really thought out. In any case, I believe it is wrong for the main reason that I have given, that the Government's only objection, as I understand it, being economic, simply is not true. Both the taxpayer and also the ratepayer, if avoidable pregnancies are to result in live births, will in fact be put to far greater expense than if there was a free and comprehensive service.
Your Lordships may have seen an article in the Observer under the heading "Free for Some", which ends by saying:Those few local authority clinics, where supplies are already free for everyone, found that new attendances went up by more than 70 per cent. Nor is the old cry of ' sex on the rates' justified, since overwhelmingly the clients are married couples or young people with a stable relationship. Why, then, wait for an unwanted child or an abortion and give supplies free for just 12 months?For the present, there is no reason why local authorities already providing free supplies for all should not continue to do so. But when the reorganised Health Service takes over family planning in 1974, thousands may suddenly have to pay up or drop out and local authorities, which are now considering a switch to totally free supplies, may be persuaded against it. Unless a way is found, therefore, the cause of a fully comprehensive service may be put back five or ten years. So, helpful though his new plan is, it is a pity that Sir Keith did not take the final plunge and make birth control completely free for all.I am profoundly convinced that the Government have made a grave mistake on this point, and I beg them to reconsider it.
§ VISCOUNT MASSEREENE AND FERRARD
I have great sympathy for this Amendment and I fully support what the noble and learned Lord, Lord Gardiner, has said on the financial provisions for the 300,000 unwanted pregnancies: I found his figures most convincing. There are three reasons why I favour this Amendment—no doubt to the annoyance of my noble friend on the Front Bench; but I cannot help that. One of the greatest problems of this country, as your Lordships know, on which I have already spoken several times, is over-population. We really must do something to prevent what I can only call irresponsible spawning. The tragedy is that many parents have large families who cannot afford them, and we then get children who are unwanted: and I am sure that the fact that we have unwanted children has a bearing on juvenile crime. Then there is the human reason, that anything that can be done to prevent abortion can only be good.
I am certainly not one to recommend that the Government should spend the taxpayers' money needlessly—in fact, I always speak against that—but if we take the human angle, and the national angle from the view of over-population, any money that the Government do pay will be money well spent. I believe that a sum of £30 million was mentioned, but if what the noble and learned Lord has said is taken into consideration, I do not imagine that the additional cost will be so great. I think it will be money well spent.
§ 4.54 p.m.
§ BARONESS GAITSKELL
This is for most of us the crucial Amendment. If it is passed, it will mean that everything we have said and done over the last fifty years will have had a really good effect. If the Government do not accept the Amendment, they will be taking a huge step backwards. Once again they have taken the path of means testing by introducing qualifications. Here, I absolutely agree with my noble friend Lady Summerskill.
§ BARONESS GAITSKELL
I agree with my noble friend Lady Summerskill on a great many subjects but not on the pill. I agree with her that this will be a real deterrent to the take-up, and will further 993 inhibit the take-up in an area which even in this day and age is beset with many psychological and moral inhibitions, so that—and this is the most important thing —contraception is made more difficult and less available to the people who need it most. The benefits of supplying free contraceptives have been proved, as has been said already, among the 16 or so local authorities who were courageous enough to introduce this service after starting with only free advice. If I may quickly give the increased figures, they are: Hammersmith, 100 per cent., Islington, 70 per cent., Lambeth, 68 per cent., Birmingham, 55 per cent. The trend of giving free supplies was catching, and other local authorities were beginning to follow. It is here, however, in this Bill, the National Health Service Reorganisation Bill, that the family planning services will be hit hardest and stand to lose most. As has been said already, no one can tell how the Area Health Authorities will act or how quickly they will take over the clinics now run by local authorities, the Family Planning Association Clinics and the Brook Advisory Clinics. The Family Planning Association estimate that even in six years' time they will still be managing nearly 200 clinics. As for the local authorities, it seems that all powers about family planning and contraception will be taken away from them. Personally, I think this is lamentable. The work of the local authorities, in conjunction with the Family Planning Association and the Brook Advisory Clinics as agents, has been growing steadily. All that was needed, it seems to me was more money.
Speaking of the cost of the prospective family planning services—and here I completely agree with my noble and learned friend Lord Gardiner—the Secretary of State mentioned the figure of £4 million a year. When one considers that to-day the current figure of annual expenditure of the Family Planning Association, a voluntary organisation, is £3 million, the Government's figure of £4 million a year does not look so generous or extravagant.
Let us take a measure of the present-day need for a free comprehensive family planning service in the 'seventies and 'eighties. There are 150.000 unwanted pregnancies each year in Britain, which, together with the number of abortions, gives a quarter of a million unwanted 994 pregnancies. Many recent surveys reveal ignorance and carelessness in the use of contraceptives and point to the fact that pregnancy should be avoided rather than terminated. I would commend to your Lordships an article by Professor Laffitte, a Professor of social policy and administration at Birmingham University, in this week's periodical, New Society. This gives, as I have already mentioned, some staggering world figures about abortion and contraception from which we can draw a moral on the need for a freely available contraceptive service, not only in Britain but in all countries of the world. Here again, I would add two more examples. France has 250,000 abortions a year, compared with Britain's 100,000. In my opinion, both figures are too high. In Latin American countries there is one abortion for two to five pregnancies.
To get back to Britain, a survey carried out by Ann Cartwright, an authority on this subject, revealed in a cross-section among married women that one-third of pregnancies were unintended and unwelcome. It is estimated that in 1967 100,000 legitimate children resulted from unwanted pregnancies. To these we can add 50,000 of the 75,000 illegitimate births. Spending on family planning is very uneven in this country. In some local authorities it is rather high and in others it is non-existent, but the average annual expenditure is 50½p per person.
Finally, we have increasing evidence that there are a great many children born to-day who are unwanted at conception —this is what I wish to stress: unwanted at conception; we are not saying that these children remain unwanted or unloved. To have every child a wanted child can be achieved only by a free comprehensive family planning service under the National Health Service. This would not only drastically reduce the number of abortions but could help to make us into a sexually educated and sexually responsible society.
§ LORD PLATT
I feel that little or nothing remains for me to say. The noble and learned Lord, Lord Gardiner, has made out an unanswerable case, and I myself feel great gratitude to the noble Lady, Lady Ruthven of Freeland, and to the noble Viscount, Lord Massereene and Ferrard, for lifting the subject right out of the political field. I hope very 995 much that the Government will accept this Amendment or, at the very least, will agree to take away this clause as printed and bring back something much better than is at present written into this Bill. I feel that somebody might speak on this from the Cross-Benches, and I have ventured to do so as I was formerly the President of the Family Planning Association and at present am the Chairman of the Medical Research Council committee that is guiding research into the contraceptive pill. However, this is not the question that we are debating to-day, so I should just like to give the Amendment my support and say that I hope that from all parts of your Lordships' House there will be an overwhelming majority in favour of this Amendment.
THE LORD BISHOP OF BRISTOL
I should like to raise a query which is in my mind, because my initial reaction was one of profound sympathy with this whole group of Amendments, despite some difficulty over the wording of the Amendment which has now been withdrawn. With regard to this Amendment, I believe that the crucial question is how far the counselling context can still be preserved in the circumstances of a free contraceptive service: because this aspect has been mentioned by many speakers, and it is counselling that is an important part of the total picture. So far as the Board of Social Responsibility of the Church of England is concerned, when a deputation waited on the Secretary of State in May they expressed the opinion that contraceptive advice and materials should be readily available to inquirers, irrespective of their marital status, provided that both were given in the context of a full recognition of the nature of sound human relationships. A counselling service was regarded as the necessary context. This should include medical advice but should not be confined to it.
I very much sympathise with this attitude, because the Amendment is aimed at diminishing human misery, and not least that particular kind of misery which the abortion rate indicates. But I believe it would not have the effect of diminishing human misery unless it were to be firmly within the context of building up, as part of the operation, deeper, more mature and responsible human relationships. Therefore on the evidence avail- 996 able to me at the moment, I feel that I should need to abstain at this stage unless it was quite clear that the free service which has already been operating in experimental areas has resulted in no diminishment whatever of the full counselling and the deepening of personal relationships that are involved.
§ BARONESS GAITSKELL
Perhaps before the right reverend Prelate sits down I might make just one comment on this matter. The Brook Advisory Centres have this very much in mind, and, as I have said, they see 10,000 new patients every year. They do this the whole time: they are counselling and are giving both psychological and physical advice; but they do not give physical advice without including all the other aspects of family planning or sexual education.
§ 5.7 p.m.
§ LORD VERNON
I should like very strongly to support this Amendment and to welcome those aspects of the new family planning policy dealing with the extension of the domiciliary services, the free advice and the additional publicity, which are certainly a great advance. But, as against that, we have the withdrawal of the free service from those boroughs which are at present practising it; and that seems to me a very retrograde step. The noble Baroness, Lady Llewelyn-Davies, mentioned Aberdeen. We know that there are also many other places where the introduction of the free service has reduced unwanted pregnancies by something like 50 per cent.
The other aspect that I regard as very unsatisfactory is the condition for establishing social need before free contraceptives are made available. A partially free scheme depends so much on the skill of health visitors in spotting those qualifying for free contraception that many will fall through the net; and many, of course, do not even qualify for the net. I should like to quote two cases to your Lordships from my personal knowledge. One concerns a young university student —a girl who was having regular sexual relations with a man. At the end of the term she found herself short of money and for a whole month went without contraception, so that she was at risk. I do not think she would have fallen within the Secretary of State's category of 997 "social or medical need ". She would merely have got free contraception after she had had an abortion, or had given birth to an illegitimate child. It really is a case, as I think was said recently in another place, of closing the stable door after the horse has bolted. The other case concerned a woman who was married to a professional man and found herself in rather difficult circumstances. There was no lack of money in the household, but her husband kept her very short of housekeeping money and she did not have enough to provide contraceptives. What happened? Her third pregnancy ended in an abortion, and that put an additional strain upon a marriage which was already under severe strain.
It does not make sense not to provide free contraception for such people as I have mentioned—people who do not come within the specified categories at present. We all know that there are thousands of cases like that up and down the country: cases where it is a question of choosing between enough money being available for the Sunday joint or the contraceptives; and so often it is the contraceptives which go by the board. The Secretary of State has said that he wishes, as I am sure he does, to reduce the number of unwanted pregnancies. If he wishes to reduce them, why on earth not go the whole hog and provide a free service at a cost of another £12 million or £15 million? The noble and learned Lord, Lord Gardiner, has pointed out so forcibly that there is not in fact going to be an additional cost on the taxpayer, because of the saving in maternity grants and all the other services. The introduction of this Bill would have been an ideal opportunity for the Government to introduce this free service which, as we know from the public opinion polls, is greatly desired by the majority of people.
Before I sit down I should like just to touch on the question of population which has been mentioned also by my noble friend Lord Massereene and Ferrard and by the noble and learned Lord, Lord Gardiner. So far the Government have maintained that no population problem exists in this country. I wish they were right, but unfortunately nearly all the evidence is against them. We had the Report of the Select Committee in 1971. It was a full Report prepared after very careful study, and it was a unanimous Report. The Committee's conclusion was 998 that the Government must act to prevent the consequences of population growth becoming intolerable for the everyday conditions of life. They reiterated that opinion again this year. In 1972 Mr. Peter Walker set up four separate Working Parties prior to the Stockholm Conference, and one of them, under Mr. Verney, that on Natural Resources, reached certain conclusions and I should like to read out recommendations 1 and 2:The United Kingdom Government must itself develop a population policy designed to bring about population stability through education and persuasion.It should as a first step provide substantial funds to publicise the facts and dangers of population growth and provide a free comprehensive service in family planning.Of course, in addition to these Reports there have been studies by many other private bodies., and particularly those confined to doctors and scientists, who have reached the same conclusions. Indeed, one hardly needs these Reports. We have only to look with our own eyes to see that this island of ours is grossly overcrowded. One has only to see the pressure on houses, the rise in land values and so on. We all know it.
The Government will no doubt say that they are awaiting the Report of Mr. Ross and his Population Panel. I hope that the noble Baroness or the noble Lord, Lord Aberdare, when replying, will be able to tell us when this Report can be expected and when it will be published. We were told earlier that it would be available by Christmas, and Christmas is getting very close. I do not know what is in this Report, but I feel it cannot have escaped the notice of Mr. Ross and his colleagues that the number of unwanted children approximates very closely to the annual increase in our population of 250,000. It seems to me astonishing that the Government should have chosen this particular moment to introduce a partially free scheme, with the defects that I have mentioned, before the Committee have reported. I regard this as a vital Amendment. I regard it as vital from the point of view of helping to alleviate human suffering by reducing the number of unwanted pregnancies: and I regard it as vital from the point of view of helping to stabilise, or helping to reduce, our annual population increase. I hope it will commend itself to the 999 Government, and, if it does not, I hope it will commend itself to this Committee.
§ BARONESS STOCKS
It may seem irrelevant, but I should like for a moment to see this debate in its historic setting. In 1926 this House debated a Motion by Lord Buckmaster, supported by Lord Wrenbury, asking the Government to allow (it had not been done before)—not require but allow—maternity and child welfare centres to give contraceptive advice for health reasons to married women. That Resolution was opposed by Lord Cave on behalf of the Government. It was carried. The House of Commons did not dare at that time touch the question. Outside Parliament it was not discussed in polite society. This House was in the van of public opinion, and I pray that it may remain so.
§ 5.16 p.m.
§ BARONESS ELLIOT OF HARWOOD
May I say one word? I was unable to be present at the Second Reading of the Bill, otherwise I should have supported my noble friend Lady Ruthven of Freeland in her view on this subject. I will not delay your Lordships for more than a moment, but from my experience of local government work, particularly social work, health work and so on, I know that the really expensive factor is just what the noble and learned Lord, Lord Gardiner, said it was: the breakdown in families. The authorities for years and years have to look after unwanted children and illegitimate children. They have to do as local authorities what the family should do if the family were united. This is where the real expense lies, if we are looking at the matter simply in terms of money. But I agree entirely with what has been said by the noble Baroness, Lady Llewelyn-Davies of Hastoe, and others: it is not a question of expense; that is only secondary; it is a question of what is the right thing to do in a very difficult matter.
I know Aberdeen well. I know Sir Dugald Baird who is the prime mover in all the reform which is taking place in Aberdeen and in family planning, and the way the scheme has worked out. That city has always been very forward-looking, and it has been due to his foresight and knowledge that this has happened. 1000 I hope that we shall persuade the Government to accept this Amendment. I speak not at all against people paying for things; I am not at all against means tests when means tests are wanted, but on this occasion I am quite sure we shall not get the people whom we really want to get to understand family planning and to consult. We may get the intelligent ones and the educated ones; they will not mind paying and they will go freely to a doctor and obtain advice. But the people I want to get at, the people who are the really difficult cases, are those who will certainly not go unless provision is free and unless they are encouraged very much by the social work departments of the country. I do not like speaking against the views of my own Government, but on this occasion I feel strongly that this Amendment is most important, and I beg them to accept it.
§ LORD HYLTON
I would say a brief word in support of the point of view put forward by the right reverend Prelate the Bishop of Bristol. In doing so I would remind the Committee that the Second Vatican Council came out fairly and squarely in favour of responsible parenthood. We can all be in very general agreement on that question. It is when we get on to contraception, and so on, for minors, persons under the age of 18, and for the unmarried generally, that we are on rather more difficult ground. That is surely where the right reverend Prelate's remarks concerning counselling and human relations were so extremely relevant. I feel that the human relations side can be even more important than the question of preventing the unwanted births.
If I may turn to the population question which several speakers have already raised, I should like to ask my noble friend Baroness Young whether, when she replies, she will confirm, or deny, that recently, both in this country and in several other countries of Western Europe, the birthrate has fallen below the replacement rate; that is to say, the rate of new births necessary to replace deaths. If this is so it will have very considerable consequences. I think it will allay the fears and apprehensions that have been raised on the question of population. I know that it is a difficult question to answer without notice, and if my noble friend is unable to reply to-day I 1001 am sure we shall understand, and it may be that she, or some other Government spokesman, will be able to make a statement on this point at a later stage of the Bill.
§ BARONESS MACLEOD OF BORVE
I should like briefly to support the Amendment. I feel very strongly about it; indeed, I think this is the turning point of the whole Bill, and future generations will commend us if we pass this Amendment. My one reason—and I feel this very deeply—is that if we have free family planning services throughout this country there will be fewer abortions. I cannot tell the Committee how deeply I feel that abortions are wrong—completely abhorrent—unless there are strong medical reasons for them. I believe that we should do everything possible to stop the escalation of abortions.
§ LORD REDCLIFFE-MAUD
I should like to raise just two brief points. First, I may have misunderstood the right reverend Prelate but I do not think he need be troubled by the point which he put to us, because the only issue at stake as between the Amendment and the clause as printed in the Bill is whether or not payment should be made. The question of the circumstances in which the advice is given, and whether, as it were, a person can go in and take the thing off the counter and go out with it (which I thought for a moment the right reverend Prelate was afraid of) is not what we have been discussing if it were, it would indeed be a serious change. But that is not at issue at all. It is simply a question of whether it is necessary for people to go through this elaborate and delicate business of deciding who may and who may not pay for the appliances in question.
The second point is a rather more general one. As a believer in local government I have to accept that the Government are perfectly right to go the way they are going in this reorganisation Bill, but in my heart I hope that in ten years' time, or eventually, we shall find that local government has grown up enough to be able to bring the National Health Service within the whole democratic pattern of our local democracy. Meanwhile, it seems to me that this is a real test of whether by making, and continuing to make, the National Health Service a 1002 national service, administered ultimately with the responsibility on the Secretary of State and, because it is so right to "comprehensivise" it, having to take certain services away from the local authorities, we have to go back on the great virtue of what local government has given us—that is, progress in certain places where there has been pioneering. Normally in this country we have relied on voluntary organisations, as indeed we have done in this area.
Here I think the result of accepting this Amendment, or something like it, would be a great consolation to those of us who feel that, despite our national inclination, we must accept that local government should give up certain of its traditional functions in order that there may be a better and more comprehensive National Health Service. If we have to stick to the Bill as drafted I think this will be a strong piece of evidence that there was something wrong in taking away from local government something which was within the area of pioneering.
THE LORD BISHOP OF BRISTOL
Perhaps I may just say to the noble Lord, Lord Redcliffe-Maud, that my question was simply whether there was any evidence that the boroughs in which free service operates are liable to have so increased a demand that there is a consequent loss of the opportunities for counselling.
§ 5.27 p.m.
§ BARONESS YOUNG
We have had a long and, I think, extremely valuable debate on this very important subject, and we who speak for the Government appreciate the great interest and concern of all those who have taken part in it. I should like to make it clear that the reason why the Government made their Statement on family planning services last week was the very real concern we felt over the whole question of the numbers of abortions and the amount of human misery that has been caused, and the wish to see whether we can do something to ameliorate a great deal of this suffering, quite apart from all the reasons which have long been understood about responsible parenthood for married couples.
At the start of my reply it might be helpful if I were to underline the points that the Government were making in 1003 that Statement. I should make it clear that it was not a statement of population policy. A number of noble Lords mentioned this, including the noble and learned Lord, Lord Gardiner, and the noble Viscount, Lord Masserene and Ferrard. At the moment we cannot consider a population policy because the population panel has not yet reported. It is not possible to make any forecasts about future developments of family planning which may be thought to be appropriate in the light of the panel's recommendations until we know what they are.
In the view of the Government the first priority in family planning is to provide a comprehensive service of advice for all who need it. At the moment, as many noble Lords have said, there are wide disparities between different areas of the country in the provision of clinics. The Government believe that in 1974, when the new National Health Service authorities assume the responsibilities at present carried out by local authorities, one of the first tasks will be to start to remedy the disparities and to tackle the problems in the least well provided areas. Secondly, the Government want to provide a choice of advice on contraception. The findings of a survey conducted by the Office of Population Censuses and Surveys indicated that a large proportion of women would like to attend their own doctor in order to receive advice. For this reason we shall shortly be entering into discussions with the medical and pharmaceutical professions to see whether satisfactory arrangements can be agreed with them under which the family doctor can take on a wider role in the provision of contraception. The noble Baroness, Lady Llewelyn-Davies, asked a question about general practitioners. We are discussing their training with the profession, and we shall be laying on a special programme of training courses in family planning for health visitors.
The third component in a comprehensive service is the hospital, and here we propose to place further emphasis on the offering of advice and treatment, with particular attention to maternity and abortion patients. But not only must service be available; people must know about the services and the public must be educated in this matter so that 1004 regretted pregnancies are less likely to occur as the result of ignorance about contraception or about the facilities available. Although we should not wish to do anything to press individuals to use the services if they have an objection of a religious or other nature to family planning. I might add that we shall see an expansion of the domiciliary service, and I think this is an important point in regard to the matter which has been raised by a number of noble Lords on the question of the take-up of the service.
We recognise that there is a very real problem about just those people to whom the noble Baroness, Lady Elliot of Harwood, referred who are perhaps the least willing to come forward to clinics—those who are the most shy or who feel diffident lest they may find themselves in difficult surroundings and who are rather unhappy about coming forward. The domiciliary services will take the service to them, and I feel that an extension of these services through the social workers identifying cases and through the health visitors will go a very long way towards meeting this problem. We accept that it is a problem, but we hope that an increase in education and public information and the fact of the existence of the clinics will help at least to overcome some of it.
§ BARONESS LLEWELYN-DAVIES OF HASTOE
I cannot feel that an extension of the domiciliary services, which we welcome, can really help in those cases to which the noble Baroness, Lady Elliot of Harwood, referred—in the slums of Aberdeen or Glasgow. Those who live in these kind of areas are not suitable for the type of counselling which the right reverend Prelate wants and which we insist upon. The domiciliary services will not go far enough to solve the problem of these particular groups whom we want to reach.
§ BARONESS YOUNG
I was about to say that one particular group of people to whom we shall be giving free supplies are those in social need. I come to this point now because I want to explain the three categories of people who will receive free supplies. The first are those in financial need; they will automatically qualify for free supplies. As we wish to 1005 keep the arrangements as simple as possible and avoid having a new means test, we propose that supplies should automatically be free to those entitled to one or more of the existing benefits, such as the family income supplement or supplementary benefit.
§ LORD GARNSWORTHY
It is well known that a great many people are not taking up these benefits. Often they will be the very class of person who is desperately in need of the kind of advice about which we are talking. What will be done to meet that problem?
§ BARONESS YOUNG
We recognise that this is a difficult problem, but we feel that a combination of all kinds of activities—the domiciliary services, the existence of clinics, the fact that when people see clinics in operation the word will get round about the possibility of having these supplies and receiving this advice—will mean that not only will all these people have supplies free, but that all the social service agencies will be trying to identify these people. We hope, too, that they will even find people who are not taking up the family income supplement and other benefits, so that the two matters will go together.
§ LORD GARDINER
May I ask the noble Baroness to explain how this will work? Will there be training for these activities? Presumably social workers without any experience of applying a means test will be faced, for example, with a woman who already has four children and who says, "All I can do with the money my husband gives me is bring up my children. I cannot afford to spend anything on myself." Will one visitor say, "You can have supplies free", while another may say, "Your husband must pay for the supplies "? What instructions will be given as to whether the answer should be "yes" or "no" in all the many varied circumstances, both financial and social, that are bound to arise?
§ BARONESS YOUNG
It would of course be impossible to lay down detailed instructions as to how this should work. My point was that there will be two groups of people—those who at present get benefits and who will automatically be entitled to free supplies, and those who are perhaps not in fact entitled to social 1006 benefits but who will also have them free because of social need. I should have thought that the second case quoted by the noble Lord, Lord Vernon, was an exact example of the kind of thing we mean when we refer to those who would receive contraceptive supplies on grounds of social need—the case of an irresponsible husband who did not give his wife enough money so that she failed to get supplies. This would be exactly the kind of case we have in mind.
§ BARONESS SUMMERSKILL
One cannot find out what a person's income is without asking how much he or she gets. My point is that once a means test is established, which it must be, the customers will be frightened away.
§ BARONESS YOUNG
I can only tell the noble Baroness that in my experience—although I did not serve on a social service committee I was for many years the chairman of a children's committee—social workers knew that for certain families it would have been advisable to provide domiciliary contraceptive services and they would have been perfectly well aware of the circumstances and conditions of the family; and under the provisions of this Bill those sort of families would get supplies free. It will of course be a decision for the social worker or health visitor and there will be no question of a means test. Patients with a medical need will pay only the standard 20p prescription charge, unless of course they are exempted under the normal arrangements for relief from this charge.
There is a new category of persons who will be helped by free supplies. For the first 12 months after the birth of a baby or having an abortion a woman will be entitled to completely free supplies. The Government believe that this is justified because some spacing of children is desirable on health grounds and patients who have had an abortion clearly need help in avoiding a further unwanted pregnancy. 1007 In offering free supplies to women who have just had a baby or an abortion the Government's objective is to make sure that there is no obstacle to the effective take-up of contraception against people with a priority need for it.
These services will cost a great deal more than the National Health Service is at present spending on the family planning services. The rate of growth in expenditure will depend on the rate at which people come forward to use the services, but we expect the cost to be £12 million in Great Britain; and if three-quarters of the women who are at risk of an unwanted pregnancy use the health services, then on the basis of these arrangements we expect the cost ultimately to reach £17 million a year for the country as a whole. This is of course a three-fold increase on the expenditure at present given for the family planning services.
The noble and learned Lord, Lord Gardiner, raised an important point about cost benefits and he gave a number of figures to show the cost of the services provided as against the cost of unwanted children. There are two points to remember here. The first is that if we increased the amount of money for the service at this very moment it would have to come from some other part of the National Health Service and we should have to make a decision about what we would give up in order to increase this money. Second, it really is very difficult to forecast with any precision the number of pregnancies that would not occur if there were a completely free service. All sorts of projections are made but it is very difficult to forecast this accurately and therefore very difficult to forecast the kind of savings we should get in the social service and in the education Departments.
I come to the question of local authorities which are at present making no charge at all. In fact, less than 20 local authorities have introduced free supplies for everyone and these have experienced a considerable increase in the number of patients attending their clinic. But it has been shown that a substantial increase in the numbers of patients attending clinics has also occurred in one area simply as a result of intensive publicity. In fact, it is not possible to disentangle the effects 1008 of free supplies, of publicity and of simply providing extra clinic facilities, all of which play some part in the take-up of the contraceptive services.
I should like to make one other point, because I think that the reason why some unmarried girls at risk do not use contraceptives raises a very complex and subtle question. We have to note the possibility that offering contraceptive facilities for single people in the wrong way could itself lead to some increase in pre-marital sexual intercourse; and we do not know the best way of attempting to solve the problem of unwanted pregnancies among the young. It is partly an educational matter and partly a question of providing contraceptive advice within the framework of personal counselling to people who need it and of doing so in a way that will make it more likely that adolescents will use the service. We do not feel confident that we have discovered how to do this, but we are aware of the valuable work that the Brook Advisory Centres are doing in this field. In the light of that and also what other bodies are doing we shall consider how to provide contraceptive services for those young people who are going to have sexual intercourse anyway.
§ LORD BROWN
I have not taken part in this very important debate, but I have listened to some very serious, logical arguments from all parts of the House in support of the Amendment. We all know and understand that the noble Baroness is in a difficult position this afternoon, but I should like to draw attention to the fact that she has not so far sought to disprove one iota the apparently logical arguments raised from Benches all round the House. May I say with great respect that her entire speech did not seem to contradict any of the arguments raised so cogently in support of the Amendment.
§ BARONESS YOUNG
I am sorry if the noble Lord opposite feels that I have not satisfied him at all. I have been doing my best to set out Government policy on this point and I was trying to explain that to think that by making free supplies available everywhere throughout the country one can be absolutely certain that one will resolve all these complex human problems, is to think that it is in many instances a much simpler 1009 problem than it really is. That was the point that I was trying to make.
Before concluding my remarks, I should like to say a word about payment for contraceptive treatment. When the Department of Health and Social Security sent out a circular to local authorities bringing into effect the legislation on vasectomy which was passed at the last Session, local authorities were told that no charges should be made for the operation since no charge was made when it was provided under the Hospital Service. We have no proposals for introducing charges in the contraceptive field for anything other than supplies on the basis that I have described. We feel that no one will dispute that there is a considerable proportion of people in this country who are able and willing to pay for their supplies and that it underpins the philosophy that what we are looking for is responsible parenthood whenever this is possible, and that this should be our aim in this matter.
I hope that I have answered most of the many questions that I was asked, but there was the point that the right reverend Prelate the Bishop of Bristol raised which was very well answered by the noble Lord, Lord Redcliffe-Maud. There is no suggestion in any of this that the counselling services will not continue. Indeed, we have a very effective programme of sex education in a great many schools, and in the clinics we would expect the counselling services to continue as they are at present. I hope that I have said enough to indicate that the Government have taken a very big step forward in developing services of advice accompanied by an intensification of health education, publicity and the provision of free supplies for particular groups. Already in two years we have enabled local authorities to treble their expenditure on clinics and domiciliary services. We are now embarking on a further trebling of the total National Health expenditure on contraception over the next four years. What we have announced represents a very considerable advance and sets out the priorities which we believe are right in the present circumstances. For these reasons, I hope very much that the Committee will support the Government in the retention of this clause.
§ 5.45 p.m.
§ BARONESS LLEWELYN-DAVIES OF HASTOE
I believe that the whole House holds the noble Baroness in the greatest affection. We all remember her most gallant debut in that simply horrible Housing Finance Bill which I, for one, do not understand, even now, and which she handled so marvellously. But, unlike my noble friend Lord Brown, I believe that she has made the very best of an absolutely hopeless case. There can be no question that from every part of the House, from every person who can be called an expert either in the medical or in the social fields, the support for our Amendment is overwhelming. Even on the basic point of whether councils who give free services will still be able to do so in 1974, we have not received a real answer. I do not want to go through the arguments; the Committee has heard them. I believe that the Committee feels very deeply on this, and I should like to say, with the noble Baroness, Lady Stocks, "Let this House, your Lordships' House, rise to this historic occasion." I should like the Government to make up their minds in the right direction. If the Government cannot, let this Committee rise and support us in the Division Lobby.
§ LORD ABERDARE
Before the noble Baroness decides what she wishes to do on this Amendment, I feel that I ought to make one point which is worrying me slightly, and that is that we are engaged in discussing a National Health Service Reorganisation Bill and I rather wonder whether we are wise in putting forward an Amendment which goes well beyond the reorganisation of the Health Service and actually lays considerable extra burdens and extra commitments on the Government. I want to make this point before we come to a Division, if the noble Baroness wishes to divide the House.
Clause 3, for example, transfers school health functions from local authorities to the Health Service. Clause 4 transfers the family planning functions of local health authorities to the now Health Service; but neither clause seeks to alter the present arrangements so far as they exist. They do not seek to increase the commitment in either case. It is left to the new Service to decide how the 1011 policy works out. I feel that I ought to make this point to the noble Baroness and to the Committee: that, in a sense, what we are asked to consider goes slightly beyond the National Health Service Reorganisation Bill. I say it with some diffidence, but this House is for the first time dealing with a major Bill, and I feel that we ought to take these matters into careful consideration.
§ BARONESS LLEWELYN-DAVIES OF HASTOE
I have listened to the noble Lord: we always do; but if one is reorganising the Health Service one should reorganise it. That is what we are here to do this afternoon; and what this Amendment seeks to do is something we have wanted for a long time, and something which we can do within the framework of the reorganisation of the Health Service. I should like to press this. I do not withdraw the Amendment but shall press it to a Division.
§ LORD LEATHERLAND
May I ask the noble Lord, Lord Aberdare, to look at the Long Title of the Bill which is, "An Act to make 'further' provision"—and I stress the word "further". It is not an Act to continue the existing provision of the National Health Service but to make "further" provision, and that is what this Amendment seeks to do.
§ LORD BEAUMONT OF WHITLEY
There is also an even shorter answer to the noble Lord, Lord Aberdare. This Bill will in fact have the effect of reducing the amount of free contraceptive advice that is possible. If it is possible in this Bill to reduce it, then it is possible to increase it.
§ 5.50 p.m.
§ On Question, Whether the said Amendment (No. 37) shall be agreed to?
§ Their Lordships divided: Contents, 76; Not-Contents, 51.1013
|Amulree, L.||Gaitskell, B.||Raglan, L.|
|Archibald, L.||Gardiner, L.||Redcliffe-Maud, L.|
|Ardwick, L.||Garnsworthy, L. [Teller.]||Roberthall, L,|
|Arwyn, L.||Greenway, L.||Ruthven of Freeland, Ly.|
|Balogh, L.||Greenwood of Rossendale, L.||St. Davids, V.|
|Beaumont of Whitley, L.||Gridley, L.||Sandys, L.|
|Beswick, L.||Hayter, L.||Segal, L.|
|Blyton, L.||Henderson, L.||Sempill, Ly.|
|Boothby, L.||Hoy, L.||Serota, B.|
|Bourne, L.||Hurcomb, L.||Shepherd, L.|
|Brock, L.||Hylton, L.||Slater, L.|
|Brockway, L.||Jacques, L.||Snow, L.|
|Brooke of Ystradfellte, B.||Janner, L.||Southwark, Bp.|
|Brown, L.||Leatherland, L.||Stocks, B.|
|Champion, L.||Lee of Asheridge, B.||Stow Hill, L.|
|Clwyd, L.||Llewelyn-Davies of Hastoe, B. [Teller.]||Strang, L.|
|Cowley, E.||Summerskill, B.|
|Davies of Leek, L.||McLeavy, L.||Taylor of Mansfield, L|
|de Clifford, L.||Macleod of Borve, B.||Vernon, L.|
|Donaldson of Kingsbridge, L.||Maelor, L.||Vivian, L.|
|Douglas of Barloch, L.||Meston, I..||Watkins, L.|
|Douglass of Cleveland, L.||Northchurch, B.||Wells-Pestell, L.|
|Elliot of Harwood, B.||Nunburnholme, L.||White, B.|
|Emmet of Amberley, B.||Phillips, B.||Willis, L.|
|Evans of Hungershall, L.||Platt, L.||Wright of Ashton under Lyne, L.|
|Falkland, V.||Popplewell, L.|
|Aberdare, L.||Denham, L. [Teller.]||Hawke, L.|
|Abinger, L.||Derwent, L.||Hylton-Foster, B.|
|Alport, L.||Drumalbyn, L.||Inglewood, L.|
|Amory, V.||Dundee, E.||Jellicoe, E. (L. Privy Seal.)|
|Auckland, L.||Eccles, V.||Limerick, E.|
|Barrington, V.||Elles, B.||Lloyd, L.|
|Belstead, L.||Ferrers, E.||Long, V.|
|Bledisloe, V.||Glasgow, E.||Lothian, M.|
|Brooke of Cumnor, L.||Gowrie, E.||Loudoun, C.|
|Conesford, L.||Grimston of Westbury, L.||Lyell, L.|
|Courtown, E.||Hailsham of Saint Marylebone, L. (L. Chancellor.)||Mancroft, L.|
|Craigavon, V.||Mar, E.|
|Daventry. V.||Hanworth, V.||Merrivale, L.|
|Monck, V.||St. Aldwyn, E.||Strange of Knokin, B.|
|Monckton of Brenchley, V.||St. Just, L.||Trefgarne, L.|
|Mowbray and Stourton, L. [Teller.]||Sandford, L.||Tweedsmuir of Belhelvie, B.|
|Shannon, E.||Young, B.|
|Nugent of Guildford, L.||Somers, L.|
On Question, Clause 4 agreed to.
§ Resolved in the affirmative, and Amendment agreed to accordingly.
§ 5.58 p.m.
§ On Question, Whether Clause 4, as amended, shall stand part of the Bill?
§ BARONESS ELLES
I beg to move that this clause be deleted, on the grounds that the reasons for introducing a family planning service have not been considered sufficiently, neither have the financial implications, the manner in which it is to be run, or the consequences to the health of the nation. We had a gradual introduction of measures designed to liberate the individual from State oppression and prohibitive legislation in the field of private morality—homosexuality, abortion, family planning, easier divorce —based, as I understood it, on the premise that the individual should be free to choose his own private standards of morality. The basic premise of freedom of choice is then transferred, by a process of strong pressure by a strident minority, to induce the State to impose comprehensive schemes so that the practices are extended as widely as possible, and at the expense of the taxpayer. This happened with abortion; it is now happening with family planning. I firmly believe that the vast majority of the people in this country, the public, are being "conned" into accepting something that they do not want.
This can be an emotive issue, and it is also a moral one, and your Lordships will be relieved to hear that I am not going to discuss any moral aspects as to the question of family planning. But since my name is on the Marshalled List and I do not share the same fame as those who have their names on this pamphlet, A Birth Control Plan for Britain, whose views are well-known, and since many of your Lordships have asked me whether I am a Roman Catholic—or have accused me of being one—I feel I should say that I am not a Roman Catholic; I am an ordinary member of the Church of England. I thought I should make my position clear from the beginning. But I accept that my religious views and beliefs may colour my conclusions, in precisely the same way as the beliefs of 1014 those who do not share my views colour their conclusions.
We must be clear about the distinction between a general family planning service, which gives medical advice to married couples about marital matters, the size of families and so on, which is invaluable and indeed can save many marriages, and advice on the use of birth control methods to other individuals, regardless of status and of age. What has been happening is that the arguments used over the last few years by pressure groups in the guise of family planning, are precisely the same as those used by birth control campaigners to extend a birth control service to all and sundry; a kind of "free-for-all" to encourage sexual relations by making them, or claiming to make them, trouble-free and, incidentally, making for the producers of contraceptives an enormous amount of money.
One of the most cogent reasons that has been put forward for extending a family planning service is the threat of a population explosion. All that needs exploding is the myth that this population explosion exists. There is, indeed, a grave crisis building up. but not the one with which we have been brainwashed in the last couple of years. We read on page 9 of A Birth Control Plan for Britain, which was published this year, about the need for a population policy, and the second paragraph states:The present high density and the projection that the population of the United Kingdom will increase from about 56,000,000 in 1971 to about 66,000,000 by the end of the century (though estimates are being continually revised) weighed heavily with the House of Commons Select Committee of Science and Technology in its report Population of the United Kingdom' (May 1971). The Select Committee concluded ' The Government must act to prevent the consequences of population growth becoming intolerable for the everyday conditions of life', and recommended the establishment of a special office, directly responsible to the Prime Minister, to tackle the problem.It went on:The immediate course of action open to any democratic government concerned about the rate of population growth is to increase the facilities for voluntary birth control, together with education and widespread publicity about their use and the need for small families.1015 After that programme came out, we had the opportunity of seeing the Fifth Report from the Select Committee on Science and Technology, entitled Population Policy, and if your Lordships compare the aims of A Birth Control Plan for Britain—which are, first, to persuade the Government to recognise and study the problem of Britain's population growth; and, secondly, to promote the provision within the National Health Service of a comprehensive birth control service with adequate facilities for contraception, sterilisation and abortion—you find, perhaps due to the fact that one of the members of the Birth Control Campaign also served on this Select Committee, almost identical wording. You find on page vii, in paragraph 17:We therefore repeat the recommendation made in our First Report in May, 1971, that as an integral and permanent part of the machinery of government a special office should be set up to advise the Government on population policy.But without waiting for the results of this population policy, they went on in the next paragraph to state:We recommend that the Government should take immediate steps to provide comprehensive family planning and birth control services as a normal part of the National Health Service.These may be parallel recommendations, but they are in no way connected one with the other, since the Government have not yet received the Report from the Committee on population policy. Indeed, the evidence which is contained in the Appendix to the same Report reads:The present projections give a population by the end of the century of 63 million, as compared with 66 million in the mid-1969 and mid-1970 based projections",and the following table summarised the broad trends. If your Lordships will look at the birth-rate figures since 1964—that is, before the Abortion Act—you will find that the birth rate has been steadily declining. In 1964 the figure was something over one million a year, and by 1972 the estimated birth rate is 870,000; that is, a drop of over 140,000 a year. Yet the next population projection here uses as an average annual number of births the figure of 930,000, because they take the average from 1966 to 1971. If you have a curve going right down—as it is now in 1972—and yet go back to 1016 1966 for a figure on which to base your projections, the projections are really valueless. If you also deduct the death rate from the birth rate and then allow for migration, you will find on the present figures that by the 1980s we shall not only have reached zero population growth but shall have gone below it. This is really the crisis that will face us.
If the present rate continues to decrease, then by the 1980s we shall be below zero population growth—even more so if, as I suspect, the next campaign from the same people is for euthanasia, which means that the death rate will go up. There will be an enormous excess of elderly people over young people, and it is not hard to visualise that those of us who are still left in 1990 will find ourselves in geriatric wards looked after by computers; if, indeed, we are allowed to live that long. On the other hand, if we do not do something now about our birth control policy in order to increase the population, or at least to stop it reducing, we shall seriously have to consider an immigration policy so as to have a young work force. So, despite the figures available and the very obvious downward curve of the birth rate, the Committee on Science and Technology with a more official title, came to the same conclusion as the Birth Control Campaign, which is the subject we are considering this afternoon. If it is accepted on the present basis, it will have as one of its consequences, if not as one of its purposes, the effect of cutting down the birth rate even more. I emphasise "consequences" as opposed to "purposes", because my right honourable friend gave very clear evidence to that Committee that population is not one of his responsibilities and that he is setting up a family planning service for social health reasons. I want to make that clear.
But before leaving that document—and it is important, because it is the official document which makes the recommendation for the service which we are considering—there is another disturbing factor in relation to environmental planning. In this Report, emphasis is laid on the fact that everything from school places to homes is being based on the estimate that the average family size will be that rather nauseating figure 1017 2.3 or under, as opposed to the 2.4 or 2.5 quoted in 1967. But we shall suffer if this is the kind of structure which we are building for future generations. We know perfectly well that it will not be the rich who suffer, because they can always look after themselves. It is always the poor at the other end of the scale who, if they have more children than the State desires, will have difficulty in finding homes suitable for the size of their families, leading to overcrowding and slum conditions. One has only to be aware of some of the problems facing housing associations and housing authorities to know that it is the poorer families who are suffering and that it is only with great difficulty that suitable accommodation is found for these families. Poorer families will be pressurised to keep down the size of their families to fit in with economic policies. If you agree that a woman has the right to control the size of her family and keep it down to one or two children, you cannot remove her right to be free to do so and choose how many children she wishes to have. If you do not provide an adequate infrastructure for varying sizes of families, you are endangering health, both mental and physical.
Health and family planning must be closely interrelated. I will touch on only one main aspect and since the noble Baroness, Lady Summerskill, has already raised the question, I will not repeat what has already been said. Although she may not like it, I agree with her absolutely on what she has said. Unlike the noble Baroness, Lady Gaitskell, I do not always agree with the noble Baroness, Lady Summer-skill, but I am very pleased to do so on this occasion. The health hazard of this proposal, which cannot be overlooked and which statistics alone show has become an enormous problem, is the risk of contracting venereal diseases. I hope your Lordships will forgive me if I go into this matter. It is a delicate one, but it is one that must be raised if we are discussing family planning services.
One of the consequences of taking the pill, indeed, one of the consequences of "sleeping around", as we know it is generally called, is the contraction of one of these diseases. Figures published by the Department of Health and Social Security show that in 1971 over a quarter 1018 of a million cases have been seen in clinics. The figure for girls under 16 has more than doubled in the last five years; that is, since 1967. A disturbing aspect of the whole problem is that ever since the Family Planning Act 1967 and the extended availability of contraceptives, abortion, illegitimate birth and cases of venereal disease have increased dramatically. The first statistics available for abortion are for 1968 as the Act was produced only in 1967. In 1969, there were 33,000 cases, but by 1971 there were 141,000; so we see that even with the adjunct of family planning the number of abortions went up. I share a horror of abortion with everybody who has said the same thing in this House to-day, because I have seen the tragic mental and physical consequences of it to young girls.
§ LORD BEAUMONT OF WHITLEY
The noble Baroness means the number of reported and recorded abortions. We do not know how many unrecorded illegal abortions there were before.
§ BARONESS ELLES
No, we do not know how many there were before; but the fact that the Abortion Act has been on the Statute Book for the last five years would lead one to imagine that as many people who now wanted abortions could get them. I would question the figure given by the Abortion Reform Society when they said that 200,000 illegal abortions were performed every year. I very much question that figure. The reason that it has been found necessary, as I understand it, to introduce a family planning service is (and I quote):We have concluded that a substantial expansion is needed if the numbers of unwanted pregnancies are to be reduced.That was the statement my right honourable friend made in another place and which was repeated by my noble friend Lord Aberdare the other day in this House. The figures have escalated annually since the Family Planning Act, since birth control centres have been established and since free advice has been given by some local authorities.
What I should like to know more about is the matter of unwanted pregnancies; for this is the purpose, apparently, according to the Government, of setting up this family planning service. Are they all unwanted and how can you prove it? The Secretary of State, in his 1019 evidence to the Select Committee to which I have already referred, mentioned the figure of a quarter of a million, according to his Department. In the Birth Control Campaign pamphlet the figure is 300,000. I should like to look at this figure because it is very important that we understand it; for it is on this basis that this Bill is being considered. I will quote from page 8 of this Birth Control Campaign pamphlet.We still have a situation in which there are many unintended and unwanted pregnancies. A study of married mothers … showed that about one-third of all pregnancies were unintended and 60,000 or more … subsequent children born each year were the result of unwanted pregnancies. In 1969, 90,260 live births in Great Britain occurred eight months or less after marriage, a great many of them presumably from pregnancies unwanted at that stage. Most of the illegitimate births (73,774 …) are clearly the result of unwanted pregnancy.But there is absolutely no proof that the illegitimate children are unwanted.
§ BARONESS GAITSKELL
There are several serious surveys by experts, by professors of social studies, which give proof that there are a great number of unwanted pregnancies; and I recommend again that the noble Baroness should read this week's New Society.
§ BARONESS ELLES
I am not questioning the fact that there are unwanted pregnancies; I question the fact of how many of these unwanted pregnancies turn into unwanted children—which is quite another point.
§ BARONESS ELLES
I am reading from the Report. What I question is when it says that most of the illegitimate births are clearly the result of unwanted pregnancy. Since I also read my Sunday papers, I have read a great many cases where people are very proud to have children without marriage. This appears to be a schism among the Humanists; for whereas in your pamphlet you call these pregnancies unwanted when they are illegitimate, it is, in fact, known that people say that they want to live without marriage. They say that it is not necessary. It is up to them to hold that view; they, naturally, according to the laws of 1020 our country, produce illegitimate children. I do not see that this figure is necessarily accurate.
§ BARONESS LLEWELYN-DAVIES OF HASTOE
If the noble Baroness wants to abolish Clause 4, how would that help this particular situation?
§ BARONESS ELLES
I shall be grateful if the noble Baroness will allow me to finish my argument. I shall continue quoting:Legal abortions are at present being performed at a rate of over 130,000 a year, while there are also at least probably 20,000 criminal abortions. A reasonable estimate of the total unwanted pregnancies in Great Britain each year is therefore 300,000, an approximate figure which has been accepted by some authoritative writers.At the moment nobody has denied that there are 300,000 unwanted pregnancies. I would question that figure. The 130,000 abortions include those of about 27,000 to 30,000 foreign girls who come to this country, as we know (and these figures have been published), so the figure would not be 130,000; it would be about 100,000.
We have no proof at all that there are about 20,000 criminal abortions. This is a completely imaginary figure. We have no proof at all that these illegitimate births are completely unwanted. This is the point I wish to make. If you choose to say that there are unwanted pregnancies, nobody will deny it. I should like to know how many of us, perhaps, were unwanted pregnancies who turned into wanted children. I would also raise the question of how .many unwanted pregnancies turned into 'unwanted children and yet turned into great figures in our national history. I 'think this is a completely false premise on which to base a programme, a service, of this kind. I will also add that there are a considerable number of couples who want to adopt a child but who cannot find enough children to adopt. I do not have the cuttings—I do not carry newspaper cuttings with me—but there was an Evening Standard not so long ago where in one column one read, "Birth control free on the rates" and in the next column, "Babies to be imported for adoption." It struck the eye that this was an illogical process. Yet these people are desperately wanting children; and this is just as much a human problem 1021 as that of the person who has the unwanted child.
Is it therefore only because the Birth Control Plan for Britain tells us that there are so many unwanted pregnancies that we are to spend millions a year extending the family planning service? Would not that money be better spent on the children who are living or on better provision for old age pensioners? If we proceed with this service, as the clause is drafted, based on a statement made by my right honourable friend in another place, let us be sure that we shall not have solved the problem of unwanted pregnancies; we shall not have reduced the number of abortions with their consequent physical and mental disorders; we shall not have reduced the incidence of venereal disease, because there will be more encouragement for safe intercourse. On the contrary, all the evidence, all the statistics, point in the other direction. This is really my main reason for asking that the clause should be removed from the Bill or that further consideration be given to it.
I have given my reasons why I find the whole policy of dealing with unwanted pregnancies and the problem of population unsound. But there are three other points I should like to mention, if your Lordships will bear with me. I should perhaps explain that at the time of the Second Reading debate on this Bill I was in New York at the General Assembly and was unable to take part in it, and so I would crave the indulgence of your Lordships if I am taking rather a long time. I will be as brief as possible but these are important points. First, my noble friend made clear in his statement in your Lordships' House last Tuesday… there is no distinction to be made between the married and the unmarried."—[OFFICIAL REPORT, 12/12/72; col. 491.]Nor is there any reference to age. I would remind the Committee that there is still in existence a law which states that it is unlawful to have carnal knowledge of a girl under the age of 16. Yet I find no definition of "person" in this Bill. I have been informed that contraceptives would be given to a girl of 14, and even younger, if it was considered socially desirable. Is therefore the National Health Service doctor to be an accomplice in crime? This aspect should be looked at more closely.
1022 The only distinction, as it appears to me, that I could find between categories of persons—I should be grateful to be corrected on this point—is that a woman in medical need has to pay a prescription charge and, curiously, it seems that a person in social need does not have to pay, even if she can afford to, which could be anyone from a schoolgirl of 12 to a hardened prostitute or anybody else, since payment will depend on the subjective judgment of the social worker. This is the point that I take with the noble and learned Lord, Lord Gardiner. How is the social worker to decide whether there is a social need and that a person should not pay? Even the Family Planning Association pamphlet, which is called Straight Facts about Sex and Birth Control, saysAt the Brook Advisory Centre you will pay £4 a year. Contraceptives are extra but not expensive, much cheaper than one packet of cigarettes a week.So I do not think we need to feel unduly worried about cost in these cases. I absolutely take the point that there are families who desperately need family advice and need contraceptives free, and that should be a matter to be considered. But it should be considered properly and in the right context, and not as this clause is at present drafted, so that in fact a person who needs medical protection has to pay the prescription charge, but the promiscuous can get her contraceptives free if the social worker so decides.
One can choose to go to a football match and pay one's own entrance fee; one can choose to have a colour television instead of a black and white set. Yet we find that the taxpayer is being, not asked, but made, to pay for a form of entertainment which is dubious to say the least. If your Lordships will not be too shocked at the use of a trendy piece of terminology, you can "have a ball" and let the public pay.
It is not principally the problem of consenting adults which is of most concern to me but the possibility of the exploitation of children. This is already happening since the easy availability of the pill. I will not take up the time of the Committee with some of the cases with which we are now confronted. I am sure that all who do social work or are involved in local authority work are only too well aware of what is 1023 happening. I will only say that in one area of London last year there were so many cases of unlawful carnal knowledge reported to the police involving girls of under the age of 13 that they could not prosecute the perpetrators. It is not sufficient therefore just to say that advisory services are to be provided. What kind of service is it to be? Who is to supervise it? Who is to control the policy? Who is to supervise the publication? Who is to write the publication? Are the publications to be the same as those now being issued by the Family Planning Association? Like their latest effort Learning to Live with Sex, a Handbook of Sex for Teenagers; or perhaps the two recommended with an asterisk in their booklet as being particularly helpful for family planners and sex educators. And which are these? They are called The Little Red Schoolbook and Sex Education, the Erogenous Zone, one which I would recommend to the noble Earl, Lord Longford, for his reading.
Who is to supervise the service? Is it to be medical, or is the advice of this plan again to be taken and seen in the light of the birth control recommendations in this birth control plan, at page 28, where it says:This birth control advisory unit should be given offices near central departments. It should be headed perhaps by an energetic young civil servant or a forceful outsider with experience of large organisations working (if not a doctor himself) with a medical adviser who might be a committed young consultant, and sufficient staff to operate effectively.So far we have taken the advice of the birth control plan in so many aspects that I wonder what is happening with this family planning scheme. It is with great regret that I cannot agree so far with the policy as it has been expounded by my right honourable friend the Secretary of State for the Department of Health and Social Security. I have tremendous regard for him and an admiration for all the work he has done in alleviating suffering, which I know is the sole motive which is guiding him in setting up this service. But I think this service has not been sufficiently thought out. We do not know enough about it. Although I do not wish to divide the Committee, because I am a member of the Government Party and I would never, if I could help it, take any action against my Party, 1024 I would ask very seriously that what I have said be considered; that medical advice be taken, that senior gynaecological specialists be consulted before this kind of service is embarked on. And if we could be so informed on Report I would withdraw my plea to have this clause removed from the Bill.
§ 6.25 p.m.
THE LORD BISHOP OF SOUTHWARK
The points which the noble Baroness, Lady Elles, has raised have, I think, been answered several times this afternoon and I doubt whether any useful purpose would be served by going over them again. I want to make only one comment. At the beginning of her address the noble Baroness appeared to suggest that your Lordships' House was encouraging a descent into permissiveness; that we ran from one disaster to another—homosexuality, abortion, birth control and now to what we are discussing to-day. She went on to say that she was a member of the Church of England and therefore I think it is only right that I should answer that comment, especially as I went into the Lobby in support of the Amendment a few minutes ago.
If the noble Baroness is right in thinking, as she appears to think, that if you do not allow people the free use of contraceptives they will become more morally aware and more responsible, perhaps there is something to be said for her case. She and I may wish that were so; I do not believe it is. I believe that you have to deal with the situation as it is and not as you would like it to be. I wish the noble Baroness would come with me this evening and cross the river into my diocese one mile from here. Then I could take her into a house where there are 19 families living in 19 rooms. I wonder whether she would still think that her case was as strong as she seemed to suggest that it was, or would she not think—
§ BARONESS ELLES
If the right reverend Prelate would be good enough to give way to me I would say that I worked in Kennington for 15 years and I know only too well about the question of overcrowding. It is precisely because the infrastructures are being built on the basis of small families that I demand that proper consideration must be given to the proper size of families and that there is adequate housing for the size 1025 of the family. We are people, not bricks, and the sooner we build houses for the size of families, and not reduce our families to the size of rooms, the better.
THE LORD BISHOP OF SOUTHWARK
I am well aware that the noble Baroness worked in my diocese. I was going on to the precise point that, having worked in that sort of area, I was wondering how she could put forward the case as she has done this evening. There is in many of those houses a tale of appalling human misery. It is easy enough for us who have been brought up perhaps in more spacious conditions to take a rather different view. But had we actually lived in those conditions, had we had to bring up a family in a house which contained 19 families, each in one room, we might be driven into realism.
In any case I want to say to the noble Baroness that those who are members of her Church and who supported the Amendment, did so far many reasons, and not least because we believe that present conditions encourage abortions. Abortion is one of the things which, as so many speakers have said, we all regret. We regret the way the trend is going in this country; at times it seems to be approaching infanticide. It is my belief that, if, with the Amendment the Government take Clause 4 into their legislation, this very ugly factor in our social life to-day may decrease, and the day will come when we shall bring into our country wanted children, by parents who know what they are doing and who will see that it is their love which is going to beget a child which, when it comes, will be loved.
I had not intended to say anything in this Committee, because I have not been present throughout the whole debate, but I should like to mention one thing in view of what the right reverend Prelate has just said about abortion. I was delighted and surprised that everybody here is now against abortion and regrets the number of abortions that have taken place. Some time ago the atmosphere seemed to be rather different. This has been called, and rightly so, an historic debate. I think it is. But if I might risk a bet of 25p with the right reverend Prelate, I should say that it will be regarded as an historic debate by the people who 1026 read some of our speeches though not many on this side have listened to the noble Baroness, Lady Elles, who seems to have been at some pains to get her statistics right, instead of producing generalisations, which I think have been punctured a great many times before. One point that she made was that everybody seems to think that an unwanted child is an illegitimate child. If I may say so, many illegitimate children are wanted and many wanted children are illegitimate. These are not things one should go into at this time of night. I will not say more because it would be wasting your Lordships' time, but I think that anybody who reads the speech we have just heard—and I hope that some people on this side will—will have food for thought.
§ 6.32 p.m.
§ BARONESS YOUNG
I am sure we have all listened with great interest to what my noble friend Lady Elles has had to say. But I think I ought to repeat what I said at the beginning of the last speech I made: that we are not concerned to-day in this Bill with a population policy. I think the information that my noble friend has given is something we may consider when we come to discuss a population policy. In fact, we have been discussing a birth control policy. The provision of family planning services has been a part of the services provided by local authorities since the passing of the National Health Service (Family Planning) Act 1967. Over recent years local authorities have been encouraged to extend the services which they provide and extra money has been made available through increases in the rate support grant. Also, under the provisions made in the 1946 National Health Service Act hospitals have been encouraged to provide a service for their patients and general practitioners have treated patients with a medical need for contraception on the National Health Service The National Health Service (Family Planning) Amendment Act 1972 enabled local authorities to make vasectomy operations available as part of the contraceptive service that they provide.
The clause in the present Bill merely seeks to continue under the reorganised Health Service the powers and duties which Parliament has already approved for existing local authorities. However, 1027 my right honourable friend the Secretary of State has recently announced in another place that, as a result of a thorough review of family planning policy, the Government are convinced that a considerable expansion of the services provided under the National Health Service is required. The present clause, as drafted, would give the necessary powers for this expansion.
The most reliable methods of birth control are those which require the involvement of the medical profession, and it is obvious that without an increase in the use of these methods little impact can be made on the problems of unwanted pregnancies. The problem cannot thus be tackled adequately other than through the National Health Service accepting its responsibilities in this area and providing adequate professional advice and treatment. The Family Planning Association has done excellent pioneering work in this field and provides a service to many people. However, as the Family Planning Association fully realises, an important service such as this cannot and should not be provided to all the families who need it by a voluntary body which is obliged to make charges for the advice which it gives. Some of the people who most need help in this area are those who cannot afford to pay for it, and the Government have agreed that these people, as well as some others with a special need, should be provided with free supplies as well as the advice which will be free to all.
My noble friend Lady Elles went on to ask a number of questions. I think the most useful thing would be if I could write to her giving full answers to the many points that she has raised, which I will undertake to do. I should only like to make it quite clear that in the reorganised National Health Service the family planning services will be under the community physician, and there will be a multi-disciplinary health care team which will represent consultants, general practitioners, nurses and probably representatives of the relevant local authority services all acting under the community physician. That is how we see the service developing.
§ 6.38 p.m.
LORD BEAUMONT OF WHITLEY moved Amendment No. 38:
After Clause 4 insert the following new clause:
§ Right of Privacy during treatment
§ ".—(1) Every person receiving treatment under the National Health Service (hereinafter in this section called "a patient") has the right to receive such treatment without any person being present other than persons who are necessarily concerned in the provision of the treatment.
§ (2) The governing body of every institution providing treatment under the National Health Service shall ensure that every patient in the institution is informed of his right under the previous subsection: and before the presence of any person not necessarily concerned in the treatment of a patient is permitted during such treatment the consent of the patient to the presence of such person shall be obtained."
§ The noble Lord said: I beg to move Amendment No. 38, standing in my name and that of the noble Lord, Lord Strabolgi. The purpose of the insertion of this new clause is to establish a right of privacy of treatment to patients receiving treatment under the National Health Service, and also to make certain that that right is known by them and that they have to give their permission before the presence of other people who are not actually concerned in their treatment is allowed at their treatment. It is true that a great deal of what I want already exists in practice. I am not saying that there is any widespread abuse of this question of people's privacy. Most doctors are extremely careful about it, and most hospitals take a lot of trouble. But there are exceptions, and I think it is right that we should legislate for those exceptions: because one of the main things that we can do in this Bill is to try to protect those patients who, when they are ill, weak and nervous, may be given considerable mental distress if something may go wrong. Although the right to privacy is well understood by hospitals and doctors, it is not that well understood by the patients themselves. They are not always told about it; there is, in fact, quite often a slight conspiracy to make certain that they do not know of this right.1029
Possibly there are not all that many cases involved, but they do happen. I have here a couple of instances, which I am not claiming to be highly representative of the situation in this country as a whole, but which come to me from one of my correspondents who works in the Health Service in the Midlands and is very active in this field. She writes:
I have recently talked to two women who had gynaecological investigations in a large teaching hospital. They had different consultants. Mrs. A., a nervous woman at a difficult time of life, was deeply distressed when her consultant came round the screen with several young students, and she was prodded and poked about without so much as a by-your-leave or a word of reassurance. She became hysterical, shouted that she was not a peepshow, and then she had to be given a sedative. Mrs. B., also rather nervous, had a consultant who behaved with considerable consideration. Putting his head round the screen, he said: 'You don't mind if I bring these chaps in to have a look at you. I am sure they will find it useful.' She gave consent, not because she was more modest or less frightened than Mrs. A but because she had been previously told that this might happen. She realised quite sensibly that doctors must learn to be doctors, and she decided she must grit her teeth and put up with it, since she had been asked properly.
I am certain that the majority of doctors behave in the way that the second consultant did; but there are occasions when that does not happen and I believe that people should be protected in such cases. There are in hospitals many patients who are elderly and a number of them have not been brought up in the permissive society. They feel considerable worry about being seen in a state of nudity or semi-nudity, even by the doctor or nurse who is looking after them, let alone by a number of other people coming round and being allowed in. I know that most doctors take the utmost trouble to see that this does not happen in any kind of offensive way; but it can, and occasionally does, happen.
§ I know there are certain objections to this Amendment. We are sometimes told—and I suspect that the Minister's advisers possibly take this view—that doctors are very much against such a right being established, because on the one hand they say there is no need for it and on the other side they consider it would reduce their opportunities to teach particularly in the teaching hospitals. If that is the argument, I do not think they can have it both ways. There is a certain need for privacy, and even with the teach- 1030 ing hospitals we have to allow the basic right of people to this privacy, if they wish for it. I believe the basic objection to this type of clause is far less widespread than people believe. My correspondent again, working in the Midlands, when we were considering establishing this right in a slightly different way from that which appears in this Bill, rang round a number of people to discover their views. I am not pretending that this is in any way a representative sample: of course it is not. She rang round six patients, two consultants and four general practitioners. The patients were very much in favour of privacy and had several sad stories of embarrassment and the fear of being subjected to experiments. The consultants were also in favour but said that the wives of other consultants of the old school might take umbrage. She was advised to take no notice of them because "they would take umbrage at anything." Those are not my words nor those of my correspondent: they are the words of the consultants. The G.P.s were also in favour, and nurses with whom I am constantly in contact think that what is proprosed in this Amendment is well overdue, especially with regard to privacy. It was added that people often want to say things to their consultant in private and in many cases become confused and sometimes totally mindless if the great man appears with a thundering great entourage with him.
§ It might be objected—and in fact it was objected when I last raised this matter in your Lordships' House—that patients should agree, because it is essential that students should be taught in the presence of actual cases and there is really nothing to be frightened of in people coming in to observe treatments. I entirely agree with that. I hope that I should not in any circumstances—and probably most of your Lordships would feel the same—object if I thought there was any good reason for it to be done. But that is not what I am talking about. I am talking about the people who do mind—the old, the nervous, the easily flustered and those who have their resistance lowered anyway by sickness and illness.
§ It may be argued that the drafting of this Amendment is faulty. If it is, I shall be delighted to take it away and have another look at it; or, indeed, if it 1031 is accepted, to amend it at a later stage. It has already been pointed out that in subsection (2) "The governing body of every institution "should almost certainly be" The Area Health Authority". It may be that this new clause is in the wrong place in the Bill. All I can say is that I have taken advice on it and I believe it to be in the right place. However, if it is not, that can be amended. I hope it will not be said that this Amendment should not be in the Bill at all. It seems to me that one of the most important things the Bill is attempting to do and has been intended to do is to improve the rights of the consumer and to give more consumer protection. This is an important bit of consumer protection, and I think it should be established. People in hospital are at their most vulnerable. It is surely up to us to see that they are protected as much as possible from things that distress them. I do not think that there are any serious arguments against the establishment of such a right to privacy. I therefore hope that the Government will see their way to the acceptance of this Amendment.
§ LORD BROWN
I should like briefly to support the noble Lord, Lord Beaumont, in his Amendment and to add this point to the very cogent arguments he has put forward. It is a psychological point, but one that is easily overlooked. There is a necessity for patients to co-operate, in the sense that they help the training of young doctors and others. If somebody is going to make a contribution to training, as indeed he does when he co-operates, it is important that he should do so by consent. Many people in this country of individualists, if they are not given the right to refuse, will bend their endeavours to preventing a thing from happening. Immediately you give people the right to refuse, the likelihood is that if they feel that by consenting they are helping a fellow human being they will consent; and it is important that it should become a virtue for a person so to consent. I believe there would be no shortage of people who would consent to help in the training of young doctors and others in this way, if it were always made clear to them that they have the right to refuse.
§ 6.48 p.m.
§ LORD PLATT
I should like to say that I agree with every word that the noble Lord, Lord Beaumont, has said, including his horrifying description of the kinds of things that can happen to patients under the care of certain consultants. I could even name one or two! My only difficulty is this: how far is it a matter for legislation, and how far can legislation make people behave humanely and properly to patients, even under conditions of teaching students?—which is of course quite difficult. I am not sure that you can make people do this by legislation. In slightly more detail, I believe there are difficulties of definition and impracticability. If these could be overcome, I should have absolutely no objection to a clause of this kind being put into the Bill.
Although I feel wholly in agreement with the principle involved, subsection (1) is very difficult to define. We must remember that this will be the law if we pass the Bill. Who is to be defined as "a person present", other than a person necessarily concerned with the provision of treatment? They are all grades, are they not? You may go around with your senior registrar who is already a fully trained man; he is on the borderline of getting a consultant post. You may also have a junior registrar and perhaps two housemen, which is quite unnecessary but you have two housemen because you are running a professorial unit and it is good for these people to come round with you. The second houseman is not really concerned in the treatment but is receiving instruction and so forth. Then maybe you have two personal students attached to you; they are obviously not necessary to treatment, but it is going to be jolly difficult to exclude one and include the other.
It will also be very difficult if we pass the second subsection to the clause about the consent of the patient always being obtained. Again, in principle I am absolutely in favour. I should like to feel that in my ward all patients knew they had the right to ask for this degree of privacy, and could exercise the right, though it is very difficult to ensure that. I should like to think that the sister in charge of the ward explained to them the kind of ward rounds which were done in this 1033 unit; and I should like to think that I have always, in a word, asked the patient, in the sense of saying, "I hope you don't mind allowing one or two of my students to have a look at you", or something like that in a polite way. Of course, the patients always agree and one is left wondering whether they say, "Yes" just to please one or whether they really want to co-operate. These are all the difficulties I see straightaway. If the majority feeling is that this clause is right I shall certainly not oppose it. If, on the other hand, there is some way of writing this privilege in and making it quite clear that the patient has this right, without perhaps laying down that the patient has to be asked in every case, that might be an improvement. I would rather look to the noble Lord who replies to see what is his way out of this particular dilemma.
§ 6.52 p.m.
§ BARONESS SEROTA
In view of the time I will take only one moment to say how glad I am that the noble Lord, Lord Beaumont of Whitley, put down this new clause. As several noble Lords have said, it represents the best practice which is now widely available in hospitals and clinics. The bad old days when patients were regarded as treatment material are fortunately fast disappearing, although there are odd cases, as we all know, when things are not handled as well as they might be. I shall be interested to hear the reply of the noble Lord, Lord Aberdare, on this because the principles underlying the new clause are the right ones, although possibly the Government might have views on the drafting. On this question of whether it should be in legislation or not, if one accepts, as I do, that good practice avoids some of the problems that have existed in this area in the past, then surely we should legislate for the marginal case. It is the marginal case where things go wrong and the noble Lord, Lord Beaumont, made a very good case for putting something of this kind in the Bill, although the noble Lord, Lord Aberdare, might wish to advise the Committee about the terms of the suggested new clause.
§ 6.53 p.m.
§ LORD ABERDARE
This is a very sensitive area and I am delighted to have the opportunity of saying something about it on the Amendment of the noble 1034 Lord, Lord Beaumont of Whitley. I do not think there is very much between any of us in the Committee on the underlying facts and the worries we have and how we can best balance the patient's need for privacy against the equally important need to train young doctors, we hope in ever increasing numbers. The difficulty which successive Governments have always faced is that just expressed by the noble Lord, Lord Platt. It is extremely difficult to put this matter into legislation.
As the noble Baroness, Lady Serota, has just said, hospitals are well aware of the right of the patient to refuse to co-operate in teaching procedures and not to be denied treatment simply because of such a refusal. But over the past year or two there have been expressions of anxiety such as the noble Lord himself has voiced this evening, and the Secretary of State has undertaken to issue guidance on this complex subject in the course of this year. Unfortunately, consultation on a draft hospital memorandum has taken a little longer than we expected. This illustrates the great complications that arise when one tries to put something into writing. It is however practically completed and it should be available early in the New Year. I hope that that will go some way to satisfy the noble Lord, Lord Beaumont. It was important that we should take the greatest care in preparing this guidance because it obviously has to be comprehensive and has to cover the application of the general principle to some awkward spots, such as the accident and emergency department and video-taping, which is a practice which takes place quite a bit now, and other kinds of work in hospitals where the obtaining of consent is not always as straightforward as it might seem when one thinks just of the patient in the medical ward.
It is such complexities that make this particular right of the patient an unsuitable subject for rigid legal definition. We feel that the principle is well established, widely recognised and generally applied. That is not to say that lapses do not occur—they sometimes do—but that any form of law does not really lessen the chance of an occasional lapse. Even the noble Lord's Amendment, I was glad to see, does not in fact create any new criminal offence; therefore no penalty 1035 is attached to it, and anyway that would be quite inappropriate. I feel the best thing we can do to lessen the chance of any occasional lapse is to issue some guidance and some advice on co-operation. I hope this will satisfy the noble Lord that we take this matter seriously, and we shall be issuing guidance in the New Year.
§ BARONESS WHITE
May I ask the noble Lord whether he would feel the same difficulty about the right of a patient to be informed of his position—or of the duty of the authority to inform the patient of his rights, I think would be the correct way of putting it? I can see clearly the problem about obtaining consent. But could we not take this in two stages? Might one not possibly enshrine in legislation that a patient must be told of his rights, and then leave it to administrative action and guidance as to how this should be given practical effect?
§ LORD ABERDARE
This would be very much in mind in regard to the guidance, but it is not quite as easy as all that. Supposing one is brought unconscious into the accident and emergency department. How can one give one's consent? How can you be informed of your rights? They are difficult matters, and I would ask your Lordships to believe that this guidance will really be the best way we can advance.
§ LORD BEAUMONT OF WHITLEY
If I may say so, I do not think the noble Lord, Lord Aberdare, quite understood the noble Baroness's last point, which was that we agree that the second half of subsection (2), about getting consent of the patient, involves very real difficulties; but if that were left out and we had just subsection (1), establishing the right, and the beginning of subsection (2), stating that every patient should be informed of this right (obviously if he was unconscious when he came in he could not be, but it would be the routine on entering hospital or on entering into treatment that patients were informed of that right), that would in fact do away with quite a number of the difficulties.
With regard to the difficulty of the noble Lord, Lord Platt, who spoke with his usual sensitivity on this particular 1036 point, I am not sure about the point he made about a person necessarily concerned in the provision of treatment and whether it is really relevant. This is not going to be a question of people suddenly saying, "No, I do not like the look of all you people coming round". It is going to be the odd and unusual case where the patient, having been told of his rights, says, "Please, I should like to be examined in privacy". I think it will then be quite clear which doctors and their assistants are necessary for the treatment, and which are not. I do not think that is an immense difficulty, although a little redrafting may be needed.
The noble Lord, Lord Aberdare, said that there is to be no penalty. That is so. But if I understand the Bill correctly, if in fact we insert this clause any abuse of it would be subject to investigation by the Health Commissioner. I think that might be an important reason for putting it in the Bill. The noble Lord has obviously given me some considerable reassurance with regard to the drafting of this advice to hospitals. I still have a strong feeling that I should like to see the right put into the Bill, and I have not yet heard the case which makes me think that this is really difficult. But as the noble Lord's Department is in fact drafting this particular advice it ought to be nearly ready in the New Year, so presumably we shall be able to look at a final draft in order to know what kind of thing it is, before the Report stage. If that is the correct situation it would give me great pleasure to ask leave to withdraw the Amendment, while reserving the right, of course, to come back at Report stage if I do not feel that the advice really meets the case.
§ LORD ABERDARE
I can only say that we hope to get it out in the New Year. I should not like to give a firm guarantee, but if the noble Lord is willing to withdraw his Amendment now, nearer to the Report stage we can see how we stand and he can then put down another Amendment if he so desires.
On one small point, I do not think it would make any difference to affairs that might be referred to the Health Commissioner whether this right is in the Bill or not. The Health Commissioner has to investigate matters of maladministration 1037 or poor service, and I should have thought if this was a well-established practice he could perfectly well investigate any such complaint.
§ Amendment, by leave, withdrawn.
§ Clause 5 [Regional and Area Health Authorities, Family Practitioner Committees and special health authorities]:
§ 7.3 p.m.
BARONESS SEROTA moved Amendment No. 39:
Page 3, line 40, leave out second ("Authorities') and insert ("Councils").
§ The noble Baroness said: With the order-making powers in this clause and the corresponding Parts I and II of Schedule 1, we come at long last to the administrative heart of the Bill which I think in the view of all members of the Committee will have a dominant effect on the pattern and quality of health care for future generations. This is the area of the Bill where the differences between the proposals of the former Administration in relation to the powers and composition of the new Health Authorities, and the principles upon which they were based, and those of the present Government are at their greatest, although the divisions of opinion on the merits of the policies underlying the provisions of the Bill go right across Party, as was evidenced in our Second Reading debate.
§ I think I should explain at the outset that although I am acting as a willing midwife to this Amendment, its real father is the noble Lord, Lord Reigate, who I know will shortly be speaking in support of it. At first glance it might seem that the Amendment is designed merely to rename the proposed Regional Health Authorities as Regional Health Councils. If it were accepted by the Committee it would of course require a considerable number of consequential Amendments which we have not troubled the Committee with to-night in order not to overload an already long Marshalled List. But its underlying powers go far deeper than a mere question of semantics. I think noble Lords will recall the impressive and authoritative speech of the noble Lord, Lord Cobbold, during the Second Reading debate, when he pointed 1038 out so graphically the apparent contradiction in the allocation of powers and duties between the regions and the areas in the White Paper and those which were spelt out in greater detail in the subsequent Grey Paper on the proposed new management structure for the reorganised Health Service.
§ In paragraph 74 of the White Paper, the regional task was defined as being in part, strategic planning; in part, coordination and supervision and only in part executive. But by the time we come to paragraph 2.27 of the Grey Paper, where admittedly it begins by suggesting that the Regional Health Authorities must delegate major executive responsibilities to its Area Health Authorities and its regional officers, we find in the preceding paragraph, paragraph 2.24 at page 24 of the Grey Paper, that the function of the Regional Health Authority is to review, challenge and approve area Health Authority plans and subsequently control Area Health Authority performance in relation to those agreed plans. As I read those paragraphs in the summer, I could not help thinking of a baby in a playpen, allowed to move only within the clearly defined limit of the bars and watched over by a conscientious mother. Others have referred to it as a "big brother" relationship but I would not myself go quite so far as that.
Perhaps most important of all, the Regional Health Authority, according to paragraph 2(1) of Schedule 1 of the Bill, will be responsible for appointing all the members of the Area Health Authority with the exception of the four local authority members and university members as the Bill at present stands. Noble Lords will recall that its own membership is to be completely under the direct control of the Secretary of State, as in the case of the present Regional Hospital Boards. In contrast, the corresponding paragraphs in the second Green Paper read as follows:
Provided national priorities are observed and statutory efficiency are obtained effective power will rest with the Area Health Authority to develop and plan its own services within the budget allocated".
That budget was to be allocated direct by the Secretary of State and not through the then Regional Councils. The executive powers of the Regional Health Councils then envisaged were only to be concerned with the performance of a range
of functions which had to be exercised over a wider area than the Area Health Authorities, such as those related to overall planning of specialist services, the blood transfusion service, the organisation of post-graduate medical and dental education and the planning of the ambulance service. Moreover, their membership was to reflect and include that of the Area Health Authorities grouped within the region.
§ We are completely opposed to the form of regional tier which is now suggested in this Bill which seems to have become even stronger since the White Paper was issued. This is the point which the noble Lord, Lord Cobbold, made so effectively. Since the proposed Area Health Authorities are to be based—apart from the few boundary adjustments—on the existing hospital regions, they begin to look more and more like the existing Regional Hospital Boards written large, with, of course, their writ now running over the former democratically controlled local authority and community health services, thus, I am afraid, confirming the fears, which I believed at one time to be quite unjustified, of those who thought that the whole purpose of this re-organisation was to give more and more power to Regional Hospital Boards and to create a hospital-dominated service instead of the community-based service which all of us now believe is necessary.
§ I fear that the form of the regional authority now proposed carries very strong overtones of bodies with rights and powers to enforce obedience through their complete control, both of resource allocation and of their duty to monitor performance. Above all, they will have power of ultimate control over the areas within the regions through their "hire and fire" rights to appoint all the members—that is, the majority of members of the Area Health Authorities with the exception of the suggested four local authority members and university representatives.
§ We shall shortly be moving Amendments designed to change the membership make-up of the regions to include both Area Health Authority and local authority members, but at this stage we are asking the Committee through this Amendment to change the name to 1040 Regional Health Council as a first step which we believe would more accurately reflect the role we should prefer to see them perform in relation to the areas, which surely should be in every sense the prime units for Health Service administration, acting in co-operation with their matching local authorities and in direct touch with the Department from which they will receive their budgets, without having to battle through the present suggested long lines of communication via the buffer state of the Regional Health Authorities.
§ I hope the Minister will consider these arguments and that the Government will be prepared at this stage to have second thoughts on the functions of the regional tier. Our suggestion to rename them as Regional Councils would in our view much more appropriately reflect their role in relation to other parts of the Service, particularly the areas. We have previously discussed this matter in principle and I have tried not to overlap into an Amendment which will deal with their specific membership. I know that I can leave further argument in the very capable hands of the noble Lord, Lord Reigate, who I know joins with me in supporting this Amendment. I beg to move.
§ 7.12 p.m.
§ LORD REIGATE
I rise to respond almost to the invitation of the noble Baroness, Lady Scrota, to support her; and, if I may say so, the midwife has done the father proud. I have very little to add to the arguments she adduced. I would begin by saying that there is something of a question mark over my paternity role, because I think the original father might be described as Mr. Cross-man, so my role is partly adoptive; it was he who used the word "Council" in this context. I hope that my noble friend will realise that this is only one step in the discussions which will take place over the role of the Regional Authorities, whose existence I equally regret—I too should like them to be called "Councils"—and the role to be played by the Area Health Authorities. I hope that neither he nor any other noble Lord—nor, for that matter, any honourable or right honourable Member of another place—will dismiss this as a matter of mere semantics. Words, even in our legislation, do mean quite a lot. I consulted that great authority, the 1041 Shorter Oxford English Dictionary, and there is a clear distinction between the meaning of a council and an authority. An authority is, as one would expect, authoritarian; that is, it exercises power, whereas a council by its very name equally is an advisory body.
If we must have a regional tier, then all of us who really have the interest of the National Health Service at heart would want it to be advisory. If one goes back to the Consultative Document one sees that it stated that the body would deal mainly with planning; but, as the noble Baroness, Lady Serota, said, gradually other words have crept in, and in the grisly Grey Book we now have this sinister word "control", which really spells out an authority. I thought from all I have heard both the Secretary of State and the Minister of State say, with their usual courtesy and understanding, that the one thing that was clearly understood was that the Area Health Authority would be the body that really wielded the power and would weld the three parts of the Service into one. If it is not to be so, then I ask myself whether this reorganisation will be worth while, because the whole of the country and the Committee must realise the extraordinary arrangements that we shall have. There will be a district management team who, in some mysterious way—my noble friend Lord Cobbold quoted that marvellous passage from the Grey Book which sounds so like the Mad Hatter's tea party—are supposed to run the hospital or district. Above them will be the area and above that the region. In the case of Greater London there will be above them a Coordinating Committee. At the top of this enormous pyramid will be the Secretary of State. I feel that we shall be saying "Goodbye" to any ideas of an independent area authority really getting down to the job. I can see—I hate to use the word "bureaucracy", because one uses it of anything one dislikes—that we shall have merely an extra tier added to the bureaucracy.
I asked a Question the other day which my noble friend answered. It is a fact that the Regional Boards' staffs have increased more than twice as fast as the staffs of the hospital management committees. I speak from some knowledge of the hospital management committees and I see no reason for their staffs to be 1042 reduced under the new set-up. Indeed, their work will probably be increased with the addition of the local authority powers. Let us assume that there is no change. We shall now have the Area Authority and above it the regional tier. Is the present staff of the regional tier to be reduced? Does my noble friend anticipate that overall the administrative staffs at all these tiers will be fewer or more? It is important that we know the answers to these questions.
I have the feeling, which others share, that we shall destroy the spirit of the Health Service and turn it into an elaborate, almost military, hierarchy. I have many friends too at the regional level and I am astonished by the number of them to whom I have spoken who have said privately that they think the regional tier is unnecessary. That matter we can discuss later, but it would be a signal example of the spirit in which the Secretary of State and the Minister of State I hope are viewing the proceedings on this Bill if at this stage they could accept this very simple Amendment which expresses the spirit that I have tried to discuss—namely, that it is the area which will have the authority and the regional tier which will advise.
§ LORD COTTESLOE
I support what has been said by my noble friend—I use the word in National Health Service language rather than in the terms of this Committee—Lady Serota and my noble friend Lord Reigate. We were always told that the Regional Health Authorities which are to be brought into existence by this Bill would be something quite different from the Regional Hospital Boards that now exist—not only that they would cover the wider field of the whole integrated Health Service but equally, and perhaps more important, that they would have limited, though broad, powers of planning and of the allocation of finance to the Area Authorities, with the Area Authority really being the effective managing authority. In fact, the Regional Health Authority was to be a different animal and not merely the Regional Hospital Board all over again but dealing with a wider field; and this was a concept with which we all agreed. However, if the Regional Authority is to be a different animal and not merely the same leopard, more powerful and with a few 1043 more spots, this must be made clear and unmistakable from the outset.
There are various ways in which this can be done. Certainly there are at least four things that could be done that would help to overcome the otherwise almost inevitable reversion to the existing pattern of organisation. First, the powers and functions of the Regional Health Authority might be clearly defined and limited in the Act itself, and that would really be the best way. But, of course, there is no such thing in the Bill before us, which is, as Lady Serota has pointed out, virtually an enabling Bill that defines very little in precise terms. However, we shall be looking at that point when we come to Amendment No. 65.
Secondly, their limited functions might be indicated and differentiated from the managing functions of the Area Health Authority in their name, and that, of course, is the purpose of this Amendment. It does not go very far, but it would be a real help in restraining the regions from interfering with the managerial functions of the Area Authorities, as they most certainly will do if there is no restraint on their powers and no apparent overlap between them and the powers of the areas. Thirdly, there could be a change of the regional boundaries. That is put forward, so far as the metropolitan area is concerned, in Amendments Nos. 40 and 41 to which we shall come in a few moments. And finally, there could be a change of domicile. The new Regional Authorities—or whatever they may finally be called—could have their offices in buildings different from those now occupied by the Regional Boards. That would certainly help.
All those four things are desirable and all would help. What is absolutely certain is that if the new Regional Authorities do not have their functions vis-à-vis the Area Authorities precisely defined and limited, and if they cover the same areas and occupy the same offices as the existing Regional Hospital Boards, they will, in the event, be found to be simply the Regional Hospital Boards all over again but covering the wider field of the integrated Health Service. That is not the intention, but that is what will happen unless positive steps are taken to make it impossible. I find 1044 it very difficult to understand why the Government appear to be rather blind to what is, to me, and to many others who are deeply concerned in this matter, a perfectly obvious and unmistakable fact, and that is why I must support this Amendment and indeed support the two Amendments that follow it.
§ LORD SOMERS
I strongly support the spirit behind this Amendment. I entirely agree with what the noble Lord, Lord Reigate, said about not increasing the Civil Service hierarchy behind all this administration of health, but I should like to be quite certain as to whether there really is all that difference between the word "council" and the word "authority". As things are at the moment we speak of local authorities when we really mean councils. If we speak of a county council, we refer to it as the local authority. So in spite of the actual dictionary difference, I wonder whether there really is, in practice, any difference.
§ LORD COTTESLOE
Before the noble Lord sits down, may I say that it is not the semantics that matter, it is the fact that there is a difference.
§ LORD BROWN
When we come to Amendment No. 45 on Schedule 1 I perhaps should warn the Committee that I have quite a lot to say, but we are now engaged in debating an Amendment which is really the tip of an iceberg. It is a very happy situation that this Bill is largely apolitical because it allows one to argue with one's own friends on one's Front Bench, and I should like shortly at this stage to commence my campaign, in which I propose to indulge, about the organisation of the Health Service, by saying that apparently—I am not quite sure—this Amendment is a criticism of the whole idea of the establishment of a clear hierarchy in the National Health Service. I do not know whether that is the intention of the movers of the Amendment, but it is easy to deduce from what they said that that would be the result if this Amendment were to be accepted.
Apparently there is a great deal of feeling about hierarchies in the country, notwithstanding the fact that our whole standard of economic life is dependent on the establishment of efficient hierarchies throughout industry and commerce, 1045 and indeed the support of our entire political life is dependent on the establishment of official hierarchies in the Civil Service and in many other parts of our working life. To attack hierarchies, which have proved to be, so far as I know, the only successful way to get large bodies of people to indulge co-operatively in getting work done, seems to me to be challenging a very important principle indeed. It is my view, therefore, that this change of wording, although in itself insignificant, is the start of a process of argument and I just wanted to make clear at this stage my own attitude.
Before sitting down I should like to say to the noble Lord, Lord Reigate, that I have always understood that people who are members of an authority in fact exercise authority and not power, which is a function of a quite different type of group. I am sorry if the Oxford Dictionary is misguided in this respect; but if he has quoted it precisely then it is misguided, as it can be.
§ 7.48 p.m.
§ LORD ABERDARE
When I saw this Amendment on the Marshalled List I certainly realised that it was more than a drafting Amendment and that it was, as one of your Lordships has said, the tip of an iceberg. So it is rather difficult to know quite how far to go in dealing with this particular Amendment without straying into the other Amendments. Perhaps I might say one or two things at this stage at any rate.
The first point that I should like to make clear is that we have not changed our views on the responsibilities of the Regional Health Authority and the Area Health Authority. There has been no tendency in the Bill to lay any greater authority on them than we always previously envisaged. To satisfy your Lordships on this point, may I quote first from the National Health Service Reorganisation consultative document, which said on page 8:This will place on the Regional Authorities a real management responsibility within the chain of command and will give them a very different function from that of the Regional Health Councils proposed in the 1970 Green Paper.That is really what lies between this side of the Committee and what the noble Baroness said about her previous Green Paper. There is a very different concept. In the White Paper we said: 1046In future there will be a clear line of responsibility for the whole National Health Service from the Secretary of State to the Regional Health Authorities and through them to the Area Health Authorities with corresponding accountability from area to region to centre.That is what the Bill reflects. But that does not mean that we do not also believe that the major task of providing the health services on the ground will be at the Area Health Authority level, because in Clause 7 the Bill makes full provision for the delegation of powers down the line from the Secretary of State to the Regional Authority to the Area Authority and specifically gives the Secretary of State power in Clause 7(2) to ensure that the Regional Health Authority does devolve the functions that it should on the Area Health Authority.
We believe that it is necessary to have a full Regional Authority. We do not believe that the system would work, as was proposed by the last Government, with simply an advisory tier. What we see as the functions of the Regional Health Authority are, first of all, to develop strategic plans and priorities (this is the long-term planning, and particularly of the major hospital building programme); secondly, to identify services (again especially hospital services) which need a Regional rather than an Area approach—for example, the location of the rarer specialities in the Region; thirdly, to co-ordinate the activities of the Area Health Authority where, for example, the health services do not fit neatly into Area boundaries; then to allocate resources between the Areas and, through the planning process, to keep an eye on how the objectives and programmes for which the resources have been allocated are being developed. Lastly, they have certain executive functions in the field of major building works, perhaps the provision of a single ambulance service in a metropolitan county, a blood transfusion service, and management services such as computers, which are better dealt with on a Regional basis.
The fact is that in the National Health Service it is the responsibility of the Secretary of State to provide the service. He is accountable for the immense sums of money that are spent, and for the service that is provided. That has always been so. We believe that it is right that there should be a clear delegation of 1047 authority from the Secretary of State to the other bodies in the chain. It is too important a tier of authority for simply an advisory council, and we believe that it should be a Regional Authority with members appointed by the Secretary of State after consulting the various bodies that are described in the Bill. This has always been the pattern of the National Health Service, and this is what we believe is the right pattern to ensure an efficient Service, with the one exception which we shall no doubt be considering and talking about later, the four local authority members at the Area Health Authority level.
There are very large sums of money involved in the Service, and one of the basic objects of the reorganisation is to achieve a better use of these resources. We believe that if we are to succeed in this, we really need a clear-cut management structure in which each tier of authority knows what its task is, has a budget, has a plan, and has a certain amount of autonomy within the plan to carry out its own objects within the budget that it has been given. We have always stressed the need for maximum devolution of power down to the Area Health Authority, but there still must remain a clear line of responsibility from the Area Health Authority to the Secretary of State through the Regional Authority. How can the region or the area be held accountable unless the majority of their members are appointed by the Secretary of State? However, we come to the membership of these bodies at a later Amendment, and perhaps I had better not go into that point at the moment. I would just make the point that it is part of the basic concept of the Service that they are small management bodies at the regional and the area level, and this is matched with strong advisory machinery of professional medical and other services, and with the consumer coming in on the community health council. These are the three pillars of the new Service as we see it, and one of them is the small, efficient management body at area and regional level.
I would stress, therefore, that we believe that for the efficiency of the running of the Service we need a regional tier. It will not weigh heavily on the area be- 1048 cause the functions will be arranged in such a way that they will be devolved from the region to the area except for those particular functions which I mentioned earlier on in my few remarks. I hope therefore that if the change of title is taken to mean a change from a management role to an advisory role, your Lordships will not accept this change.
§ 7.35 p.m.
§ LORD REIGATE
I must say that I am disappointed at my noble friend's reply. As has been said, this was the tip of the iceberg. It may be that we ought to have discussed the iceberg before we came to the tip. Judging from his reception of this Amendment, I think that the iceberg is going to remain totally unfrozen throughout the whole of our debates. Perhaps I may say to the noble Lord, Lord Somers, that I accept that sometimes "local authorities" are "councils". If the words are so very similar, then there is no reason why my noble friend should not have accepted the Amendment. I happen to believe, as I think he will now realise after following the debate, that the name did mean a change of function.
To the noble Lord, Lord Brown, I must confess that I did not follow all of his speech. I shall read it with great interest and see what I can learn from it. I should hate it to be suggested that at any stage I was trying to abolish a hierarchy in the Health Service. Of course you have to have it, as in any other organisation. What we are trying to seek is not too rigid or complex a hierarchy.
§ LORD BROWN
Will the noble Lord allow me to interrupt? If you were not trying to abolish the hierarchy, then it seems to me that in suggesting the word "councils" instead of "authorities" you must have meant the same thing as "authorities". If you really attach a different meaning to the word "councils", then you are interfering with the hierarchy.
§ LORD REIGATE
I can only say to the noble Lord that I think what happens sometimes in these debates is that those of us who are (shall I say?) occupied with the Health Service sometimes talk in different language from those who are not. I think the noble Baroness, Lady 1049 Serota, knows exactly what I was trying to say. I certainly do not want to introduce anarchy into the Health Service, but I certainly do not want to see too many tiers.
I was disappointed by my noble friend's reply because I think that we now clearly see that the Regional Authorities, as they must now be called, are going to have the same powers as the Regional Boards had, only more so. If he hopes to attract to the Area Health Authority a certain standard of people who perhaps have not been in the Health Service before, I think that this action is tending to militate against attracting them, because people do not want to be on a lower tier authority so much as on a higher tier authority which has more power. I say that now as a warning, and I think that my noble friend knows what I mean.
§ BARONESS SEROTA
May I first thank my noble Health Service friends for their support of this Amendment, and also say how delighted I am that the noble Lord, Lord Brown, has stayed for our debate. I long to debate organisation theory with him and discuss the relative merits and disadvantages of polyarchies and hierarchies, but time is limited. If we possibly can, the noble Lord, Lord Aberdare, and I would very much like to finish Schedule 1 to-night, as we originally planned.
I was very sorry that the noble Lord, Lord Brown was unable to be with us on previous occasions when we covered a great deal of this ground. A year ago last November we discussed the principles underlying the proposals in the Consultative Document, and in further debates and on Second Reading we discussed these matters. Therefore, I feel that I must not be drawn by him on to these wider issues, because most noble Lords present know my views on them, and I believe that I know theirs. I am only sorry that I have clearly failed to convince the noble Lord, Lord Aberdare,
§ that the Government ought to think again about this very important part of the proposed Health Service structure. I am sorry, too, if he misunderstood me. This is a complex subject, but I was not asking for an advisory council. I was asking for a Regional Health Council with certain specified powers and certain specified responsibilities. We shall come to the membership on a later Amendment. From what the noble Lord said when he talked about money, I can only assume that it was really his master's voice that we were hearing. We all know that it is the Treasury which is determined on the kind of organisational structure which is put before us in this Bill. We know—and I certainly know—that it is the desire of the Treasury to control money going into a national Service that is financed from taxation to its greatest extent and partly from contributions, that has determined the kind of structure which we now have to consider within the order-making powers of the Bill—it is not actually in the Bill at all.
§ I am very sorry that the Government have been unable to offer any hope to us that they might be prepared to reconsider at least certain aspects of the functions of the proposed Regional Health Authorities in relation to the Area Health Authorities. Do we have to take the package as a whole? Is it not possible for the Government to consider certain of the points that have been made not only inside this Committee, where we have inevitably concentrated our debate, but outside too? As it seems that the noble Lord is not prepared to give an inch, even in terms of offering to reconsider some of the proposals, I think I shall test the feeling of the Committee. I shall not withdraw the Amendment.
§ 7.42 p.m.
§ On Question, Whether the said Amendment (No. 39) shall be agreed to?
§ Their Lordships divided: Contents, 31; Not-Contents, 37.1051
|Alport, L.||Diamond, L.||Hoy, L.|
|Auckland, L.||Evans of Hungershall, L.||Jacques, L.|
|Beswick, L.||Gaitskell, B.||Llewelyn-Davies of Hastoe, B.|
|Blyton, L.||Gardiner, L.||Milner of Leeds, L. [Teller.]|
|Champion, L.||Garnsworthy, L. [Teller.]||Popplewell, L.|
|Cobbold, L.||Greenwood of Rossendale, L.||Raglan, L.|
|Cottesloe, L.||Hayter, L.||Reigate, L.|
|Davies of Leek, L.||Henderson, L.||Ruthven of Freeland, Ly.|
|Serota, B.||Taylor of Mansfield, L.||Wright of Ashton under Lyne, L.|
|Stow Hill, L.||Vivian, L.|
|Strabolgi, L.||White, B.|
|Aberdare, L.||Elliot of Harwood, B.||Monck, V.|
|Amory, V.||Falkland, V.||Monckton of Brenchley, V.|
|Belstead, L.||Ferrers, E.||Mowbray and Stourton, L.|
|Bethell, L.||Gainford, L.||Northchurch, B.|
|Bradford, E.||Gowrie, E.||Nugent of Guildford, L.|
|Brooke of Cumnor, L.||Hawke, L.||Rochdale, V.|
|Brooke of Ystradfellte, B.||Hylton-Foster, B.||St. Aldwyns, E. [Teller.]|
|Conesford, L.||Jellicoe, E. (L. Privy Seal.)||St. Just, L.|
|Cullen of Ashbourne, L.||Limerick, E.||Sandford, L.|
|Denham, L. [Teller.]||Lothian, M.||Sempill, Ly.|
|Devonshire, D.||Loudoun, C.||Strathclyde, L.|
|Drumalbyn, L.||Macleod of Borve, B.||Young, B.|
Resolved in the negative, and Amendment disagreed to accordingly.
§ 7.49 p.m.
BARONESS SEROTA moved Amendment No. 40:
Page 3, line 41, after ("England") insert ("other than Greater London").
§ The noble Baroness said: Since this is merely a paving Amendment for Amendment No. 41, it might be for the convenience of the Committee if I spoke to them together. Owing to the nature of this Bill there is, as noble Lords will have seen, no reference whatsoever to the very real difficulties in applying the general principles of the reorganisation of the Health Service to Greater London, owing to its very special historical, demographic and communications features. Nor is there any reference to the fact that local government in London was reorganised in 1964, at a time when the Health Service reorganisation was certainly not on the political agenda of the then-Government, and therefore has no relationship whatever to the proposed Health Service reorganisation we are now considering. In view of the very highly controversial nature of the different sets of proposals which now have been under discussion for some four years and the decisions the Government have come to recently on them, I thought it might be helpful to have an opportunity of hearing from the Minister the reasons behind the decisions he announced in reply to my Written Question in November, decisions which were arrived at after lengthy consultations with all the particular interests concerned.
§ The purpose of this Amendment therefore is simply to elicit why the Government have finally come down in favour of perpetuating the four existing Metropolitan Hospital Regional Board areas 1052 in the form of the proposed new Regional Health Authorities, each to include some of the Greater London health areas as well as some in the neighbouring Home Counties, thus completely ignoring the existence of the Greater London area boundary and breaching one of the cardinal principles of the reorganisation proposals in the rest of the country both in relation to the area of the Greater London Council and also in relation to the London boroughs; since the latter are to be grouped in Area Health Authorities with two groups of boroughs and. in three cases, three groups of boroughs.
§ The noble Lord may remind me that the former Administration also proposed to have four metropolitan regions. But that was nearly three years ago and a lot of water has flowed under the Thames bridges since then. In fact, the reason why the former Government set up the London Working Party which the noble Lord continued when he came into Office was to bring all the interests together to examine the matter in greater detail than we were able to do before we issued the second Green Paper (which was simply for consideration) so that they could consider the range of possible alternative solutions. I myself had always hoped that as the discussions in depth proceeded it would have proved possible to devise arrangements to avoid dividing the Greater London region so unrealistically into the four irrelevant segments that are now suggested. This view has certainly been strengthened by the Government's determination to give the new Regional Health Authorities such greater powers and controls over the areas as we have just discussed in the last Amendment.
§ Yesterday we heard from the Minister just what, in practice, such a division is 1053 going to mean in terms of the operational management of the Greater London Ambulance Service, an excellent Service at present unified and run as a unified service by the Greater London Council. After April 1974 it will, according to the Minister, be the operational responsibility of a joint committee of the four metropolitan regions, while the Government intend to ask the Greater London Council to continue to be responsible, for some years to come apparently, for providing the maintenance service, the radio communication and the research and development services. Could we have a more practical demonstration of the complete administrative nonsense of this four-division arrangement? Are there any other parts of the Health Service which are going to provide it in the same way over the Greater London Council area after April 1974? Why was it not decided to create one Greater London region; or, at most, two, as we suggest in this Amendment? At least it is agreed on all sides in an area where agreement is difficult that if the Metropolis must be divided for regional health services, the River Thames forms the only natural, visible and unmistakable boundary, as we suggest in this Amendment.
§ While we accept that there is a necessity to co-ordinate the strategic kernel of the health provision in Greater London, we believe that the retention of these existing four regions with the powers now to be allocated to them will prove cumbersome and will require yet another set of co-ordinating machinery to recognise the realities of the situation. This fear has been strengthened by the answer we were given yesterday on the London Ambulance Service.
§ I would submit that with only two London Regions, London Region North and London Region South, which had a very high level of containment for Health Service purposes, the strategic planning on each side of the river would be greatly simplified by being the responsibility of only one authority rather than the criss-cross arrangement now suggested by the Government. I hope that those noble Lords who were involved in the detailed consultations on this complex problem and who speak with greater knowledge than I, will take part in this Amendment in which I am supported again by my Health Service friend, the 1054 noble Lord, Lord Reigate. I beg to move this Amendment so that their voices can be heard. This will be the first opportunity we have had for a debate (other than the occasion of the Second Reading) on the details of the Government's decision concerning Greater London. I also move it to enable the noble Lord, Lord Aberdare, to explain to the Committee the reasons why the Government came to these decisions. I beg to move.
§ LORD COTTESLOE
As I said when speaking on the last Amendment, I believe it to be most desirable that it should be clearly established from the beginning that the Regional Health Authority is a quite different animal from the Regional Hospital Board, with largely different functions. This in itself makes it advisable that the existing pattern of regional boundaries should not be stamped on to the new regions. Not only that, but speaking as one who was for a period of seven years the chairman of one of the Metropolitan Regional Hospital Boards (a board whose region comprised one quadrant of London, densely populated, with a large agricultural area outside the Greater London area stretching out to Bedfordshire and Northampton-shire) in that capacity I was acutely and constantly aware of the quite different problems presented by hospital and Health Service planning in the rural areas, problems quite different from those in the urban metropolitan area. If there is a regional organisation whose prime function is a planning function, it seems to me quite clear in the light of that experience that in the metropolitan area there is everything to be said (certainly this is so in the South-East of England; though there may be different factors in the North country conurbations) for separating the urban areas of Greater London from the rural areas around them by creating different regions to exercise the functions of Health Service planning. It is my view, and in the light of long experience of the Service, that it would make for far more effective planning and administration if Greater London were a separate region for Health Service purposes, as it is for local government, or perhaps two regions as these Amendments propose.
The Government, who are concerned to establish a new and better pattern for 1055 the Health Service, seem to be determined to stamp the new Service into the same mould. If they want a new, different and better service they must not succumb to what I may call the inertia of all large-scale administrations, their extreme reluctance to be put into a new and different mould. I hope, though in the light of the fate of the last Amendment I sadly cannot much expect it, that my noble friend will accept these Amendments; or, if he cannot do so, I hope profoundly that today he will at least tell us that their content will be most seriously considered.
§ 8.0 p.m.
§ LORD ABERDARE
I think my noble friend Lord Cottesloe is being a little unreasonable when he expects a complete change of everything. He expects a complete change in the shape and size of regions; he wants to change their headquarters; he wants to reorganise them. We are changing and unifying the Service, but there has to be a certain amount of continuity. We cannot abandon entirely the long-term planning which has gone into the Service hitherto, and I think that my noble friend is expecting a little bit much in trying to suggest that we should make many changes where, certainly in our view, they are not basically necessary. I have been asked some specific questions by the noble Baroness. Lady Scrota, and I was going to remind her of her own Green Paper, not only because in that Paper it appears that there would be four Metropolitan Regional Health Councils, as they were called, but principally for the reasons it gave for maintaining continuity in planning the specialised services in London and South-East England—
§ BARONESS SEROTA
If I may interrupt the noble Lord, I would say that it just proves how conservative we all get when we are in Government.
§ LORD ABERDARE
I have no doubt the noble Baroness will be able to quote something back at me one day—and to maintain the important links between the facilities in central London and the rest of the South-East. We spent many anxious hours discussing the problems of London and we thought through many different solutions. One very attractive solution, which I found at the time more 1056 attractive than the idea of two regions, was one London region. This was something we considered extremely carefully, but finally we came down in favour of continuing the present four regions roughly on the same boundaries as at present although taking account of the new area boundaries, because this seemed to us not only to follow the pattern of the flow of patients in and out of London in the various directions, but also the way in which provision of services had grown up.
Under the proposal as it is suggested in the Amendment there would be seven Area Health Authorities that would be excluded from these two London regions. It might, I suppose, be possible to make arrangements for some of those to link up with other Regional Health Authorities, but there would be left, certainly in the South-East, a block of Area Health Authorities—Kent and Sussex—where presumably one would have to create another South-East Coast Region. That particular region would be very artificial, I should have thought, because it would have no teaching hospital, no established planning machinery, no co-ordinated future plan. But we thought it important that every region should have its own medical school and that the influence of that school should flow outwards into the region. The teaching hospitals, in many conversations—I hope they were fruitful conversations—that we had with them over the last months, made very strong proposals for larger teaching areas. We were unable to go the whole way with them because on the other side of the fence were the London boroughs who were not unduly anxious that many of them should be brought together within an area. But I think that to circumscribe London with a regional boundary, or two regional boundaries, would equally confine the teaching hospitals within London itself; whereas one would like to see their influence flowing outwards into the whole of their regions, with people coming from the South-East who are used to using the London teaching hospitals for the provision of specialties.
With respect to my noble friend Lord Cottesloe I believe that the present Regional Hospital Boards are satisfactory from the point of view of planning, and I should not—this I should have thought a good Conservative principle—think that 1057 it was desirable to disturb the forward planning of the Hospital Service more than was necessary. There are advantages in building on what is already there, although the new Regional Health Authorities will be different bodies and will have different membership.
The other point I might make with regard to the Amendment is a general objection in that it introduces regional boundaries into the Bill. Like the previous Act of 1946, the Bill provides for regional boundaries to be established by Order so as to give flexibility. This flexibility proved itself, for example, when the South-East Metropolitan Region was divided to create a separate Wessex Region. Similar adjustments could happen in the future. Who knows? Even the noble Baroness's Amendment might be introduced in future under regulations. We have thought out this matter very carefully and have come to the conclusion that there are solid advantages in retaining the four regions. May I just say, on the subject of the Ambulance Service on which I still feel very deeply, that it will be the only Service which will be administered as a single unit coveting Greater London as a whole. But we believe that the Ambulance Service in total will be undisturbed and will still be a unified Service and will work to a single committee. It is true that that committee will be made up of members of four Regional Health Authorities, but it will still be a single committee.
§ LORD REIGATE
I am more than grateful to my noble friend for his reply to the noble Baroness, Lady Serota, on this Amendment. I am glad that I heard his reply before I rose to speak, because I detect a ray of hope at the end of the corridor, since it will be possible in due course, under the powers, to create a Greater London Region, as I should prefer, rather than the two which are proposed in the Amendment. My noble friend says that he needs to maintain continuity and I think there is something in that at this stage. If you are having a total upheaval, to abolish the four Metropolitan Regional Boards at this time, desirable though it may be in the eyes of many people, including myself, might make the task during the next twelve months even more difficult. But if there is a possibility that we may come back to this matter at some later stage 1058 I think there is some hope, and I should like to advance and reinforce some of the arguments in favour of the Greater London Area.
My noble friend talked about the flow, of patients into London and of the facilities of central London. That is the reason why the four Metropolitan Regional Boards were created in 1948, and the argument was valid then. I do not frankly think it was valid when the Party opposite produced their Green Paper. Their thinking was out of date then, and it is even more out of date now. In those days the teaching hospitals were all concentrated in London, and the district hospitals in London and outside London had not been upgraded to the extent that they have been in the last 27 years. So that flow of patients no longer exists in the same way. Teaching hospitals are no longer 100 per cent. hospitals of referral in the same way. Almost the most important change under the Health Service is that most of the teaching hospitals have become district hospitals. This is suited to the—I do not know whether one calls it the spirit or the mood of continuity medicine, which is a new and important fact. So this talk of going in and out of central London is really rather out of date.
The other argument is the link with the teaching hospitals. This is a valid argument, and I accept it. It was thought necessary in 1948 that you should have the teaching hospital, in that much used phrase, as a centre of excellence. I understand that the Secretary of State is not so fond of the expression "centres of excellence", but it is true to some extent. I must point out two things. One is that it is possible to have a centre of excellence which does not actually lie inside your regional boundaries. Indeed, Wessex itself survived for nearly ten years as a region before the teaching hospital came along. So I think that the arguments are still strong for organising the Greater London Area as one.
The principle of coterminosity is so important as regards the area that I should have thought it was equally important when it comes to the regions. It was rigidly enforced in the area, and I should be happier if it were not suddenly abandoned when it comes to Greater London. For the result will be the curious hierarchy to which I and other 1059 noble Lords drew attention earlier. In fact, in Greater London there is to be a Co-ordinating Committee and there will be yet another committee for the Ambulance Service. I do not know whether one can dictate typography to Hansard, but I should like those words "yet another committee" put in block letters. I think it shows that a mistake has been made in not thinking in terms of Greater London as a region.
My noble friend referred to the areas left outside—I might describe them as, so to speak, the problem of the rumps; that is to say, Essex in the North-East, Bedfordshire and Hertfordshire in the North-West, Surrey and the two Sussexes and Kent. I think he would agree that the problem of Essex, Bedfordshire and Hertfordshire is not insoluble they could well be included in other regions, leaving Surrey, the two Sussexes and Kent. I do not think that those are any more artificial as a region than the division of Greater London into four. I sincerely hope that a new medical school may be started in one of those four counties in the foreseeable future. But Greater London should still be planned as one region.
I find it a little sad that the continued division of Greater London is the doing of the architect of Greater London, the Secretary of State who was responsible for the Local Government Bill. I remember giving him warm support through all stages of that Bill. The noble Lord, Lord Garnsworthy, used to come and sit at the back of the Committee Room, waiting to see if I was going to do anything against the ratepayers of Reigate. Actually he did not catch me out. I think the Secretary of State was entirely right in that great reform. I can only say that I wish he would extend to Greater London the words he used on the Second Reading of that other Bill, when he said:Greater London is in a very real sense a single city.He talked of:the whole of the great urban area which spreads out and is contained by the Green Belt is one Metropolis".I feel that those words are a sure indication that sooner or later Greater London will have to be a region.
§ LORD COBBOLD
I do not want to make my Second Reading speech again. I think the noble Lord is only too well aware of my opinions on this general subject, and I think I have made them clear to your Lordships. I am not quite sure whether I am on the right tip of the iceberg or at which point it is moved and whether I should have made the few observations I am going to make on the previous Amendment, or make them on this Amendment or on the next Amendment. But if I might be allowed to skid a little, I should like to make this observation. The noble Lord was saying that there has been no change in the thinking about the relative powers and authority of the regions and the areas. I absolutely accept that as the intention of the Secretary of State and the noble Lord, and the Secretary of State was good enough to reaffirm it to me only the other day. I am bound to say, however, that is has not been taken like that by the hospital world as a whole. The hospital world as a whole has read some rather sinister meanings, particularly into the words "monitoring and control". Anything that the noble Lord can say to help us on that subject would be greatly appreciated.
I should like to press the noble Lord slightly on a point I raised in my Second Reading speech. It would be nice to know something about estimates of cost in this new superstructure of area and regional authorities, and I hope that at some time before the Bill gets much further we may have some estimates of financial figures on that point. May I also ask the noble Lord if he could be a little more specific about the size and numbers of the regional authorities as proposed. Does he envisage that the numbers of staff employed at regional level will get larger, remain the same or get smaller. I should certainly hope that if a lot of people are to be employed at area level, the numbers employed at the regional level will get smaller. There again, if the noble Lord could say anything about that, it would be helpful.
Then, it is clear that the allocation of finance is the responsibility of the regional authority. I have on several occasions in your Lordships' House expressed my concern as to whether adequate financial allocation would be afforded for teaching and research in the new circumstances. 1061 This is a subject which has been discussed at great length with the Secretary of State and the noble Lord, and anything the noble Lord can say to the Committee on that subject would also be extremely welcome.
§ 8.19 p.m.
§ LORD ABERDARE
My Lords, the noble Lord has asked me a good many questions. I do not know how many I can answer satisfactorily at this moment.
§ LORD ABERDARE
That does not matter at all. I am delighted. First of all, he asked me about monitoring and control. I ought to have made the point earlier, on the noble Baroness's Amendment, that the management arrangements in the Grey Book, as the noble Lord knows, are still under discussion and have not yet been accepted. I was trying to find where it defines "monitoring". But "monitoring" is a curious word. I think that to many of us it implies a schoolboy authority. That is not what it means as it is used in the Grey Book; it simply means the right to receive information.
§ LORD COBBOLD
The hospital services have certainly assumed that it means that the chap at regional level will be continually looking to see what the chap at area level is doing.
§ BARONESS SEROTA
If I may read the definition of "monitoring" from the Grey Book, it says:The first requirement for effective monitoring will be the existence of a plan to which each management level is committed. The plan will provide a yardstick against which to measure performance and will contain targets as incentives.
§ LORD ABERDARE
I am very grateful to the noble Baroness. In fact the monitoring function is one of obtaining information and of being able to see how a plan is working out: it is in no sense concerned with controlling an individual.
§ The noble Lord asked me about finance, which is a matter he raised on Second Reading. I am afraid I cannot help him at the moment on this, but I will do so when figures are available. Staff matters, again, are being worked out, and until we have finalised the management arrangements it is rather difficult to give estimates of what the staffing might be. One would have thought that the greater devolution of powers of the Area Authority might to some extent reduce the numbers of the Regional Health Authorities. On the other hand, in a unified Service there are going to be additional demands and these will create the need for more staff. Also, I believe I said yesterday that we are developing the personnel training side of the Service, and this again will give rise to the need for further staff. I will certainly undertake to keep the noble Lord informed on these matters.
§ Regarding the allocation of staff for teaching and research, as the White Paper says, we intend that the Regional Health Authority shall receive in its financial allocation a specifically identified allowance for teaching and research. This is an endeavour to give the noble Lord and those who are interested in the teaching aspects some reassurance that the Secretary of State will oversee these matters to ensure that they are not starved of money for teaching and research.
§ BARONESS SEROTA
At this late hour I know that the House wants to move on to the next Amendment, and I would only thank the noble Lord for his usual patience and courtesy in explaining why the Government have come to these decisions. I do not want to take up more time. The noble Lords, Lord Reigate and Lord Cobbold, have already spoken on these matters and I do not think I can improve on their comments; but I very much hope that the Committee will accept this Amendment.
§ 8.23 p.m.
§ On Question, Whether the said Amendment (No. 40) shall be agreed to?
§ Their Lordships divided: Contents, 24; Not-Contents, 30.1063
|Beswick, L.||Cottesloe, L.||Garnsworthy, L.|
|Blyton, L.||Evans of Hungershall, L.||Greenwood of Rossendale, L.|
|Brown, L.||Gaitskell, B.||Hayter, L.|
|Champion, L.||Gardiner, L.||Henderson, L.|
|Hoy, L.||Raglan, L.||Taylor of Mansfield, L.|
|Llewelyn-Davies of Hastoe, B. [Teller.]||Reigate, L.||White, B.|
|Serota, B.||Wright of Ashton under Lyne, L.|
|Milner of Leeds, L. [Teller.]||Stow Hill, L.|
|Popplewell, L.||Strabolgi, L.|
|Aberdare, L.||Eccles, V.||Northchurch, B.|
|Amory, V.||Elliot of Harwood, B.||Rankeillour, L.|
|Auckland, L.||Ferrers, E.||Rochdale, V.|
|Belstead, L.||Gainford, L.||Ruthven of Freeland, Ly.|
|Bethel1, L.||Cowrie, E.||St. Aldwyn, E.|
|Bradford, E.||Jellicoe, E. (L. Privy Seal.)||Sandford, L.|
|Brooke of Cumnor, L.||Limerick, E.||Sempill, Ly.|
|Brooke of Ystradfellte, B.||Lothian, M.||Vivian, L.|
|Cullen of Ashbourne, L.||Macleod of Borve, B.||Young, B.|
|Denham, L. [Teller.]||Mowbray and Stourton, L. [Teller.]|
On Question, Amendment agreed to.
§ Clause 5 agreed to.
§ Clause 6 [Provisions supplementary to section 5]:
§ 8.31 p.m.
LORD GARNSWORTHY moved Amendment No. 42:
Page 5, line 18, at end insert ("and, if he intends to make an order containing provision for the transfer of officers, the staff representative body").
The noble Lord said: We have just disposed of Clause 5, which requires the Secretary of State to establish Regional Health Authorities and Area Authorities in England, and we now come to Clause 6, which deals with provisions supple. mentary to Section 5. Clause 6(2) enables the Secretary of State by order to
vary the region of a Regional Health Authority or the area of an Area Health Authority … and an order made by virtue of this subsection may … contain such provisions for the transfer of officers, property, rights and liabilities as the Secretary of State thinks fit".
It is particularly in relation to the power being given to the Secretary of State in regard to transfer of officers that I am moving this Amendment.
Your Lordships are I think aware that I have close contacts with a number of the trade unions who cater for the staffs who work in the National Health Service and in the field of local government. If I had been speaking on Second Reading I should have made the point that one thing that is notably absent from this Bill is any clear indication of the role of the trade unions in the set-up that is proposed for the National Health Service. I mention that fact because note has
been taken of it; and I may say that a little clearer indication in legislation of the importance of the trade union movement would be appreciated. The subsection to which I have made reference goes on to say:
but it shall be the duty of the Secretary of State before he makes an order in pursuance of this subsection to consult such bodies as he considers are concerned with the order.
My Amendment calls upon him, if he intends to make an order, to consult with the staff representative body. I do not think it is asking a great deal of the Government to accept this Amendment. Indeed, I am quite certain that it would give a satisfaction on the trade union side that would pay quite handsome dividends in the sense that they would appreciate that they were being incorporated in the legislation we are considering.
Your Lordships may wonder what is meant by the use of the words "staff representative body". I would say that in Amendment No. 124, which is an Amendment to Clause 54, I have tried to set out precisely what is meant by using those three words, "staff representative body". That expression
means an association or other body appearing, to the Secretary of State sufficiently to represent the interests of staff employed under the Health Service Acts and affected or who may be affected, by that provision".
I do not wish to take up your Lordships' time unduly at this hour of night. I hope that I have made clear the purpose of the Amendment. It is agreed that the Secretary of State should consult with somebody. It is very important that he should consult with the right people. I do not think anybody doubts that in the field of the Health Service the trade unions catering for the overwhelming body of people engaged in it are clearly
known; nobody questions their authority. I beg to move.
§ 8.35 p.m.
§ LORD BROWN
I rise to support this Amendment. I have no doubt that when the Minister replies he will point out that, as it is the duty of the Secretary of State, in the words of the clause,to consult such bodies as he considers are concerned with the order",he will inevitably consult the staff representatives. But I support the Amendment in spite of that—for I have no doubt that he would consult them—on these grounds. The Government must be well aware by now that the Industrial Relations Act, whatever its rights or wrongs (I will not go into that matter) was felt to be a psychological affront by the trade unions—rightly or wrongly, again; I do not want to debate that. But it was so felt, and one of the ways of avoiding psychological affronts is to pay due attention to the possibility of their emerging. I support my noble friend on the Front Bench by pointing out that, if the Government accept this Amendment, it will be therapeutic at least in its effect, even if it proves in the event to be unnecessary because the Secretary of State would take these responsibilities seriously. It is on these grounds that I strongly suggest that the Government pay attention to this Amendment.
§ 8.37 p.m.
§ LORD ABERDARE
While we are reorganising the Health Service I suppose we may as well put in therapeutic Amendments, but I would think there could be a great many other therapeutic Amendments which would be helpful from various points of view but might not be in the best interests of the Bill as it finally emerges as an Act. This is the clause, as the noble Lord, Lord Garnsworthy, says, which satisfies my noble friend Lord Reigate and makes provision for boundary changes and for any necessary consequential provisions, which includes the transfer of staff. The first thing I would say in reply to the noble Lord, Lord Garnsworthy, is that we certainly, as he well knows, attach enormous importance to our relationships with the trade unions and with the staff representative interests in the Health Service. I think that our relations with them on the whole are extremely cordial. With the 1066 Whitley Councils we are in contact all the time, and they do an excellent job of work. It is not for any reasons other than strictly practical ones that I would suggest that this Amendment is unnecessary.
The reasons I would give are those that the noble Lord, Lord Brown, with his immense ministerial experience, has suggested I might. It is inconceivable that where staff interests were affected the Secretary of State would not consider the appropriate staff organisations as bodies concerned with the order that he should consult. But the difficulty about a therapeutic entry of this kind is that there are many other bodies which need to be consulted before these orders are made. They would include, obviously, local authorities; they would include community health councils, and a number of different organisations concerned with the Health Service. Precisely which bodies will need to be consulted of course will depend on the particular boundary changes, and it would be inappropriate to specify in the Bill bodies which particularly should be consulted. In addition, I do not want to anticipate the debate that we shall have on Amendment No. 124—if we ever reach it!—but we have some doubts about the "staff representative body" as it is defined by the noble Lord in that Amendment. This, too, would make it difficult for me to accept the present Amendment. But I give an absolute assurance that in every case of boundary changes which would necessarily affect staff, those who represent them will be consulted through the usual consultative channels.
§ LORD GARNSWORTHY
I am greatly indebted to the noble Lord, Lord Aberdare, who as usual is extremely courteous. It seems not to matter how late in the evening it is, and how he manages to maintain his composure I do not know, but I appreciate the care that he has taken in trying to meet the point that I was endeavouring to make. May I say to the noble Lord that I think it would be well to take note of the fact that the Amendment is solely concerned with that part of the subsection dealing with the transfer of officers, and since he has indicated that when we come to Amendment No. 124 he will perhaps have more to say it may be as well if I put this point to him now.
1067 This subsection deals with the transfer of property rights and liabilities as well as officers. The most important element in all this is the officer. We are dealing with people who are worried about being moved and transferred and the Secretary of State is doing this by Order. I forbore asking how the Order was to be made. This Bill is full of references to Orders. I do not know exactly how these Orders are going to be made; at some stage I suppose we shall have a full explanation.
The noble Lord drew attention to the enormous importance that the Government attach to relations with the trade union movement, and I think my noble friend Lord Brown had a considerable point there. There has been some reference to icebergs, and I think it would not be a bad idea if somebody were to start a little snowball—something that would grow and would indicate to the trade union movement that the Government really do want their complete cooperation. I suggest to the Government that they should not shy away from beginning to introduce into legislation a recognition of the importance of the trade union movement, and show that they concede a status that surely belongs to the movement.
I do not think the Amendment calls for any reference to local authorities or anybody else. I am drawing attention to the human factor. I am suggesting that in terms of the best possible human relations the Government would do well to make some concession to meet a point that is strongly held. It is so little to ask and it seems to me that it would cost absolutely nothing, but it could pay really handsome dividends.
I should not think of pressing this matter to a Division. I am sure we shall return to it again, but I should like to think that the noble Lord, Lord Aberdare, will undertake to consider it a little further. It may be that I have said something that the Government themselves may wish to deal with at Report stage if we cannot reach an understanding before then.
§ VISCOUNT AMORY
May I say just one thing. We all understand what my noble friend said about the general difficulty of mentioning one form of consulta- 1068 tion when a number of others may be involved. But I think one sees the point made by the noble Lord, Lord Garnsworthy, that this proposal is limited to this particular case—the transfer of officers. Perhaps in that case there would be no harm in mentioning this form of consultation, which seems to be particularly relevant in this case.
§ LORD ABERDARE
I certainly will have a look at it. I think we shall have to get away from the difficulty of defining the "staff representative body", but apart from that I will certainly look at it again.
§ LORD GARNSWORTHY
That is very generous of the noble Lord and I am grateful to him. I have an indication that it is a foretaste of the Christmas spirit. I beg leave to withdraw the Amendment.
§ Amendment, by leave, withdrawn.
§ LORD ABERDARE
The reference to the word "committee" in this subsection was made to cover the family practitioner committee established under Clause 5(5), but such a committee is referred to in Clause 5(5) as a "body" and accordingly it is appropriate that it should be so described for the purpose of this provision. I beg to move.
Page 5, line 28, leave out ("committee").—(Lord Aberdare.)
§ 8.48 p.m.
LORD REIGATE moved Amendment No. 44:
Page 5, line 29, at end insert—
("(5) The Secretary of State may transfer to any Area Health Authority any property held by him for the purposes of this Act or other National Health Service Acts.")
§ The noble Lord said: This is a purely probing Amendment. I only want to try very briefly to air a matter that has been under consideration, I believe, in the Department, though not necessarily in the form in which I put it forward. It may be that the Secretary of State already has in some way or another the powers that I seek to give him in this Bill. I think I am right in saying that the Secretary of State is now the largest property owner in the country—not the largest landowner; that is the Secretary of State for Defence. Without any discourtesy 1069 to him or to the Department, I am not sure that all the property is sited in the right place. There are properties which would be more useful for other purposes. Far too many of the properties are in the wrong place and we all know the great difficulties that arise with a Governmental machine in disposing of them or, of course, in acquiring new properties. The machine is far too slow.
§ Furthermore, under this Bill the Secretary of State will be taking over a large number of properties which are now in the possession of local authorities, who are in a happier position if they wish to acquire or dispose of those properties. But the trouble really arises at a lower level, and perhaps I may give one or two examples of what has been my experience, as the chairman of a teaching hospital, of how a cumbersome machinery can operate against the interests of the taxpayer and, of course, of the hospital as well. In my hospital group we owned a nurses home which was some way away from the main hospital and became surplus to our requirements. In accordance with the usual procedure we gave notice, and it was agreed, that we should dispose of it. It had to be "hawked around" among the other Government Departments for over a year. In fact it could have been sold very suitably on the open market for a fairly considerable sum. Eventually, after a year it was acquired by, and not really very well adapted to the use of, what might be described as a para-Governmental authority. In my view that was a waste of time and money.
§ I know of another example, of a hospital which I will not name, but which has a building on a very valuable site which, unfortunately, is exactly at the junction of two busy main roads. It is a very noisy and busy crossroads. As a result a large part of that building is not used. I know that the hospital group in question would be delighted to sell that site and to rebuild the facilities it now possesses inside the perimeter of the hospital that it now has, but of course it cannot do so because the money released has to go back to the Exchequer.
§ The third example is a much more simple one and again applies to my own board. We owned four houses in Vincent Square of which we had obtained vacant possession. Alongside were four other 1070 houses which had been bought out of Exchequer funds for hospital purposes. By a very adroit manoeuvring of various Departments we were able to release that space. What we wanted to do was to convert these buildings into flats for junior medical staff. Anyone who knows anything of the problems of hospitals in big cities is aware that the housing of junior staff is one of the grave problems affecting us all. It took over one year to obtain the transfer of ownership from the Exchequer to the Board of Governors so that we could proceed with the work of converting these houses into flats. However, eventually we got it and we now have 16 flats for the purpose I have outlined. But one year was wasted, with all that that meant in terms of loss of rent and costs of maintenance. The Board of Governors of a teaching hospital is fortunate in these matters because often the hospital has its own resources and is able to buy properties and short-circuit the cumbersome procedures of a Government Department, and in the long run save the Exchequer time and money.
§ I am not asking for any action to-day on this matter, but I hope it will be considered by the Department and that my right honourable friend the Secretary of State may consider setting up a working party, including people with knowledge of the property world outside who could advise him as to how he could make the whole of this machinery much more flexible so that the Area Health Authorities, who will take over many properties from local government authorities, could be master in their own house and, if necessary, change over the properties for better use. I beg to move.
§ 8.53 p.m.
§ LORD ABERDARE
I am grateful to my noble friend Lord Reigate for raising this matter and also for giving me an opportunity to say something about it. I assure him that we have great sympathy for what he said. As he made clear, hospital land is at present vested in the Secretary of State and the normal rules affecting Government land apply to its disposal. Sale proceeds are returned to central funds, which also finance purchases of other land needed for development of the Hospital Service. In most recent years the cost of land purchased has been higher than the income from 1071 sales. However, it has become increasingly apparent that this somewhat artificial framework for land transactions has discouraged Boards from taking regular account of the value of N.H.S. assets in land and buildings, and has not encouraged them to put forward proposals for sale where there was nothing to be gained from reduced revenue costs. But it is only fair to recognise that there has been a steady stream of sales, either of complete sites no longer needed for hospital purposes or of portions of large sites, for example farm land, no longer needed by the hospitals.
The Secretary of State has recognised that some change needs to be made, and this was referred to in paragraph 158 of the White Paper which says:In addition, authorities will be given a more direct financial interest in land holdings and land transactions".There is no need to disturb the present system of ownership, as suggested in the Amendment, to achieve this. Land can continue to be vested in the Secretary of State and occupied by his agents, the N.H.S. authorities. As a Government asset, Government-held land must be properly accounted for to Parliament. But what is needed is a reflection in the financial allocations to authorities of the proceeds of sale of land, so that they can see tangible effects flowing from their decisions to make land available for sale. The Secretary of State will be revealing the change in financial arrangements when these have been fully worked out. This is a matter for the other place since it affects Votes and accountability to Parliament for Government assets. I hope that this fairly encouraging development will enable my noble friend to withdraw his Amendment.
§ LORD REIGATE
I am grateful to my noble friend Lord Aberdare for what in comparison with some of earlier speeches was a most sympathetic reply. I think he misundersood one point. How on earth will one try to expedite the procedures? I quite recognise that these bodies are accountable. I should not have thought that a body the size of an Area Health Authority could not have also been the owner and held the title to all the land 1072 within its perimeter, just as a county council or district council does, and not just always the Treasury octopus with all its tentacles all over the country. However, I am fairly satisfied with what my noble friend said. I am sure that the matter is under consideration and I shall wait to see what comes after. In the meantime, I beg leave to withdraw the Amendment.
§ Amendment, by leave, withdrawn.
§ Clause 6, as amended, agreed to.
§ LORD ABERDARE
As this might be a convenient moment to adjourn the Committee stage, I beg to move that the House do now resume.
§ Moved, That the House do now resume.—(Lord Aberdare.)
§ On Question, Motion agreed to, and House resumed accordingly.